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2/7/2013
Robin Harris, PhD, ANP-BC
Doctorate in Nursing, University of Tennessee
Post-Master’s Certificate in Adult Health Nursing, University of Tennessee
Master of Science in Nursing, University of Virginia
Bachelor of Science in Nursing, East Tennessee State University
Affiliations: American Association of Critical Care Nurses, American A
ssociation of Heart Failure Nurses
Locations: Kingsport, Bristol
Heart Failure 2013 Update
Wellmont CVA Heart Institute
Thomas M. Bulle, MD, FACC
Robin Harris, PhD, ANP-BC
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The diagnosis of heart failure is
based on the presence of
symptoms and/or signs of
pulmonary and/or systemic
edema, and/or low cardiac
output manifested by organ
hypo-perfusion in the presence
of and due to structural heart
disease.
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Not everyone who is short of
breath or has edema has heart
failure!
Biological Changes of the Failing
Cardiac Myocyte
Cellular hypertrophy
Altered Excitation-Contraction coupling
Myofilament loss
Beta Adrenergic desensitization
Mitochondrial & substrate metabolic
change
Abnormal myocyte
energetics
Myocyte cytoskeleton loss & disarray
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Ventricular Geometry
Goals of therapy:
•Live longer
•Live better
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Patient Presentation 12.15.12
75 y/o male c/o Short of breath, dry cough, fatigue,
chest pain; Seen in local Urgent Care Clinic;
referred for further evaluation with Dx “Heart
Failure”
Hx: No prior cardiac history
◦ Prior HTN-ran out of meds & cannot recall
◦ No routine medical care
Exam: BP 168/92 HR 130, BMI 38; warm
extremities; JVP 14; S3; basilar rales; edema
1+
Critical Co-Morbidities in HF
Acute myocardial ischemia/acute coronary
syndromes
Severe hypertension
Atrial & ventricular arrhythmias
Infections
Pulmonary emboli
Renal failure
Medical or dietary non-compliance
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Appropriate Initial Studies
Appropriate (guideline based) studies for
this patient include:
CBC, BMP, U/A
TSH, HgA1C
BNP
FLP, LFT’s, FBS
ECG, CXR
Echo 2D/Dop
Stress MPI or Echo
Right & Left Heart Cath
Appropriate Initial Studies
Appropriate (guideline based) studies for this patient include:
CBC, BMP, U/A, TSH, HgA1C or FBS, LFT’s, FLP (Class I)
BNP-indicated when the etiology of symptoms of breathlessness is unclear
and prognostically during hospital admission
ECG, CXR (Class I)
Echo 2D/Doppler (Class I) ”The single most useful diagnostic test in the
evaluation of patients with HF”
Stress MPI or Echo (Class IIB / LOE C)
Right & Left Heart Cath (Class 1/ LOE B)
“Coronary arteriography should be performed in patients presenting with HF
who have angina or significant ischemia unless the patient is not eligible for
revascularization of any kind.” Class I/ LOE B
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Accuracy of H&P to Detect
PCWP > 22mmHG
H&P
Finding
Sensitivity
Specificity
+ Pred Value
Rales
15
89
69
- Pred Value
38
S3
62
32
61
33
Ascites
21
92
81
40
Edema
41
66
67
40
Orthopnea
86
25
66
51
Hepatomegaly
15
93
78
39
HJR
83
27
65
49
JVP >11
65
64
75
52
JVP <8
4
81
28
33
Potential Screening & Prognostication
Uses for Natriuretic Peptides
Screening for Stage A HF
Screening for Stage B HF
R/O HF in primary care setting
Risk prediction in stable CAD
Risk prediction in unstable CAD
Risk prediction in HF
Pre-Operative risk prediction
Risk prediction with chemotherapy
JACC
2012;60:277
Predicting Risk
http://depts.washington.edu/shf
m/app.php
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http://depts.washington.edu/
shfm/app.php
Patient Presentation 12.15.12
75 y/o male Short of breath, dry
cough, fatigue, chest pain
Rhythm-Afib; LBBB; HR 130
Hemodynamics-volume expanded;
depressed CI
Metabolic-Diabetes, kidney
disease, anemia, dyslipidemia,
hyponatremia
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First Things First !
Acute Stabilization priorities
Education:
Medication:
◦
◦
◦
◦
◦
◦
ACE Inhibitor
ARB
Beta blocker?
Aldosterone antagonist?
Aspirin?
Statin?
Referral for device Rx?
Patient Education in HF
“Comprehensive written discharge instructions for
all patients with a hospitalization for HF; special
focus on:
1. Diet
2. Discharge medications, adherence, persistence,
and up-titration of ACE/ARB & Beta Blocker Rx;
3. Activity level;
4. Follow up appointments including date, time &
contact information;
5. Daily weight monitoring;
6. Response to clinical symptoms changes or
development.
Beta Blocker Rx in Acute HF
If patients are already taking BB’s, these should
be continued
BB’s with demonstrated efficacy in HF should be
prescribed (Bisoprolol, Carvedilol, Metoprolol
succinate only)
BB’s should be started ONLY after
optimization of volume status and discontinuation
of intravenous diuretics.
BB’s should be started at low doses
BB’s should be started in stable patients;
particular caution should be used in patients who
have required inotropic Rx during the
hospitalization
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Aldosterone Blockade in HF
(Spironolactone/Epleronone)
“Recommended in patients with moderately
severe or severe symptoms of HF with reduced
EF who can be carefully monitored for preserved
renal function and normal potassium concentration.
Creatinine should be </ 2.5 in men and 2.0 in women
and K+ <5.0
Potential benefit in patients with low EF post MI and
with recent decompensation with mild symptoms, in
addition to loop diuretics, “however the writing
committee strongly believes that there are insufficient
data or experience to provide a specific or strong
recommendation.”
The combination of Aldosterone blocker Rx with
combined ACE/ARB Rx “cannot be recommended.”
Atrial Fibrillation in HF
Restoration of sinus rhythm indicated if symptoms
persist following heart rate control*
*presuming effective anticoagulation control** or
TEE-documented absence of LA thrombi
◦ **>3weeks of SEQUENTIAL effective anticoagulation with
INR > 2.0
Given presence of important MR, this would be
considered “valvular” atrial fibrillation and not an
approved condition for Pradaxa or Xarelto
Complimentary role of BP control
◦ Investigative role of renal artery denervation
Cardiac Resynchronization (CRT)
Patients with LVEF < 35% in sinus rhythm and
symptomatic class III-IV HF on optimal
medical therapy and QRS > 120 msec (Class
I/LOE A)
Patients with LVEF < 35% in atrial fibrillation
and symptomatic class III-IV HF on optimal
medical therapy and QRS >0.12msec (Class
IIa/LOE B)
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“Maximal Medical Therapy”
Angina: Limiting angina that interferes with the lifestyle the
patient wishes to lead
◦ Maximally tolerated dose of at least 2 anti-anginal
medications (BB’s, CCB’s, Nit’s)
◦ HR 50-60;
◦ SBP 100-115
Heart Failure:
◦
◦
◦
◦
BB;
ACE or ARB (if Creat < 2.5
Diuretic.
CRT for patients with EF < 35% and NYHA Class
II-IV Sx’s with QRS> 0.12msec
Cardiac Resynchronization
So…what??
Measurable clinical benefits
Reimbursement tied to performance
measures
Financial penalties for failure to satisfy
performance measures
Consumer awareness
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Results: Mortality Reduction Based on Number of
Guideline-Recommended Therapies at Baseline
24-Month Mortality
Adjusted Odds Ratios (95% CI Displayed)
Number of Therapies
(vs. 0 or 1 therapy)
Odds Ratio
(95% confidence interval)
2 therapies
0.63 (0.47-0.85)
3 therapies
0.38 (0.29-0.51)
(p = 0.0026)
(p < 0.0001)
4 therapies
0.30 (0.23-0.41)
5, 6, or 7 therapies
0.31 (0.23-0.42)
(p < 0.0001)
(p < 0.0001)
0
0.5
1
1.5
2
Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26.
Incremental Benefits with HF Therapies
(Cumulative % Reduction in Odds of Death at 24 Months)
-28% to -49%
P<0.0001
-54% to -71%
P<0.0001
-68% to -81%
P<0.0001
-75% to -86%
P<0.0001
-77% to -88%
P<0.0001
-72% to -87%
P<0.0001
Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26.
HFpEF
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Table 9. Differential Diagnosis in a Patient With Heart Failure and Normal Left Ventricular Ejection Fraction
Heart Failure with Preserved EF
There are no guideline based treatment
indications for the Rx of HFpEF
◦ No clinical/survival benefit for ACE/ARB
◦ No clinical/survival benefit for Beta Blockers
◦ No clinical/survival benefit for Aldosterone
antagonists
◦ No clinical/survival benefit for CCB’s
The principal goal of Rx for HFpEF is to
manage co-morbidities and to control
volume status
Coming Up…or not
Soluble beta-galactoside-binding lectin:
Direct mediator of pro-fibrotic pathway;
Marker of myocardial remodeling and
fibrogenesis
Expressed by activated macrophages (and
other cell types);
Induces cardiac fibroblast proliferation and
deposition of type I collagen
Galectin-3 expression is substantially
upregulated in animal models of heart
failure (HF);
Precedes development of overt clinical HF
Henderson NC, PNAS, 2006
Nishi Y, Allergol Int, 2007
Sharma UC, Circulation, 2004
Liu YU, Am J Physiol Heart Circ Physiol, 2009
39 Grandin EW, Clin Chem, 2011
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Galectin-3:
Prognosis in Acute and Chronic HF
COACH
HF-ACTION
PRIDE
DEAL-HF
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Percutaneous renal denervation procedure.
Krum H et al. Circulation 2011;123:209-215
Copyright © American Heart Association
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Exercise & Heart Failure
N=2933 pts > 65 y/o
Free of HF at outset;
2-3yrs follow up
NT-proBNP
NT-proBNP
cTnT
cTnT
Final Diagnosis
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Disclosure Information
Robin Harris, PhD, ANP-BC
I have no financial relationships to disclose.
Why so much emphasis on
heart failure?
Evidence-based therapies improve patient
outcomes
25% of patients admitted for heart failure
are readmitted within 30 days; 50% of
patients are readmitted within 6 months
CMS changes in reimbursement/penalties
for hospitals effective October 1, 2012
An estimated 40% of readmissions are
avoidable
Discharge teaching/patient education has
been shown to reduce readmission rates
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Heart Failure: Symptom Progression
Asymptomatic
NYHA FC I
Dyspnea with
Exertion
NYHA FC II
Dyspnea with
minimal
exertion
NYHA FC III
End-stage HF
NYHA FC IV
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Heart Failure Management:
Continuum of Care
Inpatient Care
◦ Management of Acute Illness
Fluid Volume Reduction
Diuretics
Symptom Management
Hemodynamic Support
Evaluation and Treatment of HF Etiology
Outpatient Care
◦ Pharmacologic Management
Evidence-Based Guidelines
◦ Nonpharmacologic Management
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Heart Failure Management:
Continuum of Care - Barriers
Decentralized health care delivery
Cost, complexity, and standards for HF care
Management of complex drug regimens
Identification of treatment side effects
Mostly elderly population
Patients with multiple comorbidities
HeartSUCCESS® Program can address many
of these barriers
WHS HeartSUCCESS® Program
System-wide approach to heart failure
management to prevent avoidable admissions
and reduce readmissions for heart failure
Integration of inpatient and outpatient heart
failure care
Physician supervised-NP Managed Heart
Failure Clinics
Multiple Heart Failure Clinic locations to
increase access to heart failure care by
dedicated team of heart failure experts
Heart Failure Clinic Model: Benefit
to Patient
Improve quality of life
Improve functional
status
Improve patient
satisfaction with care
Reduce frequency of hospitalizations
Hauptman, P.J. et al. (2008). The Heart Failure Clinic: A consensus statement of the Heart Failure
Society of America. Journal of Cardiac Failure, 14, 801-815.
McAlister, F.A. et al. (2004). Multidisciplinary strategies for the management of heart failure patients
at high risk for readmission: A systematic review of randomized trials. JACC, 44, 810-819.
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High-risk for heart failure readmission
Patients recently hospitalized for heart failure
High-risk for readmission
◦ Renal insufficiency
◦ Diabetes
◦ COPD
Chronic NYHA FC III or IV symptoms
Frequent hospitalizations of any cause
Elderly patients or other patients with
multiple comorbidities
History of nonadherence to medical therapy
Inadequate social support system
Heart Failure Management:
Continuum of Care - Outpatient
◦ Pharmacologic
Medication titration and optimization
Referral for Device Therapy
Referral for LVAD, Cardiac Transplant Evaluation
◦ Nonpharmacologic
Communication of care among Health Care Providers
Management of Co-existing medical conditions
Screening for Sleep Disordered Breathing
Patient Education
Self-care Management Behaviors
Psychosocial Aspects of Chronic Illness
Depression
Anxiety
Advance Care Planning
Advanced Care Directive
Power of Attorney
Heart Failure Management:
Nonpharmacologic
Patient and Caregiver Education:
◦ Health Literacy vs. Literacy
Health Literacy is the degree to which individuals obtain, process,
and understand basic health information and make appropriate
health decisions
◦ Heart Failure diagnosis
Condition
Prognosis
Classification of Heart Failure
Treatment Goals and Plan of Care
◦ Medications
Indications
Proper dosing of medications
Plan and rationale for uptitration of medications
Side effects of medications
2/7/2013
Heart Failure
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Heart Failure Management:
Nonpharmacologic
◦ Self-care management
Weigh daily and record
Report weight gain of > 3 lbs. overnight or > 5 lbs. in a week
Dietary Sodium Restriction
< 2000mg sodium daily
Fluid Restriction
48-64 ounces daily (1.5 to 2 quarts daily)
Physical Activity
Encourage daily exercise
Improves endurance
Improves symptoms
Exercise is safe in HF patients
Symptom recognition/when to notify provider
◦ Frequent follow-up
Medication optimization
Assessment of response to treatment
Heart Failure Management:
Continuum of Care
Provide seamless transition of care from inpatient to
outpatient setting
◦ Communication and coordination of care among providers
◦ Use of evidence-based HF management guidelines
◦ Outpatient follow-up with provider
Within 7 days post-discharge
Frequent follow-up to monitor treatment response and progress
◦ Referral for advanced heart failure care
Patient/Caregiver Education
◦ Improve patient and caregiver understanding of heart
failure condition and management
◦ Teach skills of self-care management
◦ Individualize patient education to promote health literacy
and self-care management skills
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BNP levels provide no diagnostic
information in patients with
normal LV systolic function?
True
2. False
1.
False
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An appropriate initial dose of beta blocker for a
patient presenting with heart failure and reduced
Ejection Fraction without coronary artery disease
include all but the following:
Metoprolol succinate
25 mg PO daily
2. Carvedilol 3.125 mg
PO BID
3. Atenolol 50 mg PO
daily
4. Bisoprolol 5 mg PO
daily
1.
C. Atenolol 50mg PO daily
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Within 30 days of HF Admission:
• 1 in 10 dead
• 1 in 4 readmitted
• Recurrent HF
• Co-morbid illness
• 75% avoidable
• Cost: $17 Billion
Challenges facing Hospital LOS
• Selection of patients for early D/C
• Availability of early out-pt F/U
• Alternatives to readmission from ED
HFpEF-is it really HF at all?
Table 9. Differential Diagnosis in a Patient With Heart Failure and Normal Left Ventricular Ejection Fraction
Heart Failure with Preserved EF
Incorrect Dx of HF
Inaccurate measurement of EF
Primary valvular disease
Restrictive (infiltatrative) CM
Hemochromatosis
Pericardial constriction
Myocardial ischemia
High output states
COPD wiwth Right HF
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Borlaug BA, Redfield MM.
Circulation 2011;123:20062014
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Galectin-3:
General Population: Framingham Heart Study
Q1: < 11.6 ng/mL
Q2: 11.7-13.7 ng/mL
Q3: 13.8-16.4 ng/mL
Q4: >16.4 ng/mL
N=3,353; 166 first HF events
Ho JE, et al., J Am
Coll Cardiol 2012
76
Galectin-3:
Fibrosis, Scarring & Adverse Remodeling
Myocardial injury (e.g., MI)
triggers inflammatory & wound
healing response
Macrophages
release galectin-3
Collagen deposition
results in scar
formation
Macrophages carrying galectin-3
infiltrate necrotic tissue
Remodeling &
dilatation)
Galectin-3 binds and activates the
myofibroblast leading to collagen
synthesis
Galectin-3 and Natriuretic Peptides
Galectin-3
BNP/NT-proBNP
Biology
Indicator of cardiac fibrosis
Indicator of cardiac stress
Short Term Variability
- Relatively stable
- Marked variability
- Not affected by acute
decompensation
- Elevation with acute
decompensation
Population
30-50% of HF patients
All HF patients
Response to HF
Treatments
Not immediately affected by
HF treatment
Reduced by effective therapy
In HF Management
Prognosis; Segmentation of HF
population & response to
treatment
Diagnosis, Prognosis (NTproBNP), Monitoring of Rx
Galectin-3 and natriuretic peptides are independent and complementary
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Galectin-3 and Natriuretic Peptides:
DEAL-HF Study
N = 232; NYHA III-IV
6+ year follow-up
Both high: ~1.5 - 2-fold
higher mortality risk;
p=0.036 for trend
Galectin-3 added value:
21%
10%
• Identified ~21% more patients at
the highest risk of mortality
• Identified ~10% more patients at
increased risk not identified by
low NT-proBNP
NT-proBNP: (253pmol/L = 2,144pg/mL)
Galectin-3 and natriuretic peptides are independent and
complementary
79
Lok, DJA, et al. Clin Res Cardiol 2010;99:323-8.
Galectin-3:
Readmission Meta-analysis: Acute & Chronic
PRIDE
COACH
UMD
de Boer, RA, et al., J Card Fail. 2011;17:S93. (Presented at HFSA Annual 8
Scientific Meeting, 2011, Boston, MA).
0
Galectin-3:
Readmission Meta-analysis: Acute & Chronic
Meta-analysis of 892 patients
across 3 studies
Patients with galectin-3
>17.8ng/mL are >2x as likely to
be re-hospitalized (HR = 2.35)
Galectin-3 testing may be of
benefit in programs aiming to
reduce rates of hospital
readmission
P=0.0012
Odds Ratio =2.61(95% CI:1.46-4.65) p=0.0012
“Galectin-3 mediated” HF: driving near-term readmission in acute and chronic
HF
de Boer81
RA, et al. J Cardiac Fail 2011;17:S93
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Galectin-3:
General Population: Framingham Heart Study
N=3,353; 166 first HF events
Ho JE, et al., J Am
Coll Cardiol 2012
Q1: < 11.6 ng/mL
Q2: 11.7-13.7 ng/mL
Q3: 13.8-16.4 ng/mL
Q4: >16.4 ng/mL
82
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