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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