Management of Congestive Heart Failure Rocky Mountain Hospital Medicine Symposium October 4, 2010 Larry Allen, MD, MHS Advanced Heart Failure and Transplantation CASE Case Mr JC 44M no PMH Presented to PCP with 2 weeks of progressive SOB, unresponsive to Z-pak A week later presents to your ED with worsening SOB, dry cough, edema, and RUQ pain
Question #1 Which of the following should you be MOST concerned about? 1. Silent myocardial infarction 2. Pericardial effusion with early tamponade 3. Idiopathic dilated cardiomyopathy 4. Previously undiagnosed hypertensive heart disease with HFpEF 5. Asthma Case Mr JC In ER: HR 105 ST; BP 95/70 Sat 86% on RA 134 36 3.9 1.6 38 12.8 2.0 1080 1260 BNP 2450 CXR cardiomegaly and pulmonary edema Question #2 What is LEAST appropriate initial therapy? 1. Furosemide 40 mg IV x1 2. Metoprolol 5 mg IV, repeat in 5 minutes 3. CPAP 8 mmhg with oxygen 4. Nitroprusside infusion start 0.1 mcg/kg/ min, to MAP 60 mmhg 5. Dobutamine 2.5 mcg/kg/min
Case Mr JC Symptoms improve with diuresis Cr + LFTs normalized Echo done, LVEF 25%, nl valves After 6 days he is on: lisinopril 5 daily carvedilol 3.125 bid spironolactone 25 daily furosemide 40 PO bid BP 88/50, HR 90, tele NSR throughout Question #3 As you prepare his discharge instructions, which is MOST appropriate? 1. Double the carvedilol dose 2. Start warfarin to INR 2-3 3. Start digoxin 250 mcg daily 4. Delay discharge so EP can consider ICD implantation 5. Schedule f/u with cardiology next week Outline Review of HF Pathophysiology ADHF Diagnosis and Precipitants Treatment Transitions of Care / Readmission
The Basics HF is big and bad Common 500,000 American develop HF annually (incidence) 5 million Americans have HF (prevalence) Costly 1.2 million hospitalizations in the US annually 20% of hospitalizations in those > 65 years old #1 billing to Medicare 12 million clinic visits Deadly HF kills ~250,000 / yr in the US Outcomes in Patients Hospitalized with HF 100 Hospital Readmissions 100 Mortality 75 50 25 20% 50% 75 50 25 12% 33% 50% 0 30 Days 6 Months 0 30 Days 12 Months 5 Years Mean Length of Stay: 6.5 days Fonarow, GC. Rev Cardiovasc Med. 2002;3(suppl 4):S3 Jong P et al. Arch Intern Med. 2002;162:1689
HF is Largely a Disease of the Aged Population (%) 10 8 6 4 2 Males Females Median age HF = 75 years 0 20 24 25 34 35 44 45 54 55 64 65 74 75+ Age (yr) US, 1988 1994 AHA. Heart Disease and Stroke Statistics 2004 Update What is Heart Failure? Heart failure is the inability of the heart to pump blood forward at a sufficient rate to meet the metabolic demands of the body, or the ability to do so only if the cardiac filling pressures are abnormally high. A Picture is Worth 1000 Words NORMAL Stroke Volume HEART FAILURE Ventricular End-Diastolic Pressure STROKE VOLUME PRESERVED BY INCREASED END-DIASTOLIC FILLING / PRESSURE
Therapeutic Targets This is what you can change X Function Determines Dysfunction 2x pumps (left and right) in series Share a common septal wall Left, right, or both can fail These are displacement pumps Squeeze (contract) Fill (relax) Failure of either function causes HF Coordinated by an electrical system Both R and L heart beat together Too slow, too fast, asynchronous all efficiency Major Divisions of HF Systolic HF Diastolic HF Left-sided Right-sided Jessup. NEJM 2003;348:2007-18.
Main Causes of Systolic HF Direct destruction of heart muscle cells Myocardial infarction (#1) Idiopathic dilated cardiomyopathy (#2) Myocarditis (viral, lymphocytic, giant cell) Toxin (Alcohol) Overstressed heart muscle Tachycardia-mediated HF Methamphetamine abuse Stress-provoked (tako-tsubo cardiomyopathy) Volume overloaded heart muscle Mitral regurgitation High cardiac output (shunt, wet beriberi) Main Causes of Diastolic HF High afterload / pressure overload Hypertension (long-standing) Aortic stenosis Dialysis (inadequate volume removal) Myocardial thickening / fibrosis Hypertrophic cardiomyopathy Primary restrictive cardiomopathy External compression Pericardial fibrosis / constrictive pericarditis Pericardial effusion The truth is rarely pure and never simple Oscar Wilde Systolic dysfunction is typically accompanied by diastolic dysfunction and vice versa Myocardial Contractile Inefficiency and Dyssynchrony in With Preserved Ejection Fraction and Narrow QRS Complex Thanh et al. JASE 2010;23:201. Terms HFpEF and HFrEF are preferred
Classification by Severity ACC/AHA HF Stage 1 NYHA Functional Class 2 A At high risk for heart failure but without structural heart disease or symptoms of heart failure (eg, patients with hypertension or coronary artery disease) None B Structural heart disease but without symptoms of heart failure I Asymptomatic C Structural heart disease with prior or current symptoms of heart failure II Symptomatic with moderate exertion III Symptomatic with minimal exertion D Refractory heart failure requiring specialized interventions IV Symptomatic at rest Carvedilol is indicated for use in patients with mild to severe chronic HF and in patients with HTN. 1 Hunt SA et al. J Am Coll Cardiol. 2001;38:2101 2113. 2 New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890 897. Worsening HF Clinical Course is Non-Linear
Precipitants of ADHF (1) Increased circulating volume (preload) Sodium load in diet Dietary nonadherence Renal failure Increased pressure (afterload) Uncontrolled hypertension (LV) Worsening aortic stenosis (LV) Pulmonary embolism (RV) Worsened contractility (inotropy) Myocardial ischemia Initiation of negative inotrope (BB, nondhp-ccb) Precipitants of ADHF (2) Arrhythmia (heart rate) Bradycardia Atrial fibrillation Increased metabolic demands Fever, infection Anemia Hyperthyroidism Pregnancy Non-adherence with HF medications Rule out secondary causes and/or precipitants Vitals/EKG (HTN, HoTN, tachyarrhythmia, AFib, PVCs) Routine Labs BMP / CBC / LFTs (ARF, anemia, infxn) CXR (PNA, CM, pulmonary edema, effusions, PM leads) BNP (diagnosis, prognosis, response to therapy) Echo / CMR / CT (LVEF, diastology, morphology, valves) Thyroid function tests Iron studies (iron deficiency, hemochromatosis) Toxicology (stimulants, alcohol) OTHER: Stress, coronary angio, RHC, HIV, Chagas, Lyme, ANA, thiamine, selenium, phosphate, calcium, urine cortisol, metanephrines, sleep study, and more
Natriuretic Peptides Two assays: 1. BNP Normal? (<100) Half life ~20 minutes 2. NT-proBNP N-terminus breakdown product of BNP Half life ~120 minutes ~6 times the BNP Both increase with age, renal dysfunction; decrease with obesity Use of BNP BNP = rule out symptomatic HF The negative predictive value of BNP is most useful (a low BNP makes ADHF unlikely as the cause of symptoms) In patients with chronic HF, BNP trends can provide some insight into clinical stability BNP = risk stratification High BNP = high risk Failure to BNP during admission = high risk Check at admission and once prior to discharge Echocardiography Provides LVEF (systolic function) determines Rx decisions Chamber size (dilation) LV wall thickness (hypertrophy) Measures of relaxation (diastology) Valvular anatomy and function Estimated filling pressures (LA, CVP) Estimated pulmonary pressures Advantages Real time Non-invasive No radiation Relatively inexpensive
Hemodynamic Data CVP / IVC compressibility (if JVP unclear) Swan-Ganz / RHC Pressures (filling: RA, LA) Flows Resistance (SVR, PVR) Consider if you are in trouble Shock End-organ dysfunction (cardiorenal, increasing LFTs) Failure to respond to therapy (ESCAPE argues not useful for routine tailoring of Rx) Management Specific HF Goals of Rx Correction of the underlying cause of HF e.g. revascularization for ischemia not possible for many causes Elimination of precipitating factors e.g. infection, anemia, nonadherence Reduction of congestion Improve blood flow Modulate neurohormal activation Devices / transplantation
Rx depends on the HF Chronic (Stable) Acute (Unstable) HFrEF (LVEF 40%) BB ACEI/ARB Aldosterone antagonist Hydralazine / ISDN ICD/CRT??? IV diuresis Nitrates (if BP allows) CPAP/BiPAP (if SOB) Pressors (if low CO) HFpEF (LVEF > 40%)??? Control risk factors DM, HTN, obesity Control volume status??? IV diuresis Nitrates (if BP allows) CPAP/BiPAP Rx of ADHF?? Goals in ADHF (for HFrEF) Dry PCWP <18 JVP down Wet PCWP >18 JVP up Warm CI > 2.2 UOP good Warm ext Happiness Diurese +/- Vasodilate Cold CI < 2.2 Oliguria Cool ext Fluids? Consider advanced Rx? Warm up then dry out (Consider inotrope)
Diuretics The most common HF therapy 90% of HF hospitalizations, 70% only Rx Δ Which one? Loop diuretics preferred Questionable data on one versus another Augment with thiazide prn (after max loop?) Metolazone PO, Diuril IV No survival data doses signify worse disease DOSE Study Design Acute Heart Failure (1 symptom AND 1 sign) <24 hours after admission 2x2 factorial randomization Low Dose (1 x oral) Q12 IV bolus Low Dose (1 x oral) Continuous infusion High Dose (2.5 x oral) Q12 IV bolus High Dose (2.5 x oral) Continuous infusion 48 hours 1) Change to oral diuretics 2) continue current strategy 3) 50% increase in dose 72 hours Co-primary endpoints 60 days Clinical endpoints Pt Global Assessment by VAS Dosing IV furosemide: Q12 vs. Continuous Q12 Q12 VAS AUC, mean (SD) = 4236 (1440) Continuous VAS AUC, mean (SD) = 4373 (1404) P = 0.47 Continuous Hours
Dosing IV furosemide : Low vs. High Intensification Pt Global Assessment by VAS Low High Low VAS AUC, mean (SD) = 4171 (1436) High VAS AUC, mean (SD) = 4430 (1401) P = 0.06 Hours Change in Creatinine at 72 hours Change in Creatinine (mg/dl) 0.15 0.1 0.05 0 p = 0.45 p = 0.21 0.08 0.07 0.05 0.04 Q12 Continuous Low High Death, Rehospitalization, or ED Visit Proportion with Death, Rehosp, or ED Visit 0.6 0.5 0.4 0.3 0.2 0.1 HR for Continuous vs. Q12 = 1.19 95% CI 0.86, 1.66, p = 0.30 Continuous Q12 Proportion with Death, Rehosp, or ED visit 0.6 0.5 0.4 0.3 0.2 0.1 HR for High vs. Low = 0.83 95% CI 0.60, 1.16, p = 0.28 High Low 0 0 10 20 30 40 50 60 Days 0 0 10 20 30 40 50 60 Days
Diuretic Dosing Vasodilators for HF Arterial vasodilation (ACEI, ARB, hydralazine) in LV afterload / cardiac work Less mitral regurgitation Goal MAPs in HFrEF low (60-70 mmhg?) Venous vasodilation (nitrates) in preload Pulmonary arterial vasodilation (PDEi) in RV afterload Aldosterone Antagonists Spironolactone and eplerenone Effect: Additional sodium loss Antifibrotic (? Benefit in HFpEF) Avoidance of hypokalemia (K drop on Lasix) Side effects Hyperkalemia (requires close monitoring) Guidelines say within 3 days of starting Reasonable to start in hospital
Beta-Blockers Antagonize effect of sympathetic system β1: Positive remodeling Rate control for tachyarrhtymias Side effects: Negative inotrope and chronotrope Short-term loss for long-term gain Cautious use in ADHF: Continue home dose if stable Consider reduced dose if concern Stop for shock or use of IV inotrope (dobutamine) Typically do not increase during active diuresis Data suggest start/restart prior to discharge in most pts Increase dose by no more than 50% at 2 week intervals IV Inotropic Agents Types: Dobutamine (IV) β agonist (opposite of BB) Milrinone (IV) PDEi Clinical Use IV agents used short term to reverse shock Long-term they worsen remodeling If you go to IV inotrope, discontinue BB Avoid milrinone in renal failure Options for End-Stage HF Requires assumption of significant risk (and cost) Requires paradigm shift to shorter life for improved quality
Discharge / Transitions of Care Performance Measures HF-1: Discharge Instructions Activity Diet Follow-up Medications Worsening Symptoms Weight Performance Measures HF-2: Evaluation of LVSF HF-3: ACEI or ARB for LVSD LVEF <40% HF-4: Smoking cessation advice
Performance Measures GWTG additional measures Influenza vaccination Pneumococcal vaccination Anticoagulation for AF DVT prophylaxis (Beta-blocker for LVSD) (Aldosterone antagonist for LVSD) (ICD for LVSD) (ASA, statin for CAD) Outcomes Reporting 30-day Risk Standardized Rates Readmission Mortality Measure what you want Performance measure documentation rarely correlates with outcomes e.g. pulling nurses to check measures Controversial Case mix adjustment adequate? (e.g. SES) Mortality and readmission are not correlated Clearinghouse for ideas Three main goals Education Medication reconciliation Early follow up (within 7 days)
ADHF Summary Key Concepts Approach should be rooted in physiology Systole / diastole Left / right Filling / flow / resistance Think broadly about possible precipitants Tailor therapy to the patient and situation HFrEF v. HFpEF Acute v. chronic Finish strong with good transitions of care CASE Case Mr JC 44M no PMH Presented to PCP with 2 weeks of progressive SOB, unresponsive to Z-pak A week later presents to your ED with worsening SOB, dry cough, edema, and RUQ pain
larry.allen@ucdenver.edu