Download Heart Failure

Heart Failure
At the end of this self study the participant will:
• Describe physical changes occurring from
heart failure.
• Identify common medications given for heart
failure
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Heart Failure Statistics
•
•
•
•
4.6 million people have CHF
About 550,000 new cases/year
Almost 1 million hospitalizations/year
About 22% male & 46% female MI victims
will be disabled with heart failure w/in 6 yrs
• 50% die within 5 years of CHF diagnosis
• Current mortality rate > 45,000 / year
Am. Heart Assoc. 2000 Heart & Stroke Statistical Update, 1999
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Evolution of Heart Failure Clinical Stages
NORMAL
Asymptomatic
No Symptoms
LV Dysfunction
Normal Exercise
Normal LV
Compensated
Function
No Symptoms
CHF
Normal Exercise
Abnormal LV Symptoms
Decompensated
Function
controlled by
CHF
medical therapy
Activity limitations Symptoms persist
Refractory
Abnormal LV
despite usual
CHF
Function
therapy
Activity limitations Symptoms not controlled
Abnormal LV
with treatment
Function
Bolger, AF & Lopez Sendon, J. Chronic Congestive
Heart Failure (slide presentation). 1999.
Compensatory Responses
Sympathetic Activation
• Increased HR
• Increased contractility
• Vasoconstriction
• Increased preload
• Increased MVO2
(myocardial volume
oxygen consumption)
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Renin-AngiotensinAldosterone Activation
• Sustained sympathetic
response
• Vasoconstriction
• Volume expansion
• Cellular proliferation
Successful HF Management
Essential Building Blocks:
– HF Disease progression
– Symptom (including depression) & medication
management
– Salt (sodium) & water restriction
– Exercise & energy conservation
– Support services
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Patient & Family
Education
Heart Failure Pharmacology:
Fitting the Puzzle Together
Diuretics
Vasodilators
Neurohormonal
Antagonists
Inotropes
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Others
Diuretics
Diuretics:
Eliminates sodium & water
• Loop Diuretics (furosemide, bumetanide)
– inhibits Na+/CL-/K+ exchange in ascending Loop of
Henle
• Thiazide Diuretics (hydrochlorothiazide)
– inhibits active Na+/Cl- exchange in renal cortex
• Potassium-sparing Diuretics (spironolactone)
– inhibits Na+ reabsorption in distal/collecting tubules
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Diuretics
PLAN:
If weight increases
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Diuretics:
Patient Management
• Record daily weight with plan for
intervention when elevated
• Take early in day to limit nocturia
• Take with food or milk
• Rise slowly to minimize dizziness
• Monitor hearing (loop diuretics)
• Limit unprotected sun exposure
• Monitor electrolytes
Arterial
Vasodilators
Drug in this Class:
hydralazine
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Vasodilators
• Arterial vasodilator (reduces
afterload)
• Not shown to be effective alone
• Combination therapy with
Nitrates for HF patients unable
to take ACE-I
Gheorghiade, et al. Heart & Lung; 2000: 29:16-22
Cohn, JN et al. (V-HeFT II). NEJM. 1991: 325:303-310..
Arterial Vasodilators
Vasodilators
Patient Management
• Indications
• Essential hypertension • Give IV doses over one
minute
• Heart Failure (may
•
Following
initiation
of
increase activity
therapy and each dose or
tolerance)
change in infusion rate:
– Stabilizes
heart rate, blood pressure,
hemodynamics
and respiratory rate every 5
– Decreases systemic
minutes x 3, then every 15
vascular resistance
minutes x 3
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Gheorghiade, et al. Heart & Lung; 2000: 29:16-22
Cohn, JN et al. (V-HeFT II). NEJM. 1991: 325:303-310..
ACE Inhibitors
Neurohormonal
Antagonists
Drugs in this Class:
captopril
enalapril
ramipril
lisinopril
quinapril
fosinopril
benazepril
moexipril
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First line therapy
Outcomes:
• Slow HF progression
• Improve symptoms
• Reduced morbidity &
mortality
ACE Inhibitors
Indications:
LV Dysfunction
(EF <40%)
with/without
symptoms
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Neurohormonal
Antagonists
Undesirable Effects
–
–
–
–
–
–
–
hypotension
weakness/fatigue
hyperkalemia
dry cough
renal insufficiency
skin rash
angioedema
Gheorghiade, et al. Heart & Lung; 2000: 29:16-22
ACE Inhibitors
Patient Management
Neurohormonal
Antagonists
• Begin with adequate hydration using low doses
(adjust diuretic - not ACE-I)
• Educate patient about effects (hypotension)
• Monitor electrolytes/renal function
• Titrate to therapeutic doses
• Avoid NSAIDS & K+ sparing diuretics
Gheorghiade, M. et al. Heart & Lung, 2000.
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Angiotensin II
Receptor Blockers (ARB)
Drugs in this Class:
losartan
losartan with HCTZ
valsartan
irbesartan
candersartan
Neurohormonal
Antagonists
• Selective & competitive
blocker of AT-1 receptors
(vasodilation)
• No effect on bradykinin or
prostaglandin
(no cough)
Gheorghiade, et al. Heart & Lung; 2000: 29:16-22
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Angiotensin II
Receptor Blockers (ARB)
Indications
• Hypertension
• CHF: persistently
symptomatic patients
with reduced ejection
fraction
• May help control atrial
fibrillation
Neurohormonal
Antagonists
Patient Management
• Monitor kidney function
• May increase serum
potassium
• Rare but serious side
effect is angioedema
(face, lips, throat
Gheorghiade, et al. Heart & Lung; 2000: 29:16-22
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ß-Adrenergic Blockers
Drugs in this Class:
metoprolol
carvedilol
bucindolol
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Neurohormonal
Antagonists
Potential Benefits:
• Inhibits cardiotoxicity of
catecholamines
• Decrease HR, BP
• Antianginal
• Antioxidant
• Antiproliferative
ß-Blockers:
Patient Management
Neurohormonal
Antagonists
• Initiate after acute decompensation is managed
(normal volume state)
• Use low doses & titrate slowly
• If needed, withdraw slowly to avoid rebound
tachycardia & sudden death
• Monitor drug effect on blood sugar
Gress,TW, et al. NEJM: 2000: 342.
Milfred-LaForest, SK. J Cardiovasc Nurs. 2000.
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Cardiac Glycosides
Inotropes
Drug in this Class:
digoxin
• Introduced in 1785
• ACC/AHA Indications:
– systolic dysfunction not
responsive to ACE-I &
diuretics
– atrial fibrillation & SVT
• Reduced admissions but not
HF mortality
• Therapeutic range for HF
0.5-0.8 *
* Rathmore et. al. (2003) Association of Serum Digoxin Concentration
and Outcomes in Patients with Heart FailureJAMA 289(7),
871-878
ACC/AHA
HF Guidelines. Circulation, 1995
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Digitalis Investigators Group. NEJM, 1997
Cardiac Glycosides
Inotropes
Patient Management:
• Monitor heart rhythm
• Monitor pulse rate
Toxicity:
• Visual Disturbances
– Blurred vision
– Yellow tint
– Halos around lights
• Almost any
dysrhythmia can occur
with digtoxicity
ACC/AHA HF Guidelines. Circulation, 1995
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Digitalis Investigators Group. NEJM, 1997
Inotropes
Positive Inotropes:
ß-Adrenergic Stimulants
Drugs in this Class: • IV for acute/chronic HF
• Dopamine: enhanced renal
dopamine
perfusion (low doses) & BP
effects
dobutamine
• Dobutamine: direct ß-1 to 
contractility & SV; Use lowest
or intermittent dosing
• Use only when other therapies
maximized/failed
Gheorghiade, M. et al. Heart & Lung, 2000.
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Levine, BS. J Cardiovasc Nurs, 2000.
Inotropes
Positive Inotropes:
ß-Adrenergic Stimulants
Considerations:
• Dopamine is a vesicant – monitor for extavasation
• Dose dictates level of care needed
– If dose needs titration, patient needs to be in ICU
– If dose stable can go to level 2 nursing divisions
• See IV Medication guidelines for details
Gheorghiade, M. et al. Heart & Lung, 2000.
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Levine, BS. J Cardiovasc Nurs, 2000.
Natriuretic peptides
• Nesiritide
–
–
–
–
–
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IV only, ICU and level 2 nursing divisions
Requires heart monitoring/telemetry
Vasodilator
Stimulates renin angiotension aldosterone cascade
Monitor closely for hypotension, may need to
decrease infusion rate or discontinue for
hypotension
Heart Failure
Patient Specific Discharge Instructions
Activity Level
 Diet
 Medications
 Follow-up appointments
 Weight Monitoring
 Symptoms Worsening
 Smoking Cessation

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Heart Failure:
Fo cus on Prevention
• Primary Prevention
– Prevent coronary artery disease
– Manage lifestyle risk factors
• Secondary Prevention
– Limit infarct size; Prevent recurrent MI
– Prevent CHF post-AMI
• Tertiary Care
– Prevent CHF progression
Advisory Board Company. CHF Prevention, 1999
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Heart Failure in the 21st Century:
Science is just beginning to unlock the door to all the
processes that occur from the onset of LV dysfunction to endstage deterioration. The etiologies and treatments are evolving
- the important concepts to take home with you include
• Assess & classify cardiac dysfunction
• ACE-I, combined with diuretics & digoxin are primary
treatments
• Prepare patients & families to “partner” in their self-care
• Consider ß-adrenergic blockers after basic therapy; Low
/ slow dosing
• Monitor for research re: new therapies
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References
• Gheorghiade, M., et al. Heart &Lung, 2000, 29 (1): 16-32
• Bourassa, MG, et al. JACC. 1993. 22 (Supp A) 14A-19A
• Chakko, S. & Gheorghiade, M. Am Heart J. 1992, 124: 260264.
• Stevenson, WG, et al. Circulation, 1993, 88: 2953-2961
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