Download Pearls of Heart Failure Management

Deborah Crawford, APRN-CNS
PEARLS OF HEART
FAILURE MANAGEMENT
Disclosures
Speaker for Otsuka
Objectives
1 Identify the treatment objectives for acute heart
failure vs chronic heart failure.
2. Identify the stages and classifications of Heart
Failure.
3. Describe the exercise guidelines for Heart Failure
patients.
4. Describe the Pharmacoligical treatment for Heart
Failure.
Acute Decompensated Heart Failure
(ADHF)
Heart Failure:
 Complex clinical
syndrome,
Cardinal symptoms:
 fatigue
 dyspnea
 Can result from any
structural or functional
cardiac disorder that
impairs ability of
ventricle to fill with or
eject blood.
Hunt SA et al. Circulation. 2001;104:2996
Clinical signs:
 fluid retention
 exercise intolerance
Pathophysiology of ADHF
Myocardial Injury
Fall in LV Performance
Activation of RAAS and SNS
(endothelin, AVP, cytokines)
Myocardial Toxicity
Change in Gene Expression
Morbidity and
Mortality
ANP
BNP
Remodeling and
Progressive
Worsening of
LV Function
Shah M et al. Rev Cardiovasc Med. 2001;2(suppl 2):S2
Peripheral Vasoconstriction
Sodium/Water Retention
HF Symptoms
HFSA 2010 Practice Guideline (12.5-12.20)
Overview of Treatment Options for Patients
with Acute Decompensated HF
 Fluid and sodium restriction
 Diuretics, especially loop diuretics
 Ultrafiltration/renal replacement
therapy (in selected patients only)
 Parenteral vasodilators
(nitroglycerin, nitroprusside,
nesiritide)
 Inotropes * (milrinone or
dobutamine)
*See recommendations for stipulations and restrictions.
Treatment Objectives
Acute Heart Failure1
1.
2.
3.
4.
5.
6.
7.
8.
Improve symptoms
Optimize volume status
Identify etiology
Identify precipitating factors
Optimize chronic oral therapy
Minimize side effects
Identify patients who might
benefit from revascularization
Educate (medications/self
assessment of HF)
Chronic Heart
Failure2
1.
2.
3.
4.
5.
6.
7.
 Survival
 Mortality
 Exercise capacity
 Quality of life
 Neurohormonal
changes
 Progression of CHF
 Symptoms
1
2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e.
2
ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.
NYHA Functional
Classifications in
patients with HF
 Class I: No limitations
 Class II: Slight limitations
of physical activity
 Class III: Marked limitation
of physical activity
 Class IV: Symptoms at rest
Unable to carry on any
physical activity without
discomfort.
Stages of Heart
Failure
 Stage A: At risk for
developing HF
 Stage B: Structural heart
disease associated with HF
but asymptomatic
 Stage C: Known systolic
heart failure & current or
prior symptoms
 Stage D: Systolic heart
failure and presence of
advanced symptoms after
receiving optimal care
Pharmacoligical Treatment of Heart
Failure
 ACE Inhibitors: Inhibit renin-angiotensin system in all HF
patients with LV dysfunction
 ARB: Recommended to patients with LVEF <40% intolerant
of ACE
 Beta Blockers: Shown effective in patients with HF with
LVEF < 40% (start when euvolemic)
 Aldosterone blockade: Recommended in patients with
NYHA class III or IV, LVEF <35% while receiving standard
therapy
Dosing ACE/ARB
 Start with low dose ie:
 Lisinopril/Enalapril 2.5mg BID
 Stagger away from Beta Blocker dose
 Avoid Orthostatic Hypotension
 Usually Lunch and Bedtime
 “Stair step” the dosing when up titrating
 Monitor Renal function
 Can use in mild, stable renal insufficiency
Dosing Beta Blockers
 Carvedilol and Metoprolol Succinate are
the Beta Blockers that have an indication
for Heart Failure
 Start low dose and titirate up slowly
 Stagger away from ACE I/ARB
 Start or up titrate when the patient is
euvolemic
 “Stair step” the dosing when up titrating
 Titrate one drug at a time.
Dosing Aldosterone Blockers
 Spironolactone, Eplerenone
 Helpful in the setting of Hypertension for
better BP control
 Monitor Renal function : can use in mild,
stable renal insufficiency
 Does have mortality benefit in patients
with LVEF < 35 %.
Compensated/Decompensated ?
Diuretic Therapy
Agent
Initial Daily
Dose (mg)
Furosemide 20-40mg qd
Maximum
Total Daily
Dose (mg)
Duration of
Action (hr)
600mg
4-6
or bid
Bumetanide
0.5-1mg
qd or bid
10mg
6-8
Torsemide
10-20mg qd
200mg
12-16
Metalozone
(thiazide)
2.5mg qd
20mg
12-24
Equivalent doses: Furosemide 40mg=bumetanide 1mg=torsemide 20mg
Dosing Thiazide Diuretic
Metolazone (Zaroxlyn)
 Usually 2.5 – 5mg
Hydrochlorothiazide
 Usually 25mg
Usually give 30 min prior to the Loop Diuretic
More effective and increases the diuretic effect of the Loop
Dosing Potassium and Magnesium
Potassium:
Goal 4.0 – 5.0
Magnesium:
Goal 2.0 – 2.5
 Usually 10-20mEq /
 Usually 250mg BID for
Furosemide 40mg dose
equivelent.
 Usually will double the
Potassium dose when you
double the Loop diuretic
dose
 Depending on renal
function of the patient
1 week then once a day
 Check the Mg level in 1
month after starting
Mg supplement
CMS recommendations for
Cardiac Rehab for CHF patients
 CMS determined
that the evidence is
sufficient to expand
coverage for Cardiac
Rehabilitation
services to
beneficiaries with
stable chronic heart
failure.
Stable chronic HF
 LVEF < 35%
 NYHA class II-IV
despite optimal HF
therapy for at least 6
weeks
 Stable patients
 No recent (< 6 wks ) or
planned (< 6 mo) major
CV hospitalizations or
procedures
Exercise Guidelines for
HF patients
 Start slow, warm up




and cool down
Start by walking 5-10
min 1-2 times a day.
Walk 3 - 5 times a
week
Increase the time and
frequency as tolerated
Goal is 30 min, 5 times
a week
Don’t Let this Happen to Your
Patient
Alternative treatment in Diuretic
resisitant patients
Aquapheresis (Ultrafiltration)
What Is Diuretic Resistance ?


10 lbs or more over
dry weight
>
Previous
hospitalizations with
ineffective diuretic
effect

Patient cannot achieve
a goal of -2 liters at 24
hrs

No significant
difference in patient’s
global assessment of
symptoms in 24 hrs
 Non-significant
symptom improvement
noted after escalating
to high-dosing strategy

Worsening renal
function during diuretic
therapy

Post-operative fluid
overload

Peri-operative fluid
overload
Ultrafiltration
 Indicated for patients with Heart Failure not
responding to diuretic therapy
 24 hour diuretic dose >80mg Furosemide or
equivalent
 Removes excess salt and water from patients
with fluid overload
 Need to monitor Renal function closely esp.
during inpatient ultrafiltration
 Fluid removal rate should not exceed
250ml/hr (inpatient) or 350ml/hr (outpatient
for 8 hrs)
The Aquadex System
is indicated for:
Temporary (up to 8 hours)
ultrafiltration treatment of
patients with fluid overload
who have failed diuretic
therapy
AND
Extended (longer than 8
hours) ultrafiltration
treatment of patients with
fluid overload who have failed
diuretic therapy and require
hospitalization.
Goals of Ultrafiltration
 Reduction in hospital readmission:
 Prevent patients from being discharged when they
are still “wet”
 Reduction of Length of Stay:
 If ultrafiltration is started early (< 24 hr of
admission).
 Stable renal function during treatment:
 Monitor BMP every 12 hours while on ultrafiltration
to prevent worsening renal function. Can reduce
rate of fluid removal as needed.
Pearls after Ultrafiltration

Hold diuretic while on ultrafiltration
 Restart diuretic after ultrafiltration
complted usually the next day at a lower
dose

May respond better to diuretics after
ultrafiltration due to reduction of “gut
edema”
Patient selection
Inclusion / Exclusion
Criteria for Outpatient
Ultrafiltration
Inclusion Criteria:
1. 24 hour Diuretic dose > 80mg Furosemide
or equivalent * OR
2. Fluid overloaded diuretic resistant
a. < 10 lbs over stable weight
b. Serum Creatinine < 3.0 or Creatinine
clearence > 20ml/min or on fluid
restriction or frequent hospitalizations
* 1mg Bumetanide or 20mg Torsemide =
40mg Furosemide
Exclusion Criteria:
1 Fluid overloaded and
diuretic resistant
a. > 10 lbs over stable
weight
b. Consider hospital
admission for in patient
Ultrafiltration
c. Serum Creatinine > 3.0
consider Renal consult
Ultrafiltration
Pre-Treatment
Day of Treatment
1. Obtain IV access:
a. 6Fr Dual lumen ELC venous access catheter
2. Obtain Laboratory: CMP or BMP, Mg, CBC, PT/INR (if
patient on Coumadin)
3. Obtain Aquadex Flexflow pump
4. Obtain UF 500 Circuit set :
a. Prime filter/tubing with Normal Saline
5. 10 ml syringe
6. Heparin 20,000/500ml D5W
a. Heparin infusion 1000-1200 units/hr or as need
by the patient
7. Start Heparin 30min prior to starting Ultrafiltration
Thank You !!