Download 20061028_heart_failure_orthopedic_nurses

Heart Failure
Orthopedic Nurses
Education Day
Jeffrey P Schaefer MSc MD FRCPC
October 30, 2006
Objectives
• Heart Failure
– definition
– epidemiology
– prognosis
– diagnosis
– management
What is Heart Failure?
A complex clinical syndrome that can result
from any structural or functional cardiac
disorder that impairs the ability of the
ventricle to fill with or eject blood.
American College of Cardiology 2001
Cardinal Manifestations of HF
dyspnea
fatigue
fluid retention
“and / or”
limits exercise
tolerance
peripheral edema
pulmonary congestion
impairment of
Functional Capacity and QOL
Incidence of CHF
Staging of Heart Failure
NYHA Cardiac Status
• Class I: uncompromised
• Class II: slightly compromised
• Class III: moderately compromised
• Class IV: severely compromised
– updated from old NYHA Classification
• ‘usual activities’ ‘minimal exertion’
Specific Activity Scale
Goldman Circulation 64:1227, 1981
Stage I
• patients can perform to completion any
activity requiring 7 metabolic equivalents
– can carry 24 lb up eight steps
– carry objects that weigh 80 lb
– do outdoor work [shovel snow, spade soil]
– do recreational activities [skiing, basketball,
squash, handball, jog/walk 5 mph]
Specific Activity Scale
Goldman Circulation 64:1227, 1981
Stage II
• patients can perform to completion any
activity requiring 5 metabolic equivalents
– have sexual intercourse without stopping
– garden, rake, weed, roller skate
– dance fox trot, walk at 4 mph on level ground
– but cannot and do not perform to completion
activities requiring 7 metabolic equivalents
Specific Activity Scale
Goldman Circulation 64:1227, 1981
Stage III
• patients can perform to completion any
activity requiring 2 metabolic equivalents
– dress, shower without stopping, strip and make
bed, clean windows
– walk 2.5 mph, bowl, play golf, dress without
stopping
– but cannot and do not perform to completion
any activities requiring 5 metabolic equivalents
Specific Activity Scale
Goldman Circulation 64:1227, 1981
Stage IV
• patients cannot or do not perform to
completion activities requiring 2 metabolic
equivalents
– CAN’T:
• dress without stopping
• shower without stopping
• strip and make bed
• walk 2.5 mph
• bowl, play golf
Prognosis of HF = generally poor
JACC 1993;22:6A-13A
Progression of Cardiac Status
• most patients do not show an uninterrupted and
inexorable deterioration
• deterioration may be independent of LV function
Drug Therapy Improves Outcome
Diagnosis of Heart Failure
• Heart Failure is mainly a clinical diagnosis
• HF is correctly diagnosed initially in 50% of
affected patients. Eur Heart J 1991
• High Index of Suspicion
– is your patient at risk???
• “““Rapid Onset Heart Failure””” …
– did we under appreciate the findings?
Symptoms of Heart Failure
• pulmonary
– resting or exertional dyspnea
– orthopnea
– paroxysmal nocturnal dyspnea
– cough
– wheezes ‘Cardiogenic Asthma’
Symptoms of Heart Failure
• other volume issues
– nocturia
– lower limb edema
– gastrointestinal symptoms
• abdominal bloating
• anorexia
• fullness in the right upper quadrant
• fatigue
• cachexia
Signs of Heart Failure
•
•
•
•
delirium
vital signs - normal or abnormal
fluid weight gain
peripheral edema
– detected when extracellular volume > 5 l
– stasis dermatitis
– chronic venous stasis
– hyperpigmentation
– ulceration
Signs of Heart Failure
elevation of JVP > 4.5 cm
spec = 90%
sens = 30%
Distinguishing JVP/CP
variation with respiration
variation with position
varies with hepatic pres
occludes
non-palpable
wave form
Palpate Contralateral Carotid Artery
- if what you FEEL is not= to what you SEE --> JVP
Signs of Heart Failure
– S3 (Ken-tuc-ky)
• sensitivity for HF = 24%
• specificity for HF = 99%
– S4 (Ten-nes-see)
• reduced ventricular compliance
– pulmonary examination
• crackles (may be absent even with edema)
• signs of pleural effusion
• wheezes
B-type Natriuretic Peptide (BNP)
Post-op HF Labs
CBC
exclude anemia, adequate platelets
Electrolytes
diuretic effect on potassium
low sodium is c/w heart failure
Creatinine
diuretic response
safety of ACE / ARB
Mg
arrhythmia risk
Albumin
edema issues
Troponin T
recent myocardial infarction?
INR and PTT
in case of heparin or thrombolytics
Type & Screen
in case transfusion needed
Post-OP HF: labs
• Chest Radiography
– ‘the best chest examination’
• Electrocardiography
– confirm rhythm
– LVH?
– ischemia?
• Echocardiography
– variably helpful
• Thallium
– variably helpful
Diagnostic Imaging
‘Congestive’ heart failure
Pulmonary Edema
indistinct arteries
interstitial markings
increased
redistributed
peribronchial cuff
pleural effusions
Ventricle enlarged
increased CT ratio
enlarged silhouette
Interstitial Pulmonary Edema
What’s
wrong
here?
Small
Cardiac
Silhouette
this effusion
is from
tuberculosis
Common causes of Heart Failure
• Heart Failure = High Operative Risk
– patients should not go to OR if heart failure is
not controlled
Risk Calculator
http://www.vasgbi.com/riskscores.htm
• Poor left ventricular function
– coronary artery disease
– hypertension
• Valvular heart disease
• Fluid Retention
Other causes of Heart Failure
Infections (viruses (including HIV) bacteria, parasites)
Pericardial diseases
Drugs (alcohol, doxorubicin, cyclophosphamide, cocaine)
Connective tissue disease
Infiltrative disease (e.g., amyloidosis, sarcoidosis, hemochromatosis, malignancy)
Persisting tachycardia
Obstructive cardiomyopathy
Neuromuscular disease (e.g., muscular or myotonic dystrophy, Friedreich's ataxia)
Metabolic disorders (e.g., glycogen storage disease type 2 [Pompe's disease] and type 5
[McArdle's disease])
Nutritional disorders (e.g., beriberi, kwashiorkor)
Pheochromocytoma
Radiation
Endomyocardial fibrosis
Eosinophilic endomyocardial disease
High-output heart failure (e.g., intracardiac shunt, atrioventricular fistula, beriberi, pregnancy,
Paget's disease, hyperthyroidism, anemia)
Peripartum cardiomyopathy
Dilated idiopathic cardiomyopathy
Approach to causes of Heart Failure
• Cardiac causes
– pericardium
– myocardium
– endocardium
– neuro-electrical system
• Non-cardiac causes
– pre-load & after-load
– other organ dysfunction
• anemia, respiratory disease, sepsis…
– iatrogenesis & adherence
Cardiac Causes of HF
• 1 Pericardium
– tamponade, constrictive pericardial disease
Cardiac Causes of HF
• 2 Myocardium
– ischemia
• coronary, non-coronary ischemia (hypoxia / anemia)
– cardiomyopathy
• dilated: idiopathic, alcoholic, end stage CAD-HTN,
peripartum, post-viral
• hypertrophic obstructive cardiomyopathy
• restrictive: hemochromatosis, amyloidosis, sarcoidosis
– endocrinopathy
• thyroid, adrenal disease (cortico / pheo)
Cardiac Causes of HF
• 3 Endocardium
– valvular heart disease (including infective)
– tumors (myxomas, sarcomas, melanomas)
Cardiac Causes of HF
• 4 Conducting System
– tachycardia
• mostly atrial fibrillation
• hyperthyroidism
• sepsis (use acetaminophen in vulnerable febriles)
– bradycardia
• excess medication effect
• third degree heart block
Atrial Fibrillation - with rapid rate
Bradycardia - 28 / min
Non-cardiac Causes of HF
• Pre-load issues
– too much (or too little) fluid to the heart
• Afterload issues
– too much (or too little) resistance to arterial flow
• Examples of causes
– saline, renal dysfunction versus blood loss
– medication effect or lack of adherence
– other organ dysfunctions
• respiratory, sepsis, anemia, thyroid, liver, neuro...
Preload
Salt + Water (Saline)
=
Pulmonary and Tissue Edema
Fluid Shifts Post-Op
Salt, NSAIDS, Coxibs, TZDs,
Nephrotoxins --> Fluid Retention
IV
contrast
(not po)
Afterload --> Hypertension
Medication
• Bioavailability
• Adherence
– we didn’t give
– patient didn’t take
20 mg IV
twice as useful as
40 mg po
in Heart Failure
•
Clin Phar Ther 1995
Management of Heart Failure
Post-operative Period
versus
Chronic Ambulatory
Management of Chronic HF
A
high risk
normal heart
no HF
B
abnormal
heart
no HF
B
A
‘A’+
smoking
ACE / ARB
hypertension
BB
lipid / DM
valve dx
lifestyle
revascularize
C
abnormal
heart
prior or
current HF
refractory
C
‘B’ +
diuretics
digoxin
salt restrict
D
‘C’ +
transplant
mech assist
IV inotrope
hospice
D
HF
Management of Post-op Heart Failure
• Diagnose It !!!
• Determine the cause(s) !!!
• Remove things that make it worse
– cardiac related
– non-cardiac related
• Initiate things that make it better
– cardiac related
– non-cardiac related
Cardiac Medications are just Tools
Cardiac Effects
DRUG
HR
diuretics

ace-inhibitors

arbs

beta-blockers 
ccb
- diltiazem

- nefidipine

- amlodipine 
digoxin

nitrates

morphine

PRE




AFTER
















Case #1
POD 2 - total knee replacement
• 75 yr old
• past medical history
– heart failure 2 yr ago
– MI 3 yr & 7 yr ago
– hypertension
• Meds
– Pre-op: ASA, ramipril, atorvastatin
• Normal Saline 125 ml/hr since OR
– Saline Boluses post-op
• Now: SOB, edema, crackles
• Diagnostics
– hx: sob, no chest pain
– pe: ++ edema, + crackles, + wheezes
– lab: Hgb 100 g/l, CXR: ++ heart size, edema
• What’s the Diagnosis?
– HF owing to poor LV fx + saline loading
• What’s the Intervention?
– oxygen
– stop saline
– diuretics
– reduce afterload: especially ACE-I / ARB
Case #2
POD 3 - ORIF hip
• 87 yr old
• past medical history
– moderate hypertension
• Meds
– amlodipine, benazepril, HCTZ
– Normal Saline 100 ml/hr since OR
– 2 units blood yesterday
• Now: BP 85/43, HR 150/min, SOB
• Diagnostics
– hx: feels weak
– pe: tachycardia, JVP elevated
– lab: Hgb 105 g/l, K= 3.2, CXR: enlarged heart
– ECG: Atrial Fibrillation + LVH
• What’s the Diagnosis?
– HF: Atrial Fib + LVH + Volume Expansion
• What’s the Intervention?
– oxygen
– stop saline
– diuretics & +++ potassium
– rate control
Case #3
POD 4 - pathological hip #, ORIF
• 79 yr old
• past medical history
– advanced prostate cancer (no heroics)
– hypertension
– diabetes
• Meds
– Pre-op: ASA, Adalat XL, metformin
• Now: Chest Pain, SOB, edema, crackles,
• Diagnostics
– hx: chest pain relieved with S/L NTG
– pe: HR 110, 190/100, JVP normal
– lab: Hgb 70 g/l, CXR: mild edema
– ECG: LVH with ST-T wave changes
• What’s the Diagnosis?
– HF: anemia, myocardial ischemia, HTN-> LVH
• What’s the Intervention?
– oxygen
– transfuse RBCs (pre-diuretic!)
– beta-blocker +/- CCB
– ASA + (already on heparin)
Summary
• Heart Failure
– high index of suspicion
– preventative strategies
• Work-up
– what are the contributers?
• Therapy
– cause oriented
Acknowledgements
• You
– thank you for your kind attention