Susan P. D Anna MSN, APRN BC February 14, 2019

Transcription

1 Is there Equal Opportunity in Heart Failure?? Susan P. D Anna MSN, APRN BC February 14, 2019 Disclosures: I have no financial disclosures. I am not an expert on this topic, but see a lot of women with heart failure (multiple etiologies) in my daily practice. I am a woman who struggles daily to maintain a healthy lifestyle. I may express a few opinions.

2 Objectives Lightning overview of HF definitions, epidemiology Discuss issues unique to women that increase risk of cardiomyopathy and heart failure specifically HFpEF, breast cancer and pregnancy... Plus a lot more! Heart disease is for men Cancer is the real threat for women. Fear

3 CVD is the leading cause of death in women More women are dying of CVD than Men Source: American Heart Association

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5 Only 45% of women perceive heart disease to be a leading cause of death Less than ½ of PCPs consider CV disease to be a top concern after breast health and weight AHA/ACOG partnership to promote early RF identification, modification, and intervention

6 Definitions Cardiomyopathy (CM) is a disease of the myocardium in which the heart s pumping ability is affected. Heart Failure (HF) is clinical syndrome or constellation of symptoms resulting from cardiac disease that impairs ventricular systolic or diastolic function, or both. Heart Failure is the inability of the heart muscle to keep up with the body s metabolic demands. Etiology Ischemia / CAD Hypertension Valvular (severe aortic regurgitation, aortic stenosis, mitral regurgitation) Rheumatic heart disease Congenital Heart disease Everything else (long list, often classified by phenotype) Non ischemic dilated cardiomyopathy y Hypertrophic cardiomyopathy Restrictive cardiomyopathy Left ventricle Non compaction Images from Cleveland Clinic Website. Congenital Heart Disease in the Adult. Richard Krasuski. Published August Image from Medtronic Corevalve Website

7 What is Heart Failure? This clinical syndrome can result from heart muscle problems: Pericardial disorders Myocardial disorder (abnormal pump function or abnormal relaxation) Endocardium disorder Severe heart valve disease Metabolic abnormalities Systolic Heart Failure HFrEF Diastolic Heart Failure HFpEF

8 Symptoms of Heart Failure: Edema Ascites Dyspnea and dyspnea on exertion Orthopnea Paroxysmal nocturnal dyspnea Fatigue and exercise intolerance

9 Epidemiology

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11 Who Gets Heart Failure Men with HF more often have a history of MI and ischemic cardiomyopathy Men with HF more often HFrEF (systolic (y dysfunction) Who Gets Heart Failure Women with HF tend to be older than men with HF Women with HF more often have a history of HTN and AF Women with HF tend to have HFpEF (diastolic dysfunction)

12 Diastolic Heart Failure (Restrictive i cardiomyopathy) HFpEF now recognized as ~50% of all hospital admits for HF. EF is NORMAL; muscle fails to relax during diastole, reducing cardiac output. Who is at risk???

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14 Yancy et al 2013 ACCF/AHA Heart Failure Guideline Yancy et al 2013 ACCF/AHA Heart Failure Guideline

15 Echocardiogram Initial Presentation After therapy

16 Best Treatment of HFpEF Control HTN If Afib, control ventricular rate Reduce sodium intake very salt sensitive! Evaluate for and treat ischemia There are no clear guidelines on drug therapy to treat this group of patients

17 So what can we do???

18 Risk factors specific to women Breast Cancer Female predominant Cancer therapies can cause multiple cardiotoxicities including cardiomyopathy and HF (focus today is HF) Goal is to adequately treat the cancer while protecting the heart

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21 Cardiotoxicities with AC can occur anytime Acute during initial treatment < 1% and usually reversible Early within first year of treatment Late median 7 yrs post treatment as high as 10% in women > 65 yrs in one study

22 Trastuzumab (Herceptin) LV monitoring at baseline and then every 3 months for duration of therapy unless metastatic disease If the LVEF declines 16 or more percentage points from baseline or 10 to 15 percentage points from baseline to below the lower limit of normal, trastuzumab is withheld for four weeks, at which time the LVEF is reassessed. If the LVEF remains below these levels, trastuzumab should be discontinued. If the patient has symptomatic heart failure while receiving trastuzumab, trastuzumab should be discontinued. A word about radiation therapy Can cause both systolic and diastolic dysfunction Can cause VHD leading to HF Can be subclinical No completely safe dose Risk factors: Higher total dose >35Gy Use of adjuvant cardiotoxic chemotherapy Existing CAD Fadol AP Ed Cardiac complications of cancer therapy.

23 HF in Pregnancy Outcomes depend on underlying CV disease Pregnancy is poorly tolerated in in the presence of preexisting CM Appropriate prepregnancy counseling should occur in the presence of existing CM Joint multidisciplinary care (Cardiology, high risk OB) is recommended High risk for irreversible deterioration in LV function, maternal mortality, fetal loss Pregnancy often unmasks previously undetected HF

24 Case review 34 yo female G1P0 14w 4d Presents to OSH with: frontal HA progressive SOB scheduled to see pulmonary abd discomfort bilateral LE edema orthopnea BP 134/81 HR 110s PMHx: Type 1 DM, tachycardia, hypothyroid, migraines

25 Evaluation at OSH then Transfer to DHMC CXR with Bilat pleural effusions Ascites on CT scan and PE TTE showing LVEF 35% with moderate MR LHC excluded CAD Echo confirmed LVEF 35% severely dilated probnp 1900 HR 105

26 European HeartJournal (2018) 39, ESC GUIDELINES doi: /eurheartj/ehy340 Co management with High Risk OB Initiated GDMT (BB, no ACE, hydralazine/isdn, torsemide, spironolactone relatively contraindicated) At 20 weeks: Requiring increased doses of torsemide +S3 Echo unchanged

27 European HeartJournal (2018) 39, ESC GUIDELINE doi: /eurheartj/ehy340 European Heart Journal (2018) 39, ESC GUIDELINES doi: /eurheartj/ehy340

28 Concerns Peripartum cardiomyopathy (PPCM) Development of heart failure (HF) toward the end of pregnancy or within five months following delivery. Absence of another identifiable cause for the HF. Left ventricular (LV) systolic dysfunction with an LV ejection fraction (LVEF) of less than 45 percent. The LV may or may not be dilated.

29 Circulation. 2016;133: Who is at risk? Age greater than 30 years African descent Pregnancy with multiple fetuses A history of preeclampsia, eclampsia, or postpartum hypertension Maternal cocaine abuse Long term (>4 weeks) oral tocolytic therapy with beta adrenergic agonists such as terbutaline

30 Treatment and Recovery Standard HF medical therapies Stop lactation Bromocriptine controversial, but blocks prolactin 20 60% of patients recover within 6 12 months but reports vary

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32 So what can we do???

33 Summary Gender matters Many women still perceive other comorbidities (not CV disease) as the leading cause for death There are RF unique to women that increase risk of CV disease specifically HF