9:00 10:30 Workshop Overview Mr. M Who is this document primarily intended to reach? What is the format? How soon should I see a newly referred heart failure patient? How often should my heart failure patient be seen? Who can I discharge from my heart failure clinic? How quickly and in what order should standard heart failure therapy be titrated for most patients? When should I measure electrolytes, serum Creatinine and BUN? How should I manage hyper or hypokalemia in my patients? I know I should get a baseline measure of left ventricular ejection fraction- but should I measure it again? If so, when should it be measured? Can heart failure medications ever be stopped? If so, then when? How should I manage an acute episode of gout? In what ways do I care differently for frail elderly patients with heart failure? How do I teach self- care to my patients? 71 year old man with an ischemic cardiomyopathy. NYHA III, LVEF 30% COPD, diabetes, chronic renal failure, atrial fibrillation Takes 12 different types of medications daily (blister pack) Lives alone in an apartment- 4 admissions for heart failure in the past year Mrs. Tetley ID: 85 yr female referred from GP for new onset HF HPI: 3/12 progressive SOBOE, 2+bilateral pitting edema, nocturnal cough, 2 pillow orthopnea. GP started furosemide 2 weeks ago; SOBOE improved and orthopnea resolved. PMHx: o HTN (x 30 years, well controlled) o DM (x 15 years, diet controlled) o Atrial fibrillation (x 5 years) o GERD/PUD (UGIB x 3 years ago) o OA
9:00 10:30 Medications: HF: Furosemide 40mg daily (started 2 weeks ago) HTN: HCTZ 25 mg daily, Potassium chloride 20MEq daily, Amlodipine 5mg daily, ECASA 81mg daily DM: Diet controlled, Rosuvastatin 10mg daily Atrial Fibrillation: Metoprolol 25mg BID, Dabigatran 150mg BID GERD/PUD: Pantoprazole 40 mg daily OA: OTC: Naproxen 220mg daily Vitamin D 2000IU daily, Calcium 1500mg daily, multivitamin daily, Vitamin E 800IU daily, Vitamin C 1000mg daily, Vitamin B Complex 50mcg daily Investigations: Echo: LV dilation, dilated LA, EF = 40%, diastolic dysfunction, aortic sclerosis MIBI: normal perfusion ECG: atrial fibrillation, HR = 68bpm CXR: mild pulmonary edema Labs: Scr = 100umol/L; K = 4.8 mmol/l; Na = 135mmol/L Weight = 40kg BP = 114/68 mmhg sitting; 110/60 standing CVS Exam = JVP 5cm ASA; Bilateral crackles; II/IV MSM; 2+bilateral pitting edema to mid- shin Q1. Plan? Furosemide (Options: increase, decrease, maintain) Q2. Plan? Metoprolol (Options: increase, decrease, maintain, discontinue) Q3. Plan? ACEI (Options: yes, no) Q3. Plan? Other medications (Options: stop amlodipine, stop HCTZ, stop potassium, stop ASA, stop vitamins, stop naproxen, all the above) Additional Information: Baseline Scr = 40umol/L = CrCl 68ml/min Current Scr = 100umol/L = CrCl 27ml/min Q4. Does this change your plan? (Options: yes, no) Additional Information: Baseline K = 3.2mmol/L
9:00 10:30 Current K = 4.8mmol/L Q5. Does this change your plan? (Options: yes, no) Follow- up via telephone (1 week later): Furosemide and metoprolol were maintained and ramipril 1.25mg BID was started; other medications were streamlined She reports feeling better, but still has some SOBOE and mild peripheral edema Blood work done the day prior reveals: o SCr = 101 umol/l (was 100umol/L) o K = 5.5 mmol/l (was 4.8 umol/l) Q5. What is your plan? (Options: hold ACEI repeat BW in 3-5 days), hold ACEI and give sodium polysterene (Kayexalate ) (repeat BW in 2 days), assess dietary intake (ensure K+ supplement was discontinued) (repeat BW in 5-7days)) Mrs. Doe Diagnosed with pre- ecclampsia at 24 weeks Progressive edema Went into labour at 34 weeks o Pulmonary edema day 2 post natal o Nearly intubated ECHO: LV 57 mm (EDD), EF 18%, moderate MR She was treated with vasodilators and diuretics Improved ACE and BB started Tolerated, titrated Clinical improvement Follow- up: Now asymptomatic Diuretic stopped due to hypovolemia Repeat ECHO EF 54% o LV EDD 48 mm o No MR o Normal RVSP est but only trivial TR
9:00 10:30 Q1. She would like to stop her medications. (Options: yes, no) If yes, which medications? Case 4 74 yo male with 10 year hx DCM (normal coronaries), followed in HF clinic ICD inserted 6 years ago Has done very well since you have seen him Perindopril 8 mg OD Digoxin 0.125 mg OD Carvedilol 25 mg BID Spironolactone 25 mg OD Lasix 40 mg OD- patient has not been taking it BP 120/70, HR 60 reg JVP ASA, - AJR HS: S1, S2, no murmurs, no rub 1+ pretibial edema bilaterally No palpable organomegaly Chest: clear Hb 128, WBC 6.5 (n diff) Na 139, K 4.7, creat 100 LVEF 54% and LVID 55 mm o Had been 23% and 64 mm 3 years ago Q1. Would you stop his medications? (Options: yes, no, it depends) Q1. Would you replace his ICD? (Options: yes, no, leave it to EP, it depends) Case 5 39 y.o. male Seen last year with A Flutter and LVEF 22% o Was drinking heavily at time and was hypertensive Cardioverted and in NSR since then Now LVEF on ACE and BB and OAC is 60% Asymptomatic Q1. Do you stop his medications? (Options: yes, no, it depends) Follow- up:
9:00 10:30 Patient still drinking 2 drinks per day (what he admits to) Patient has gained 30 lbs (salesman, travel) and BP is elevated 150/94 Patients has developed diabetes during the past year Mrs. PP 60 year old female presented 1 year ago with breat cancer, HER + Underwent FAC and Trastuzamab therapy for 6 months 9 month EF showed EF 60 to 44% Trastuzamab stopped Progressive heart failure 3 months later Placed on Ace and BB and diuretic and Trastuzamab stopped Q1. Would you stop trastuzamab for good? (Options: yes, no) Q2. When would you re- check LVEF? (Options: yes, no) Follow- up: 3 months later LVEF is 55% on therapy Q3. Do you stop therapy? (Options: yes, no) Why or why not? Q4. How long would you follow if EF stayed normal? Mr. CC 62 year old man- presents to ER: 4 week history of increasing SOB, 3 pillow orthopnea, PND PMHx- viral cardiomyopathy (8 years ago) EF 35%, NYHA class I symptoms (until recently) Hypertension, family history CAD, non- smoker, rare ETOH, no diabetes, lipids normal Normal coronaries coronary angiogram 8 years ago Medications: Ramipril 12.5 mg daily, metoprolol 25 mg BID (not taking these for a few months- Weight: 103.7 Kg BP 159/96 mm Hg ECG: Sinus rhythm- 80 bpm (narrow QRS) Lab: Creatinine 110umol/L, urea 9.2mmol/L, K+4.3 mmol/l, Na+140mmol/L
9:00 10:30 CXR: mild pulmonary edema Echo: global hypokinesis, EF 15%, no significant valvular abnormalities, RVSP 54 mm Hg. Dilated LA, RA, LV Q1. How would you optimize the pharmacological management for this patient? Q2. Does he need to be followed in a heart function clinic? Q3. How do you work through adherence issues? Q4. Does he need an ICD? Progress over next 2 years: Followed in HFC- optimization No hospitalizations NYHA Class I within 6 months o Optimized medications o Working through challenges with adherence * trust, negotiation o Sleep clinic assessment o Developed atrial fibrillation o No ICD Medications Atacand 32 mg OD Coreg 37.5 mg BID Lasix 40 mg prn- rarely uses Norvasc 2.5 mg OD Pradaxa 110 mg BID Other Weight: 100 Kg BP 124/82 mm Hg ECG- Afib 72bpm Echo: global HK- EF 35-40%. No valvular abnormalities, RVSP <35mmHg RNA- EF 34% Case 8 78 year old lady with a history of mildly obstructive cardiomyopathy for the past 30 years
9:00 10:30 Very stable on diltiazem 180 mg daily Lives with husband and used to walk everyday No history of CAD Over the past 2 years, developed shortness of breath on exertion and palpitations, also presents occasional dizziness Referred for evaluation at CHF clinic PEx: JVP 15, irregular HR 80/ min, loud systolic murmur of aortic stenosis, no S3, mild hepatomegaly and no pedal edema. ECG Afib and LVH Echo small LV with asymmetric hypertrophy and normal LVEF Severe calcified aortic stenosis Grad 80/45 with very small LVOT, very calcified mitral annulus with 20/10 gradients and severe LA dilatation No significant MR Moderate TR with PA pressure 50 mmhg +JVP Q1. What is your plan? (Options: anticoagulation and cardioversion, diuretics, change cardizem for B blocker, cardiac cath with intended surgery, keep in CHF clinic)