Heart Failure: Management of a Chronic Disease Jenny Bauerly RN, CHFN, APRN-BC Heart Failure (HF) Definition A complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. American College of Cardiology Foundation 2013 Objectives: Upon completing the session, the participant will have improved standardization and knowledge of: Systolic and Diastolic Heart Failure (HFrEF and HFpEF) Etiology of HF Common HF medications Common HF therapies Current HF outpatient monitoring tools Heart Failure Incidence and Prevalence Only form of heart disease increasing in prevalence Estimated 5.7 million Americans with HF Projections show that the prevalence of HF will increase 46% from 2012 to 2030, resulting in >8 million people 18 years of age with HF 915, 000 new HF cases annually, HF incidence approaches 10 per 1000 after age 65 At age 40, 1 in 5 lifetime risk of developing HF for both men and women One in 9 deaths has HF mentioned on the death certificate, more costly than all forms of cancer combined Heart Disease and Stroke Statistics 2016 Update A Report From the AHA
HFrEF EF <40% The loss of a critical quantity of functioning myocardial cells after injury to the heart due to: Ischemic Heart Disease Hypertension Idiopathic Cardiomyopathy Infections (e.g., viral or bacterial myocarditis, pericarditis, sepsis) Toxins (e.g., alcohol, illicit drugs or cytotoxic drugs) Valvular Disease Prolonged Arrhythmias Pregnancy Heart Failure Physical Signs Peripheral Edema Jugular Venous Distention Hepatojugular Reflux Hepatomegaly Ascites Basilar Rales/Crackles S3 Gallop Cheyne-Stokes Respiration RAAS Angiotensin II Sympathetic Nervous System Norepinephrine ACE-I ARB Aldosterone Antagonists Beta-block ers Hypertrophy, apoptosis, ischemia, arrhythmias, remodeling, fibrosis Morbidity and Mortality Optimal medical management of HFrEF EF <40% Beta Blockers: block sympathetic nervous system Reduce myocardial oxygen demand Side effects: bradycardia, hypotension, heart block, fatigue Only 3 approved medications/ Referred to as Evidence Based Beta-Blockers: Carvedilol, Bisoprolol, and Metoprolol succinate ACE-I/ARB: Block renin-angiotensin-aldosterone system Reduces afterload by preventing vasoconstriction Relieves symptoms and improves exercise tolerance Side effects: hyperkalemia, elevated creatinine, hypotension Examples: lisinopril, enalapril, losartan, valsartan
Optimal medical management of HFrEF EF < 40% Aldosterone Antagonists: Block aldosterone reduces sodium retention Side effects: hyperkalemia, worsening renal failure Examples: spironolactone (also has anti-androgen effects, so may cause gynecomastia), eplerenone Hydralazine and nitrates Used in combination to replace ACE/ARB in patients with severe renal disease Afterload reduction by vasodilation Added to usual medications for African-American patients Optimal Medical Management of HFpEF NO GUIDELINE-DIRECTED TREATMENT Focus on treating underlying mechanisms Hypertension Atrial fibrillation control heart rates anticoagulation Exercise program Research demonstrates aldosterone antagonists reduce HF hospitalizations TOPCAT study Diuretics for symptom management Optimal medical management of HFrEF Entresto (sacubitril/valsartan) Replaces ACE/ARB in patients with NYHA class II-IV Blocks angiotensin Promotes natriuetic peptides Diuretics Used to relieve fluid retention Improve exercise tolerance Electrolyte depletion a frequent complication Higher doses of diuretics are associated with increased mortality Thiazides Cortex Medulla Inhibit active exchange of Cl-Na in the cortical diluting segment of the K-sparing ascending loop of Henle (Metolazone) Inhibit reabsorption of Na in the distal convoluted and collecting tubule Loop of Henle Collecting tubule (spironolactone, amiliride, trimateren) Loop diuretics Inhibit exchange of Cl-Na-K in the thick segment of the ascending loop of Henle (Lasix, Bumex, Demadex)
Disease Course Symptom Management Daily Weights Consistent, accurate weights is key! Same scale, same time of day, similar clothing Dietary restrictions Sodium intake less than 2000 mg daily Fluid intake goal of 64 ounces Medication adherence Symptom management Symptom Management Recognize decompensation early Daily Weights Weight gain of 2 lbs overnight or 5 lbs in a week is concerning Daily assessment of symptoms Dyspnea Orthopnea Dry cough Abdominal bloating or nausea Edema Take action Notify provider of weight gain or symptoms Medication changes to treat underlying cause of decompensation Increase in diuretics Assure adherence to dietary restrictions Patient/family education Evaluate Response Weight back to baseline? Symptoms improved?
Common Complications Hypotension Do not hold beta-blocker or RAAS inhibiting medications if patient is asymptomatic Heart failure patients have a reduced cardiac output, therefore blood pressure is usually low Notify provider if BP is less than 90/50 mmhg or patient is symptomatic Hypotension & fluid retention --- reduce HF meds Hypotension & dehydrated --- reduce/hold diuretics Viral illness resulting in vomiting/diarrhea Hold diuretic to avoid dehydration 30-day Readmission Rates 30 day readmission rate--25% nationally Common Complications Illness resulting in worsening atrial fibrillation Need to control heart rates Change in patient's food intake Reduced appetite should result in weight loss Need to adjust goal dry weight parameters Important to assess for symptoms, not just monitor weight Treatment with steroids COPD flare, joint injections Frequently leads to fluid retention Follow Up Appointment within 7 calendar days of discharge HF clinic enrollment Aquaphoresis CardioMEM s OnTrack ipad monitoring Telemonitoring scales Devices (Latitude, Carelinks) Support Group Advanced HF consults
Advanced HF Consult Team approach lead by HF board certified Dr. Jamie Pelzel Discuss nature of illness Discuss prognosis At Stage D, determine appropriate pathway -Transplantation -LVAD -Palliative Care consult QUESTIONS??? HF Clinic: Heart and Vascular Clinic Open Monday through Friday- can accommodate same day appointments if needed Advanced practice providers working under the direction of Cardiology focused on HF specific Can assist with difficult to control CHF symptoms Can administer IV medications if needed No referral needed Please send weights, vital signs, and medication administration record to all appointments