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Management of CHF on Hospice David Kregenow, MD Evergreen Health Hospice and Palliative Care Disclosures • I have no relevant financial conflicts of interest • My background is in Pulmonary and Critical Care Medicine • The material that follows comes from: Consensus Statement: End-of-Life Care in Patients with Heart Failure. J Cardiac Failure 2014;20:121-134 on behalf of the Quality of Care Committee for the Heart Failure Society of America. Outline • • • • • • • • • Classification and Prognosis in HF Case #1 Diastolic vs. Systolic Failure Connections to Renal and Respiratory Physiology Symptom Inventory #1 Case #2 Systolic Failure and Therapies Symptoms Inventory #2 Mechanical Circulatory Support (LVAD) Prognosis of Heart Failure, NYHA Classification Class Symptoms I Cardiac disease, but no symptoms and no limitation in ordinary physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath). II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath). III Marked limitation in activity due to symptoms, even during less-thanordinary activity, e.g. walking short distances (20–100 m). Comfortable only at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea. IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients. Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases. Prognosis of Heart Failure, Objective Assessment Class Description A No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity. Risk factors but no structural heart disease. B Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest. Structural heart disease but minimal symptoms. C Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest. Symptomatic heart failure. D Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest. Refractory symptoms despite guideline-directed medical therapy. Prognostic Tool Seattle Heart Failure Model www.seattleheartfailuremodel.org/ Hospice Eligibility • Models may help • Guidelines help – NYHA Class IV Symptoms – Symptoms despite maximal therapy – Persistent resting tachycardia • Physiology helps – Combination of heart failure and renal impairment is medically very challenging • HF Survival on Hospice is 81 days longer on average than without Hospice. J Pain Symp Mgmt 2007; 33(3): 238-46. Case 1 Presentation • Phyllis is an 87 year old woman hospitalized four times this year with shortness of breath and fluid overload. • She has a long history of hypertension, with moderate chronic kidney disease, macular degeneration, and paroxysmal atrial fibrillation, and a history of TIAs. • She has recurrent difficulty with falls complicated by persistent lower extremity edema, and chronic bilateral pleural effusions. • Her ECHO shows LVH, EF 65%, Biatrial Enlargement, and Mod-Severe Pulmonary Hypertension. • She is widowed and lives in a AFH. The Picture of CHF Two Main Paths to CHF HFnEF Normal HFrEF HFpEF and HFrEF HFpEF • Older • F>M • Hypertension • Few Treatment Options • Maintain Euvolemia HFrEF • Younger • M>F • Ischemia • Medical Therapies • Inotrope Infusions • Implantable Devices • Mechanical Circulatory Support • Cardiac Transplantation Normal Echocardiogram https://www.youtube.com/watch?feature=pla yer_detailpage&v=7TWu0_Gklzo Normal Echocardiogram HFpEF ECHO Sensation of Dyspnea Sensation of Dyspnea Treatments for Dyspnea • Maintenance of euvolemia – Sodium and fluid restrictions – Diuretics – Leg elevation above the atrium • Digoxin (Narrow therapeutic window) • When near EOL: – – – – Opioids (Careful of impaired renal excretion) Oxygen if hypoxemia is present Benzodiazepines Elevation of the Head of the Bed, Fan Leg Elevation Sleep Disorders in CHF • Approximately 50% of HF patients have sleep disordered breathing – – – – – Orthopnea Nocturia Obstructive Sleep Apnea Central Sleep Apnea Cheynes-Stokes Respirations • Sleep Maintenance vs. Insomnia • Treatments: – – – – Sleep Hygiene CPAP Nocturnal Oxygen Nocturnal urination aids Kidney Physiology Diuretics • Loop of Henle: Furosemide, Torsemide • Distal Tubule: Metalazone, Thiazides • Potassium Sparing/Neurohumoral: Spironolactone Kidney Physiology Thiazide Diuretics Loop Diuretics Fatigue and Weakness in CHF • Multifactorial – Cardiac insufficiency – Muscle loss – Deconditioning – Other: anemia, sleep disorders, depression, hypothyroidism • Optimize what you can • Stimulants? Causes of Confusion and Delirium in CHF • Impaired cerebral blood flow and micro emboli • Medications (e.g.. Sleep aids) • Sleep-wake cycle disturbance • Low BP associated with high doses of ACE Inhibitors and Beta Blockers Case 2 Presentation • Paul is a 54 year old man with ischemic cardiomyopathy living at home on hospice hoping for a heart transplant • He has a family history of early death from MI, and suffered his first heart attack at age 45, presenting initially with a large anterior MI • He’s had an ICD placed for syncope for paroxysmal ventricular fibrillation Case 2 Presentation Continues • His CHF progressed over the last 9 years • He has been felt to be a good candidate for heart transplant, but deteriorated before a suitable organ became available • He has been placed on mechanical circulatory support (LVAD) and a milrinone infusion • However, he has developed a chronic strep infection associated with his device and is no longer able to have a transplant Dilated Cardiomyopathy ECHO https://www.youtube.com/watch?v=37KDMNi V3AU&feature=player_detailpage Dilated Cardiomyopathy ECHO Diuretics Potassium Sparing Diuretics Beta Blockers ACE Inhibitors Diuretics Pain in CHF • Common in advanced CHF • Angina – Nitrates • Other types of pain – Opiates – Avoid NSAIDs GI Disorders in CHF • Cardiac cachexia – Anorexia – Increased catabolism • Nausea – Medications (e.g.. ASA) – Reduced Intestinal Perfusion • Constipation – Decreased intake and activity – Medications (e.g.. Opioids) Depression and Anxiety in CHF • 1/3 of patients with advanced HF have clinical depression – Higher symptom burden – Increased adverse outcomes • Spiritual Care • Cognitive Behavioral Therapy • Medications – SSRIs at low dose, watch for fluid retention and hyponatremia (mental status changes with edema) – TCAs can prolong the QTc – Psychostimulants Cough • Often worse at night – Pulmonary Congestion – Pneumonitis – Bronchitis • ACE Inhibitors – Transition to ARBs • Secretions Discontinuing Medications for CHF on Hospice • Medical management of CHF (that has helped raise life expectancy in the last 40 years) truly pushes the limits of low BPs and low HRs • On Hospice, the Goals of Care are more nuanced than survival so expectations and therapies need adjusting – ACE Inhibitors – Beta Blockers Conclusion • Heart Failure is common and often chronic • Salt and water retention produce much of the morbidity so understanding diuretics helps management • Preserved EF vs. Reduced EF are significantly different entities that can look alike clinically • There is a high symptom burden, but many tools • Often less is more for the patient • “The LVADs are coming!”