CHF ICU to community. Disclosure slide CHF. Diagnosis. Diagnosis. Diagnostic modalties Therapeutic modalities. Talks. Advisory boards.
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1 CHF ICU to community CHF Diagnostic modalties Therapeutic modalities ICU Pacer/ ICD Medication CHF clinic ASV - Nejm. Sept. 17,2015. Advanced care directives Disclosure slide Talks most companies Advisory boards none recently (10 yrs) Stocks none CHF Research Trials VALIANT Clinical JVP Edema Crackles Diagnosis Radiology CXR Diagnosis 1
2 Diagnosis BNP Laboratory Sodium Worse prognosis with low sodium Creatinine Worse prognosis with poor renal funciton BNP Brain naturetic peptide Normal range varies with age Echocardiography EF Tracing Ejection fraction Normal 55-65% Use cylinders Can have CHF and normal EF Diastolic dysfunction. ~ 20% of CHF Volume overload CRF. / IV fluids Valve status Usually no CHF unless severe valvular lesions. MUGA EF assessment Nuclear Imaging MIBI Ischemia assessment Invasive studies Cardiac cath Hemodynamic LVEDP measure pressure LVEDP = LA Pressure in diastole LVESD > 20 mmhg wet lungs Right heart cath PCWP Coronary anatomy Valvular assessment AS / MR. 2
3 Swan Ganz catheter OPTIVOL CHF Dx. In pacer/icd pts. Medications Pacemakers Exercise CHF clinics CHF therapies CHF Admission Ask why?? Valvular LV dysfunction prior MI, Cardiomyopathy Ischemia Diastolic/ Hypertensive Congenital 3
4 CHF Admission Why Now?? Dietary indiscretion chinese food Non-compliance with meds. New AF New ischemia/ MI Alcohol Offending drugs NSAIDs (Naproxen) Oxygen BIPAP Acute Pulmonary Edema IV NTG IV morphine IV Diuretic Rx. IV Bbblocker Revascularization PCI CHF Rx. Behavioural & lifestyle modificatons are essential to success of CHF Rx. Salt restriction H20 restriction Bail out plan lasix, zaroxyln Medication compliance CHF - Diuresis Furosemide (Lasix) Metolazone (Zaroxylyn) Spironolactone (aldactone) CHF - Treatment CHF essential medical Rx. ACEI AND Beta-Blockers are cornerstones to CHF Rx. Reduce hospitalizations Reduce mortality Often require slow gradual uptitration Best done in CHF clinic Opposing forces 4
5 CHF Rx. ACEI / BB Reduced cardiac work Reduce HR/ BP Beta-blockers Metoprolol Carvedilol Bisoprolol Reduce perpheral resistance ACE Inhibitors Ramipril (Altace) Perindopril (Coversyl) Lisinopril ARB Angiotensin Receptor Blockers Similar effect to ACEI. ARB if ACEI intolerant (cough) Drugs Valsartan (Diovan) Telmisarten (Micardis) Candasarten (Atacand) Losarten (Cozaar/ Hyzaar) Inotropes Most oral inotropes for CHF associated with higher mortality exception digoxin Most beneficial Rx. Reduces BP and OK to have SBP < 80mmhg for many patients Evidence for utility of IV inotropes in cardiac patients is very limited. ICU Docs like inotropes more than cardiologists Dizzy or breathless - Heart function pills not BP pills CHF clinic 5
6 CHF & Exercise CHF & Exercise Do not restrict exercise in patient with CHF HF-ACTION Trial Safe Improves well being Trend to mortality reduction Improved exercise tolerance BC CHF - Patient resource Device Rx. bcheartfailure.ca Patients and families E-learning module Living well with heart failure Excellent on line tool. ICD Rx. CHF / LBBB Who?? Risk of SCD > risk of non sudden death Implantable AED Cardiac conditions with low EF EF < 35% - despite good CHF Rx. Device life 5-7 yrs Need reasonable life expectancy. 6
7 CRT / BIV pacing Pacemakers to Rx. CHF??? Consider CRT / Biventricular pacing in patients with: CHF with any Sx. (class 2-4) LBBB with QRS > 130ms. EF < 30% On optimal medical Rx. **** Esp. younger, normal renal function and reasonable non-cardiac mortality/morbidity. Rx. - LVAD LVAD Left Ventricular Assist Device Portable adjunct to C.O. Continous flow Patient has no pulse can t do usual BP. Risks Infection Thrombosis CVA Bleeding - anticoagulants Bridge therapy Bridge to transplant Bridge to recovery LVAD Destination Rx. Final Rx. no transplant 7
8 IABP IABP Intra-aortic balloon pump Helium filled balloon / Femoral Access Often post MI/ PCI for support Gated (timed) to patients rhythm/ ECG Systole (balloon down) Reduces afterload Diastole (balloon up) Improves coronary perfusion Impella Catheter Percutenous Ventricular Assist Device (VAD) Worlds smallest heart pump augments C.O. Use During high risk PCI provide support For transient cardiogenic shock Provides additional cardiac output. 2 sizes 2.5 & 5 l/min. flow Catheter (femoral access) remains in LV cavity Usually 1-3 days. Risk Bleed, thrombosis, infection, groin Rx. - Impella Rx. - ECMO 8
9 ECMO Extra-Corporeal Membrane Oxygenation Provides both cardiac & respiratory support Blood taken from veins usually femoral access Returned to artery VA-ECMO Returned to vein VV-ECMO no cardiac support ECMO Who Failure to wean post OHS Refractory shock Bridge to VAD/transplant Complications Bleeding CVA HIT Heparin Induced low platelets. Vascular Pressure support? CHF & Sleep Disordered breathing Cheyne stokes in 25-40% Independent risk factor for poor prognosis and death. CANPAP CPAP vs. no CPAP Negative trial ASV Inspiratory pressure support Expitatory positve airway pressure. ASV SERVE-HF Trial CHF with central sleep apnea EF < 45%, class 2 4. AHI > 15/hr. > 50% central events 1325 pts. Randomized. ASV vs. placebo (medical Rx.) Endpoints death, CHF hospitalization, ICD shock, 9
10 Cumulative Incidence Curves for the Primary End Point, Death from Any Cause, and Cardiovascular Death. SERVE-HF - Results No impact on QOL 6 min. Walk CHF Sx. Composite endpoint (death, ICD shock, CHF hospitalization) Cowie MR et al. N Engl J Med 2015;373: CAST Trial CAST Trial VPB s Common in sick hearts Marker for worse prognosis Can suppress PVC s with drugs Lets get rid of PVC s Result Advanced Care Directives Symptom related Rx. d/c statin etc. Narcotics Deactivate ICD Plans for deterioration BIPAP, ER, home care mgmt., directives for EMS. Code Status Advance Care Planning: Living For Today Planning For Tomorrow 10
11 CHF RT extra roles Patient education Medication compliance CHF clinic Dietary restriction Water Salt Exercise Assessment & Rx. Of OSA 11
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