Download Heart Failure Objectives Definitions Presentations Causes Causes

8/11/2014
Objectives
• Review the trajectory of heart failure as a
clinical syndrome
• Describe the methods of classification of heart
failure
• Describe current recommendations for goaldirected medical therapy (GDMT) across a
continuum
Heart Failure
Brian Widmar PhD, RN, ACNP-BC
Assistant Professor, Nursing and Anesthesiology,
Critical Care
Vanderbilt University School of Nursing
Vanderbilt University Medical Center
Definitions
Presentations
• Complex clinical syndrome that can develop
from any cardiac disorder that impairs the
ability of the ventricle to either fill properly or
eject optimally.
• Dyspnea and fatigue
– Impacts exercise and activity intolerance
• Extracellular fluid retention
– The heart cannot pump enough blood to meet the
metabolic demands of the body
– Syndrome: HF is manifested and recognized by
combinations of “hallmark” symptoms/signs
– Causes peripheral edema and pulmonary
congestion
– Impact on sense of well-being and quality of life
3
Causes
4
Causes
• Clinical syndrome with multiple possible
etiologies.
• Regardless of the cause – there is a typical
pathological remodeling that occurs and over
time the remodeling/compensatory changes
lead to
– Progressive cardiac enlargement
– Decline in cardiac function
• Neurohormonal model of HF (TBDL)
5
6
1
8/11/2014
Acute vs. Chronic
Classifications and (more) terminology
• Acute decompensated heart failure
• Variability in documentation of HF treatment
plans, new billing requirements, etc.
• Different classifications are used to best
describe patient presentation, acuity,
subjective/objective findings.
– G: improvement of sx, hemodynamics, volume
status, ↓injury to heart/kidneys, initiating lifesaving therapies
• Chronic heart failure
– Acute or chronic? Systolic or diastolic HF? Right or
left-sided HF? Disease progression? Heart Failure
symptoms?
7
Right vs. Left Sided HF
•
•
•
•
•
•
•
•
•
Elevated CVP
Jugular venous distention
+ HJR
Peripheral edema
Weight gain
Sternal heave
Abdominal distention
Liver engorgement
Anorexia, nausea
Right-Sided Forward Failure
• Decreased pulmonary perfusion
(forward failure)
• Dyspnea
• Tachycardia
• Hypoxia
• Cyanosis
• Decreased LV filling
8
The American Heart Association/American College of Cardiology
staging system classifies heart failure as a progressive disorder.
Left-Sided Backward Failure
•
•
•
•
•
•
•
•
•
• Difference relates to patient presentation and
hemodynamic stability – treatment goals
reflect that
AHA/ACC Heart Failure Staging
Comparison of Right-Sided and Left-Sided Heart Failure
(Jacobsen et al, 2007)
Right-Sided Backward Failure
– G: reduction of mortality, improvement of sx,
QOL, ↓ hospital admissions s/t ADHF.
Dyspnea, tachycardia
Orthopnea
Cough
Wheezes, rhonchi
Crackles
Respiratory alkalosis
Hypoxemia, hypoxia
S3 heart sound
Systolic murmur of mitral regurgitation
Left ventricular dysfunction begins with an initial insult to the
myocardium, and even without any further insults, LV
dysfunction continues to progress.
Stage A
Left-Sided Forward Failure
High risk for developing
HF
• Fatigue, weakness, poor exercise
tolerance
• Chest pain, arrhythmias
• Exertional dyspnea
• Tachycardia
• Cool, pale, diaphoretic
• Decreased urine output
• Decreased mentation
No identified structural or
functional abnormalities
No signs or symptoms of
HF
AHA/ACC Stages of Heart Failure
Stage B
Stage C
Presence of structural
Part or present symptoms
heart disease strongly
of HF associated with
associated with
underlying structural
development of HF
heart disease
No signs or symptoms of
HF
Stage D
Advanced structural heart
disease
Specialized interventions
required
Marked symptoms of HF
at rest, despite maximal
medical therapy
9
10
NYHA Functional Classification
for Heart Failure
• Most commonly used system to assess functional capacity.
• Rating scale – so some variability in classification.
• Based upon patient report of heart failure symptoms with varying
degrees of activity.
• Patients can move between classes.
• Other tests: 6MWT, maximal exercise testing, and peak O2 consumption.
New York Heart Association Functional Classification for Heart Failure
Class II
Class III
Class IV
Cardiac disease resulting
Cardiac disease with slight Cardiac disease with
in inability to carry out
limitation of physical
marked limitation on
any physical activity
activity
physical activity
without discomfort
Comfortable at rest, but
Comfortable at rest, but
Ordinary activity free of
less than ordinary activity May have symptoms of
ordinary activity results in
fatigue, palpitation,
results in fatigue,
cardiac insufficiency at
fatigue, palpitations,
dyspnea, or anginal pain
palpitations, dyspnea or
rest
dyspnea, or angina pain
11
angina pain
Killip Classification
• Originated from a study in 1967 in a CCU unit in the US
• Post-MI patients were evaluated for risk of death 30 days after
the coronary event based upon hemodynamics and
signs/symptoms of heart failure/shock at initial presentation.
• You might find the picture below familiar.
Class I
Cardiac disease with no
resulting limitation in
physical activity
Killip Class I
PCWP < 18
CI > 2.2
12
2
8/11/2014
New Names for Systolic and Diastolic
Dysfunction
Systolic vs. Diastolic HF
• Systolic or diastolic dysfunction
• Systolic dysfunction
• New terminology from the AHA/ACC Guidelines for 2013
• HFrEF (HF with reduced ejection fraction)
– Replaces systolic dysfunction/HF
– EF < 35-40%
• HFpEF (HF with preserved ejection fraction)
– Replaces diastolic dysfunction/HF
– EF > 50%
• Learn the new names, but you’ll still hear the old names
thrown around.
– Heart failure with reduced EF
– Abnormality of ventricular emptying d/t impaired
contractility or greatly excessive afterload
• Diastolic dysfunction
– Heart failure with preserved EF
– Abnormality of ventricular relaxation during
diastole/ventricular filling
13
14
Systolic Dysfunction: HFrEF
Diastolic Dysfunction: HFpEF
• 3 criteria for dx:
• EF < 40% defines
systolic dysfunction
1. Signs/symptoms of HF
2. Normal or only slightly
↓ EF
3. Increased diastolic
filling pressure and
abnormal relaxation of
the LV
• SD is found in 2/3 of
patients with HF,
and they have low
cardiac output.
• The affected ventricle has a ↓capacity to eject blood due
to impaired myocardial contraction or pressure overload.
• Loss of contractility – from myocyte destruction, abnormal
function or fibrosis
• Often the LV wall thins and the cavity dilates – causing an
eccentric hypertrophy.
15
•
•
•
•
•
•
↓ diastolic relaxation or ↑ stiffness of ventricular wall.
Ventricular muscle thickens (concentric hypertrophy).
Cavity size normal, or may become smaller
Ejection isn’t impaired – ventricular relaxation and filling is.
Associated with chronic HTN and LVH
Symptoms often seen with exertion when HR is ↑
Neurohormonal Responses in HF
• Series of natural compensatory mechanisms
that occur to help the body adjust to ↓ CO
and to help preserve BP needed to perfuse
vital organs
• Initially they help. Over time, they lead to
clinical deterioration.
• SNS stimulation, activation of the RAAS
• ↑ levels of endothelin, vasopressin, and
cytokines
16
Neurohormonal Responses
•
•
•
•
•
Sympathetic Nervous System Stimulation
Renin-Angiotensin-Aldosterone System
Vasopressin and Endothelin
Inflammatory Response
Positive Neurohormonal Responses
– Atrial and brain natriuretic peptides (ANP, BNP)
• Left ventricular remodeling
17
18
3
8/11/2014
Exam
Patient Evaluation
Comparison of Right-Sided and Left-Sided Heart Failure
(Jacobsen et al, 2007)
• Assess patient stability
• Patient History
Right-Sided Backward Failure
•
•
•
•
•
•
•
•
•
– Risk factors and possible etiologies for HF
– Functional status
– Volume status
Elevated CVP
Jugular venous distention
+ HJR
Peripheral edema
Weight gain
Sternal heave
Abdominal distention
Liver engorgement
Anorexia, nausea
Right-Sided Forward Failure
• How can you assess patient volume status?
• Decreased pulmonary perfusion
(forward failure)
• Dyspnea
• Tachycardia
• Hypoxia
• Cyanosis
• Decreased LV filling
19
Left-Sided Backward Failure
•
•
•
•
•
•
•
•
•
Dyspnea, tachycardia
Orthopnea
Cough
Wheezes, rhonchi
Crackles
Respiratory alkalosis
Hypoxemia, hypoxia
S3 heart sound
Systolic murmur of mitral regurgitation
Left-Sided Forward Failure
• Fatigue, weakness, poor exercise
tolerance
• Chest pain, arrhythmias
• Exertional dyspnea
• Tachycardia
• Cool, pale, diaphoretic
• Decreased urine output
• Decreased mentation
Objective evaluation of the
patient’s perfusion and
volume status.
There are other physical
findings suggestive of HF
than just heart and breath
sounds.
Nail beds, capillary refill,
skin color/temperature,
hair distribution,
alertness/mentation, pulse
character/quality, mucous
membranes, etc.
20
Management
AHA/ACC Stages of Heart Failure (Crawford, 2009).
Stage A
Stage B
Presence of structural heart
disease strongly associated
with development of HF

No signs or symptoms of HF
High risk for developing HF

No identified structural or
functional abnormalities

No signs or symptoms of HF

GOALS: Treat HTN, quit

smoking, treat dyslipidemia,
regular exercise, discourage
ETOH, discourage illegal

drug use, control metabolic
syndrome

THERAPY: ACEi, ARB for
vascular dz or DM
Stage C



Part or present symptoms
of HF associated with
underlying structural heart
disease
Stage D

Advanced structural heart
disease

Specialized interventions
required
Marked symptoms of HF at
rest, despite maximal
medical therapy

Treatment Goals
GOALS: Measures under

GOALS: Measures under
Stage A
Stages A and B; Dietary salt
restrictions
THERAPY: ACEi, ARB, or BB
in appropriate patients

THERAPY: Diuretics (fluid
retention); ACEi, BB

In selected patients:
aldosterone antagonist,
ARB, digitalis,
nitrates/hydralazine

In selected patients:
Biventricular pacing; ICD

GOALS: Measures under
Stages A, B, and C.

THERAPY: Compassionate,
end-of-life care, hospice

Extraordinary measures:
heart transplantation, longterm inotropes, permanent
mechanical support,
experimental surgery/drugs
21
Case 1
• JW is a 48 year old woman with a hx of HTN,
HLD and obesity who presents to clinic for
yearly evaluation
– PMH: HTN, obesity; FX: Mother- MI, CHF; Father –
DM, HTN
– SH: tobacco use
• What are our goals? What drug therapy might
be indicated?
4
8/11/2014
Stage A
• High risk for heart disease
– Primary prevention focus
• Heart healthy lifestyle, prevention of coronary disease
and LV structural abnormalities
– Drugs: ACEi or ARB as appropriate (vascular
disease or DM); statins as appropriate
– Goals for tx of HTN and dyslipidemia*
– Treatment of other disorders that inc. risk for HF
Case 2
• MS is a 62 year old man with PMH of HTN,
HLD, MI, bicuspid aortic valve who presents to
clinic for follow-up.
– PMH: HTN, HLD, MI (2012), mild AS (bicuspid AV)
EF normal
• What are our goals for therapy?
• Drug choices?
• Obesity, DM, atrial fibrillation, cardiotoxics
Stage B
• Include recommendations for stage A
• Added specific therapeutic guidance for
treating structural HD to prevent sx of HF and
to reduce morbidity and mortality rates
associated with disease progression
– Hx MI or ACS w/ reduced EF: ACEi (class I) or ARB
– BBs (bisoprolol, carvedilol, metoprolol)
– Class III recommendations warn against
nondihydropyridine CCBs (negative inotropy)
Case 3
• JS is a 59 year old man with hx of MI, HTN, DM
who presents to clinic with c/o palpitations
and exertional dyspnea of 1 day duration.
– PMH: MI (2013), HTN, DM
– PE: HR irreg rate/rhythm, BBS = w/ scattered
crackles in posterior bases, 2+ pretibial edema,
Pulses 3+ equal bilaterally
• VS: HR 122 (AF per 12-lead, no ST changes), BP 144/97,
RR 18, T 98.8F
• Goals? Strategy for tx? Treatment choices?
5
8/11/2014
Stage C
HFpEF
• Includes recommendations for stages A/B
• Includes known SHD and HF s/sx
• Further divided into
– HF with preserved EF
– HF with reduced EF
HFpEF
• Goals
– Control symptoms, improve QOL, prevent
hospitalization and mortality
• Identify comorbidities
• Treatment
– Diuresis to relieve congestion symptoms
– Follow guidelines for management of identified
comorbidities
Diuretics
• Class I rec’s for evidence (or hx of) fluid
retention to improve symptoms
– Balance to dose appropriately to achieve target
effect without dehydration, AKI, etc.
– Loop diuretics most common
•
•
•
•
HFrEF
• Goals
Bumetanide/torsemide – increased oral bioavailability
Na+ restrictive diet
Electrolyte monitoring/replacement
Drug tweakage (adding thiazide, reducing doses, etc.)
– Control symptoms, prevent hospitalization and
mortality, and patient education
• Drugs for routine use
– Diuretics, ACEi/ARB, BB, aldosterone antagonists
• Drugs for selected use
– Hydralazine/nitrates; ACEi/ARB; digitalis
• Other considerations
– CRT, ICD, revascularization/valve replacement
ACE Inhibitors
• HFrEF and current/prior symptoms
• Watch for SBP < 80, creat > 3, bilat RAS, or K+
> 5.0
• Dose low and increase as tolerated
• Watch renal function and K+ levels
– Angiotensin suppression/kinin production 
cough experienced by 20% of patients
– Rash and taste disturbances are also reported
6
8/11/2014
Angiotensin Receptor Blockers
• Class I rec’s for use if intolerant to ACEi
– Effective hemodynamic/neurohormonal/clinical
effects. Reasonable alternative to ACEi.
• Small risk of angioedema in patients who
react to ACEi
• Class III rec’s – warn of potential harm if
combined use of ACEi, ARB and aldosterone
antagonists in HFrEF
Beta Blockers
• Should be initiated as soon as HFrEF is
diagnosed in all stable patients without
contraindications
– Metoprolol succinate; carvedilol; bisoprolol
– Abrupt cessation should be avoided
– Adverse rx: fluid retention/HF; fatigue;
bradycardia; heart block; hypotension
– Worsening HF can usually be managed by titrating
other drugs so BB therapy can be continued
Aldosterone Antagonists
Hydralazine/Nitrates
• HFrEF with NYHA Class II to IV with EF ≤ 35%
• NYHA II with prior CV hospitalization
• Following acute MI in patients with EF < 40%
• Addition of combination for African American
patients with NYHA III-IV HFrEF on GDMT with
ACEi/ARB
– Symptoms of HF or history of DM
• Watch renal fx and electrolytes
– Creatinine < 2.5 (men); 2.0 (women)
– Potassium < 5.0
– Serial monitoring of these required, especially if
ACEi/ARB is used
Digoxin
• IIa recommendations include use in HFrEF to
decrease hospitalizations for HF.
– Persistent symptoms of HF during GDMT
– Added to initial therapy in patients with severe sx
who have not yet responded to GDMT
• Latest research suggests increased mortality when used
in patients with newly diagnosed systolic HF
• Loading doses not typically required. Low dosing
recommended in > 70 yo, impaired renal function or
low lean body mass
– Research shows additional morbidity/mortality
benefit
• IIa recommendations in HFrEF pts who cannot
tolerate ACEi/ARB
– Additional morbidity/mortality benefit
Anticoagulants
• Long-term anticoagulation in patients with
chronic HF with
permanent/persistent/paroxysmal AF and an
additional risk factor of cardioembolic stroke
– Age > 75, Hx HTN, DM, previous stroke, or TIA
• CHA2DS2-VASc score
– Reasonable tx without additional risk factors
– Not beneficial in absence of a-fib
7
8/11/2014
Strategies for Achieving Optimal
GDMT
• Up-titrate in small increments, see patients/monitor
lab results more frequently, monitor vitals closely
before/during titration, alternate adjustments of
different medication classes (ARB/ACEi; BB); monitor
renal fx/electrolytes
• Reassure patients of transient med-related sx
• Discourage sudden med cessation; review doses of
all medications when adjusting drug doses; consider
temporary adjustments during noncardiac issues
• Patient/family education about GDMT
Device Therapy in HFrEF
• HFrEF – high risk for SCD due to ventricular
arrhythmias. Current guidelines coordinate
previously conflicting recommendations
• Primary prevention: nonischemic dilated CM
or IHD at least 40 days after MI with EF of 35%
; NYHA II or III receiving GDMT, expected to
live > 1 year
• Special CRT recommendations*
Case 4
• MA is a 71 year old woman with PMH of CAD,
HTN, HLD, DM, and CRI who was admitted to
VUMC after increasing worsening of SOB and
edema refractory to increasing diuretics.
– PMH: CAD, MI (2007), HFrEF with EF 20% by echo
HLD, DM, CRI (baseline 3.1); 3rd HF admission in 9
months
– PSH: CAB x 3 (2007), MVR (2007)
– ROS: NYHA class IV HF symptoms, palpitations
8
8/11/2014
Stage D
• Advanced HF with refractory symptoms
– Repeat hospitalizations, progressive deterioration
in renal fx, intolerance to GDMT, frequent ICD
shocks, serum Na+ level < 133, worsening
functional status (inability to perform ADLs),
escalation of diuretics to high dose or need for
addition of thiazide, signs of cardiac cachexia
– Explore etiologies of worsening symptoms
– Evaluate patient adherence
Hospitalized Patients with HF
• Specific subgroups based upon precipitant
event
– Accelerated HTN, acute cardiac ischemia, ADHF,
shock, acute right-sided HF, decompensation after
surgical procedures
– Recommendations focus on investigation into the
contributing causes of the decompensation that
led to admission
Stage D
• Specialized treatment strategies
– MCSD, procedures to remove fluid (aquapheresis
[Iib], SCUF/CRRT), continuous IV inotropes,
transplantation
– Palliative care/hospice
• Consider including palliative care early in any treatment
plan at this point is important – discuss goals of care
with patient and family
Hospitalized Patients with HF
• Classify patient with congestion or perfusion
issue (think Killip table)
• Warm-Wet: diuretics/vasodilators
• Cool-Dry: Inotropic support
• Cool-Wet: combination of
inotropes/vasodilators/diuretics
– Use of BNP recommended in evaluation of acute
HF and to r/o other dx as causes of symptoms
Transitions and Coordination of
Care
• Big emphasis in new guidelines due to
potential for fragmentation of care during a
very fragile time
• Multidisciplinary care team approach essential
– Evidence-based treatment plan with phone
follow-up 3 days s/p discharge; visit within 1 week
– Continued assessment of volume and end-organ
lab indices
– Palliative care; home health; rehabilitation
9
8/11/2014
Other Considerations
• Guidelines also include nonpharmcological
treatment considerations
– Social support, sodium restriction, treatment of
OSA, weight loss for obesity, and
activity/rehabilitation
– Surgical, transcatheter and percutaneous
therapies are also discussed
References
Final Points
• Increasing number of patients living with
heart disease
• Increased complexity of patient presentations
• Guidelines present HF management across a
continuum and levels of care
• Adherence to GDMT essential to reduction of
mortality and increase in quality of life
Thank you!
• Buonocore, D. & Wallace, E. (2014). Comprehensive guideline for care of
patients with heart failure. AACN Advanced Critical Care, 25(2). 151-162.
• Go, A.S., Mozaffarian, D., Roger, V.L., et al. (2013). Heart disease and stroke
statistics – 2013 update: A report from the American Heart Association.
Circulation, 127. e6-e245.
• Yancy, C.W., Jessup, M., Bozkurt, B. et al. (2013). ACCF/AHA guideline for
the management of heart failure: A report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines. Journal of the American College of Cardiology, 62(16). 14951539.
10