HEART FAILURE Martina Frost, PA-C Desert Cardiology of Tucson Northwest Medical Center Heart Failure in the US Prevalence - ~5 million 650,000 new cases annually 300,000 deaths annually Leading DRG among hospitalized pts above age 65 (nearly 2% of all admissions) Average stay 6 days w/ high readmission rate Total cost in the US >$30 billion/year Over 1million hospitalizations > half of cost Number of deaths with any mention of HF as high in 2006 as in 1995 Heart Failure (HF) A complex clinical syndrome in which the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return abnormality of ejection and/or ventricular filling Associated with episodes of decompensation interspersed with periods of relative stability Associated with significant reduction of quality of life 1
Mortality and HF NYHA Class IV 75% mortality at 2yrs Determinants of Cardiac Output Preload Contractility Afterload Stroke Volume Heart Rate Cardiac Output Pathophysiology of HF 2
Pathophysiology of HF Prevalence of HF by Gender and Age Types of HF Left sided HF Systolic > HF with reduced EF (HFrEF) Diastolic > HF with preserved EF (HFpEF) Acute Chronic Acute on Chronic Right Heart Failure 3
Types of Cardiomyopathy Dilated most common Left Ventricular dilatation Multiple causes Hypertrophic Ventricular muscle mass enlargement can obstruct blood flow if septal hypertrophy Restrictive least common myocardium becomes "rigid (e.g. amyloidosis) Etiology (List not inclusive) Ischemic - CAD Non-ischemic Hypertension Arrhythmia (tachyarrhythmia) Valvular disease Drugs (ETOH, cocaine, meth, cardiotoxic meds) Infection/inflammation (myocarditis, viruses, Lupus/RA) Others peripartum, Chagas disease, OSA, idopathic RHF LV HF Pulmonary pathology (PAH, PE, COPD) > 75% due to CAD and HTN Normal or Reduced Ejection Fraction (EF) Reduced EF Preserved EF Preserved EF (HFrEF) EF < 40% HFpEF EF > 50% (borderline) EF 41 49% 4
NYHA Functional Classification focus on exercise capacity and symptomatic status of disease ACC/AHA Stages of HF emphasize on development and progression of disease Stage A: At high risk for HF in the future but no functional or structural heart disorder Stage B: Structural heart disorder but no symptoms at any stage Stage C: Previous or current symptoms of HF in the context of an underlying structural heart problem, but managed with medical treatment Stage D: Advanced disease requiring hospital-based support, a heart transplant or palliative care refractory HF The Heart: 2 Halves with Lungs In Between Right Heart Lungs Left heart Rest of the Body 5
Symptoms Left Ventricular Failure Exertional dyspnea Orthopnea Paroxysmal Nocturnal Dyspnea (PND) Cough Swelling Fatigue Exercise intolerance Physical Signs Basilar rales/crackles Jugular Venous Distension (JVD) Edema S3 Gallop Tachycardia Cheyne-Stokes Respiration Jugular Venous Distention Pulmonary Edema/Effusions 6
Right Ventricular Failure Symptoms Swelling Abdominal Pain Anorexia Nausea Bloating Physical Signs Peripheral Edema Jugular Venous Distention Abdominal-Jugular Reflux Hepatomegaly B-type Natriuretic Peptide (BNP) Released by ventricles in response to ventricular volume and pressure overload Many factors increase BNP CKD, HTN, pulmonary disease, age, sepsis/critical illness, cirrhosis, hyperthyroidism, female sex Use to guide clinical decision, developing prognosis Treat the patient, not the number Echo ALL HF patients General Workup Establishes EF and ventricular morphology Labs CBC, electrolytes, renal functions, LFTs, thyroid, glucose, lipids, BNP or NT-proBNP, UA Coronary angiogram Stress testing, cardiac CTA, cardiac MRI 7
The Vicious Cycle of Heart Failure Management Chronic HF Diurese & Home SOB Weight Hospitalization IV Lasix or Admit Emergency Room PO Lasix MD s Office Management of HF Pharmacology Rx mainstay Start low, Go slow Goals of pharmacologic Rx Symptomatic Relief Reduce Preload Reduce systemic vascular resistance (afterload reduction) Improve morbidity and mortality Inhibition of RAAS and vasoconstrictor neurohormonal factors produced by SNS Device Therapy Biventricular Pacing/ ICDs General Measures Daily weights Fluid and sodium restriction 2 and 2 (2l fluid, 2 g sodium) Weight reduction Smoking Cessation Avoid alcohol and other cardiotoxic substances Exercise 8
Medical Considerations Treat HTN, hyperlipidemia, diabetes, anemia, arrhythmias, sleep apnea Coronary revascularization Anticoagulation Immunization Close outpatient monitoring HF Clinic Early Follow-Up Diuretics For relief of congestive symptoms (pulmonary and peripheral edema) no mortality benefit, symptom relief only never use as only drug for HF First choice: Loop diuretics Furosemide, bumetanide, torsemide Thiazide diuretics Chlorthalidone, metolazone Typically used in severe HF in combination with loop diuretics for synergistic effect Potassium-sparing - spironolactone Monitor: renal functions and electrolytes, esp K+ Beta Blockers Reduce mortality and symptomatic HF For all patients with reduced EF with or without history of MI or ACS (recent or remote) Stages B to D and all functional classes Only three BB have shown to be effective in reducing risk of death in HF Sustained-release metoprolol ( succinate ), bisoprolol, carvedilol Blockade of excessive SNS stimulation Monitor: HR and BP SE: bradycardia, hypotension 9
Ace Inhibitors For all patients with reduced EF with or without history of MI or ACS (recent or remote) Stages B to D and all functional classes Reduce mortality and disease progression Reduce hospitalizations RAAS blockade Lisinopril, Ramipril, Captopril, Enalapril Monitor: K+, BP SE: hyperkalemia, hypotension, cough, angioedema Angiotensin Receptor Blockers RAAS blockade No benefit in combination of ACEI and ARB (potentially harmful) Alternative for patients intolerant of ACEI due to cough or angioedema Candesartan and valsartan only ARBs recommended for ACEI substitution SE: same as ACEI except cough Valsartan/Sacubitril Approved in 2015 for HFrEF 2016 guideline update gives it Class I recommendation as alternative to ACEI/ARB Requires 36 hr washout period when switching from ACEI/ARB Decreases HF hospitalizations and death Sacubitril inhibits neprilysin improves renal blood flow and improves diuresis SE: hypotension, kyperkalemia 10
Aldosterone Antagonists Shown to reduce heart failure-related morbidity and mortality Improves survival among patients with moderate to severe or chronic HF (NYHA class III IV) and HF after myocardial infarction Spironolactone, Eplerenone Monitor: K+, BP Potassium and creatinine levels should be closely monitored in particular if used with ACEI SE: hyperkalemia, gynecomastia Hydralazine and Nitrates Hydralazine Direct vasodilator that decreases afterload Isosorbide Mononitrate Long-acting nitrate that decreases preload Combination has similar effects to ACEI/ARB but without RAAS blockade Alternative when ACEI/ARB contraindicated Digoxin No longer first choice drug for HF (Class II recommendation) May be considered to reduce risk of hospitalization in patients with persistent symptoms despite maximum treatment No mortality benefit 11
HFpEF (aka Diastolic Dysfunction) No convincing evidence that medical Rx reduces mortality Supportive Rx Diuretics, sodium restriction Treat HTN, CAD Ok to use calcium channel blockers or digoxin for rate control in AF Cardiac Resynchronization Therapy Biventricular pacing (with or without AICD) Added to optimal medical therapy in persistently symptomatic patients Moderate to severe HF (NYHA Class III - IV) patients QRS 130 msec No benefit without widened QRS LVEF 35% Improves quality of life, functional class and exercise capacity Other Therapies Ivabradine Add-on Rx to maximally tolerated Beta blocker in stable symptomatic chronic HF EF <35%, HR > 70 CardioMEMS HF System Pulmonary artery implant for wireless remote PA pressure monitoring Allows for adjustment of meds before symptoms appear Decreases hospitalizations 12
Hospital to Home Campaign Readmission w/in 30 days ~ 24% of cases Medicare penalizes hospitals Strategies to reduce HF readmissions Emphasis on improving transitions of care and pt/family education prior to discharge Correct list of medication ( medication reconciliation ) Forward discharge info to PCP F/U with PCP or specialist within 7 days In-hospital HF education prior to discharge In-home or in-clinic HF education and monitoring Acute decompensated HF Requires hospitalization telemetry, ICU Oxygen to maintain SPO2 > 94%; may need CPAP or BiPAP Initial Goal: symptom relief Preload and afterload reduction for symptomatic relief Diuretics loop diuretics Vasodilators - nitrates, hydralazine, nipride, nesiritide (human BNP analogue) typically reserved for hypertensive patient Inhibition of neurohormonal activation (RAAS and sympathetic nervous system) ACEI/ARB, beta-blockers, and aldosterone antagonists Hemodynamic instability may require inotropic agents and/or mechanical circulatory support (IABP, LVAD) Diuretics IV administration preferred Bolus vs continuous infusion Dose based on response to first dose 2-4 hrs after it was given Increase dose or frequency if inadequate response Sometimes loop diuretic combined w/thiazide diuretic for synergistic effect Metolazone kickstarts lasix; give 30min before lasix Close monitoring of electrolytes usually 2:1 dosing of Lasix/potassium Keep serum potassium between 4 5 mmol/l Transition to PO when pt reaches near-euvolemic state Strict I/Os and DAILY weights! 13
Summary Heart failure is a chronic, progressive disease that is generally not curable, but treatable Most recent guidelines promote lifestyle modifications and medical management with ACE inhibitors, beta blockers, and diuretics It is estimated 15% of all heart failure patients may be candidates for cardiac resynchronization therapy. Close follow-up of the heart failure patient is essential, with necessary adjustments in medical management Stages of HF and recommended Therapy by Stage From: 2013 ACC/AHA Guideline for the Management of Heart Failure Copyright American Heart Association, Inc. All rights reserved. 14