Heart. Severe. Failure. Congestive heart failure (CHF) is very. What you can do for your patients

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1 Focus on CME at the University of Université Manitoba de Sherbrooke By Anne Fradet, MD, FRCP, CSPQ Severe Heart Failure What you can do for your patients The case of Mr. White Mr. White, 72, comes to your office complaining of progressive exertional dyspnea, upon returning from Florida where he spends six months of the year. In the last month, he has noted shortness of breath even with light efforts, such as getting dressed, taking a shower, and shaving. He sleeps with three pillows and sometimes wakes up with shortness of breath. He denies chest pain. He had gained ten pounds, and has noted swelling of his legs, and palpitations. His medical history includes a myocardial infarct in 1998, Type 2 diabetes, hypertension, and dyslipidemia. He smokes a pack of cigarettes per day. He describes his alcohol intake as social. Upon examination, he is overweight with a waist measurement of 104 cm. His blood pressure is 160/95 mmhg. His heart rate is 90 beats per minute slightly irregular. He presents with distended jugular veins at the jaw angle. The apex is displaced to the left and is enlarged. There are third and fourth sounds with a systolic murmur at aortic II/VI radiating to apex. Upon lung examination, there are decreased breath sounds at both bases with slight crackles. Mild peripheral edema is present. In this article: 1. What is the presentation of severe heart failure? 2. How do I investigate it? 3. What is the treatment? 4. What are the new treatments? Congestive heart failure (CHF) is very common, accounting for the largest number of hospital admissions in North America in patients over 65. CHF is most commonly associated with systolic and/or diastolic left ventricular dysfunction, with ischemic heart disease as the most frequent cause of systolic dysfunction. What is the presentation? Exertional dyspnea is frequently the first complaint, and should be qualified to establish the functional class (Table 1). A careful history can identify orthopnea and paroxysmal nocturnal dyspnea. Fatigue The Canadian Journal of CME / July

2 Table 1 Functional Classes Table 2 Precipitating Factors Class I: No limitation: ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation. Class II: Slight limitation of physical activity: such patients are comfortable at rest. Ordinary physical activity results in symptoms. Class III: Marked limitation of physical activity: although patients are comfortable at rest, less than ordinary activity will lead to symptoms. Class IV: Inability to carry on any physical activity without discomfort: symptoms of congestive failure are present even at rest. and cough are common but non-specific symptoms. A syndrome of fluid retention can be manifested by leg or abdominal swelling. It is very important to identify the precipitating factors (Table 2). Upon physical examination, blood pressure and heart rate should guide treatment. Cardiac examination may provide insight into the etiology of CHF, specifically valvular disease. The presence of a third sound on auscultation suggests a volume overload, and a fourth sound suggests a diastolic dysfunction. In patients with right heart failure, the clinical signs present are distended jugular veins, as well as edema of the legs, liver enlargement, and ascites. Dr. Fradet is a cardiologist and clinical consultant, Memphrémagog Hospital, Quebec. Increased myocardial oxygen demands uncontrolled hypertension hyperthyroidism anemia infection, fever tachyarrhythmias: rapid atrial fibrillation, ventricular tachycardia Lack of compliance with diet (dietary excess of sodium and water) with medication Fluid overload medication: nonsteroidal anti-inflammatory agents, glucocorticoids renal disease Myocardial ischemia angina myocardial infarct The elements of an effective investigation are listed in Table 3. What is the treatment? Non-pharmacologic Non-pharmacologic therapy includes salt and liquid restrictions, and physical activities adapted to the patient s condition. Specialized CHF clinics provide patient education and reduce hospitalization rates. Pharmacologic ACE inhibitors: Angiotensin-converting enzyme (ACE) inhibitors are first line treatments for 74 The Canadian Journal of CME / July 2003

3 Table 3 How to investigate CHF Investigations include: chest X-ray 12-lead electrocardiogram blood tests: complete blood count, serum electrolytes, blood lipids, renal and hepatic function, thyroid stimulating hormone urinalysis echocardiography Practice Pointers Prescribe ACE inhibitors to patients without postural hypotension, if serum creatinine concentrations are below 220 µmol/l and potassium less than 5.5 mmol/l. Renal function and serum potassium should be assessed one week after initiation of therapy. Keep in mind that a rise in serum creatinine levels of less than 30% is not unusual and should not be a reason to discontinue treatment. Watch for hyperkalemia, particularly in patients with renal insufficiency, Type 2 diabetes, or in patients taking drugs, such as potassium and spironolactone. patients with symptomatic CHF and asymptomatic left ventricular systolic dysfunction (ejection fraction < 40%). ACE inhibitors reduce morbidity and mortality. The maximum tolerated dosage should be given. ARBs: Angiotensin receptor blockers (ARB) are not superior to ACE inhibitors, but are better tolerated. They are an alternative when ACE inhibitors are not tolerated or when beta blockers Table 4 Summary of medications vs functional class (NYHA) Medications Functionnal class I II III IV ACE inhibitors or ARB (if ACEI not tolerated) Beta blockers Digoxin Diuretics Spironolactone + + 1: Post-infarctus 2: Congestive phase cannot be used (in combination with ACE inhibitors). Beta blockers: Beta blockers reduce morbidity and mortality in all grades of CHF. This medication should not be started during a decompensation phase. Start with the lowest dosage (carvedilol mg to 6.25 mg twice a day; bisoprolol 1.25 mg die; metoprolol 6.25 mg to 12.5 mg twice a day). Increase the dosage every two weeks, if well-tolerated. Diuretics: Patients with evidence of fluid retention should take a diuretic. The most commonly used diuretic is furosemide. Optimal use of diuretics is the cornerstone of any successful approach to the treatment of CHF. Spironolactone reduces mortality for patients with severe symptomatic CHF (class III or IV and ejection fraction < 35 %). Start spironolac- The Canadian Journal of CME / July

4 What happened with Mr. White? Mr. White has class IV (NYHA) heart failure. He has many precipitating factors: lack of compliance with medication, and liquid restrictions; uncontrolled hypertension; and possibility of myocardial ischemia and arrythmia. Investigation Chest X-ray: increase cardiothoracic ratio with pulmonary vascular congestion Electrocardiogram: sinus tachycardia with ESV beats and old anterior myocardial infarct Echocardiography: left ventricular ejection fraction: 26% with dilated left ventricle and slight aortic stenosis He improved with the following medications: furosemide, ACE inhibitor, lanoxin, and spironolactone. He is presently on fluid and salt restriction. tone if plasma creatinine is < 200 mg/l and potassium < 5 meq/l. The average daily dosage is 25 mg. Spiranolactone reduces mortality and hospitalizations. Digoxin: Digoxin reduces CHF hospitalizations but has no benefit on mortality. It is recommended to improve the symptoms and the clinical status of patients with CHF, in conjunction with ACE inhibitors, beta blockers, and diuretics. Take-home message Congestive heart failure is most commonly associated with systolic and/or diastolic left ventricular dysfunction. ACE inhibitors are first line treatment for patients with symptomatic CHF and asymptomatic left ventricular systolic dysfunction. ARBs are not superior to ACE inhibitors but are better tolerated. Renal function and serum potassium should be assessed one week after initiation of therapy. Nitrate: Nitrate can be used in combination with hydralazine only for patients who are intolerant or have contraindications to ACE inhibitors or ARBs. Nitrate is also used for cardiac ischemic disease. What are the new treatments? Vasopeptidase inhibitors Vasopeptidase inhibitors, such as omapatrilat, are part of a new class of treatment with benefits in the treatment of heart failure. Their actions are through the inhibition of ACE and neutral endopeptidase. 76 The Canadian Journal of CME / July 2003

5 Resynchronization therapy Ventricular conduction abnormality is frequent in heart failure leading to cardiac contractile dyssynchrony. To restore contractile synchrony one may install pacemaker leads in both ventricles. Patients with heart failure may still be severely symptomatic despite optimal medical therapy and correction of reversible causes, and have reasonable rehabilitation potential, a mean QRS duration above 130 ms and left ventricular ejection fraction < 35%. These patients may be considered for evaluation of resynchronization therapy for symptomatic improvement. This treatment is even better if a defibrillator is present. CME Web sites ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001 See page 22 for Frequently Asked Questions on severe heart failure. Suggested Readings 1. Johnstone DE, Abdulla A, Arnold JM, et al: Diagnosis and management of heart failure. Canadian Cardiovascular Society. Can J Cardiol 1994; 10: Liu P, Arnold M, Belenkie I, et al: Canadian Cardiovascular Society consensus guideline update for the management and prevention of heart failure. Can J Cardiol 2001; 17(Suppl E): 5E-25E. 3. Liu P, Arnold M, Belenkie I, et al: 2002/3 CCS guideline update for diagnosis and management of heart failure. Can J Cardiol 2003;19: Family Tree Anti-inflammatory analgesic agent. Product Monograph available on request. General warnings for NSAIDs should be borne in mind. CELEBREX is a registered trademark of G.D. Searle & Co., used under permission by Pharmacia Canada Inc.

6 FAQs Severe Heart Failure As presented at Université de Sherbrooke Presented at La Grande Maladie Ambulatoire, CME, October 2002 By Anne Fradet, MD, FRCPC, CSPQ 1. What is the first symptom? Exertional dyspnea is frequently the first complaint. This should be qualified to establish the functional class. 2. How should I investigate for CHF? The investigation should include: chest X-ray 12-lead electrocardiogram blood tests: complete blood count, serum electrolytes, blood lipids, renal and hepatic function, thyroid stimulating hormone urinalysis echocardiography *Trademark Call PHYSICIANS HOTLINE For Samples

7 3. Who should be prescribed ACEIs? 4. What are the functional classes? ACEIs are the first line treatment for patients with symptomatic CHF and asymptomatic left ventricular systolic dysfunction (ejection fraction < 40%) For an in-depth article on severe heart failure, please go to page 73. Class I: No limitation: ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation. Class II: Slight limitation of physical activity: such patients are comfortable at rest. Ordinary physical activity results in symptoms. Class III: Marked limitation of physical activity: although patients are comfortable at rest, less than ordinary activity will lead to symptoms. Class IV: Inability to carry on any physical activity without discomfort: symptoms of congestive failure are present even at rest. Children s MOTRIN * : On Duty For 8 Hours. ibuprofen Recommend the #1 selling pediatric ibuprofen. 1 Works fast and lasts longer than acetaminophen for fever relief 2,3 Safety profile demonstrated comparable to acetaminophen in a study of over 84,000 generally well children 4 - Excellent GI tolerability Incidence 3 to 9%: nausea, epigastric pain, heartburn - No link with Reye s Syndrome found Ibuprofen should not be administered to patients who are known to be hypersensitive to ASA or other NSAIDs, have systemic lupus erythematosus, acute peptic ulcer, gastrointestinal bleeding or are severely dehydrated. Please see prescribing information for warnings, precautions and contraindications. Suspension Drops Suspension Liquid Chewables Strong Relief That Lasts. From The Makers of Children stylenol * acetaminophen