Download Heart Failure

HEART FAILURE
Mary Alt, APRN, MSN, CCRN
Cardiovascular Institute
• Definition
• Treatment over time
• Causes
• Incidence
• Risk factors
• Risk stratification
• Prevention
• Conclusion/Future direction
QUIZ
1)
Initial evaluation of heart failure should include all but the following:
a)echocardiogram
b)heart catheterization c)clinical presentation d)Lab data
2) Heart failure patients are at a higher risk for sudden cardiac death ? True or False
3)The main underlying cause of fatal arrhythmias is
a) Long QTS, Brugada syndrome, congenital problems
b) Cardiomyopathy
c) Coronary Disease
d) Electrolyte Abnormalities
4 )Patients with an Acute MI and low ef (<35%) qualify immediately for ICD?
True or False
4
HEART FAILURE-A SYNDROME
Heart failure is a constellation of symptoms and
signs produced by a complex circulatory and
neuro-hormonal response to cardiac
dysfunction
Heart failure is a complex clinical syndrome that
can results from any structural or functional
cardiac disorder that impairs the ability of the
ventricle to fill with or eject blood.
HEART FAILURE~ A LOOK AT THE PAST
THE DIAGNOSIS OF HEART FAILURE
ECHOCARDIOGRAPHIC
EVALUATION
OF CHF
• LV function
(EF),chamber size,wall
motion
• Segmental dysfunctioncoronary disease
• MS-severity, valve area
• AS- valve gradient,
valve area
• AR/MR severity
• TR- RV systolic pressure =
PA pressure
• RV function
• R/O IHSS, HCM
• R/O Pericardial Disease
• R/O rare causes e.g.
myxoma, infiltrative
disorders- restrictive
cardiomyopathy
• Diastolic function
• Hyperdynamic states
10
CLINICAL CLASSIFICATIONS
• Systolic:
• Impaired ability of the heart to contract
• Weakened muscle, enlarged heart size
• Inability of heart to empty
• Left ventricular ejection fraction (LVEF) <
40–45%
• Diastolic:
• inability of the heart to relax is impaired
• Stiff, thickened myocardial wall but normal
size
• Inability of heart to fill
• LVEF  45%
11
CLINICAL CLASSIFICATIONS
• Acute
• sudden onset with associated signs and symptoms
• Chronic
• secondary to slow structural changes occurring in the
stressed myocardium
• Acute Decompensated
• sudden exacerbation or onset of symptoms in chronic
heart failure
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CLINICAL CLASSIFICATIONS
Heart Failure is a Symptomatic Disorder
New York Heart Association-Functional
Classification
Class I: No abnormal symptoms with
activity
Class II: Symptoms with normal activity
Class III: Marked limitation due to
symptoms with less than ordinary
activity
Class IV: Symptoms at rest and severe
limitations in functional activity
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CLINICAL CLASSIFICATIONS
Heart Failure is a Progressive Disorder
ACC/AHA Stages of HF
Stage A--Presence of risk factors for heart
failure
Stage B--Presence of structural heart disease
but no Symptoms
Stage C--Presence of structural heart disease
along with signs and symptoms
Stage D--Presence of structural heart diseases
and advanced signs and symptoms
SEVERITY OF HEART FAILURE AND
MODES OF DEATH
12%
26%
64%
24%
59%
15%
33%
NYHA Class II n = 103
56%
11
%
NYHA Class IV n =
27
NYHA Class III n =
103
CHF
Other
Sudden Death
SCD RATES IN CHF PATIENTS
WITH LV DYSFUNCTION
Control Group Mortality %
50
Total Mortality
Sudden Death
44
42
41
39.7
40
30
20
20
19
17
15
11
9
10
7
6
8
4
0
CHF-STAT
GESICA
SOLVD
V-HeFT I
MERIT-HF
CIBIS-II
CARVEDILOL-US
45 months
13 months
41.4 months
27 months
12 months
16 months
6 months
Total Mortality ~15-40%; SCD accounts for ~50% of the total deaths
% Sudden Cardiac Deaths
RELATION OF LVEF TO RISK OF SCA
8
7.5%
7
6
5.1%
5
4
2.8%
3
2
1.4%
1
0
0-30%
31-40%
41-50%
LVEF
> 50%
Note: 56.5% of all SCA
victims had an LVEF <
30%
SCA RELATIONSHIP TO HF
• Patients with HF are overall at 6-9 times higher risk for SCD than general
population
• As HF progresses, pump failure (rather than SCA) becomes relatively more
likely as the cause of death
Heart Disease and Stroke Statistics—2005 Update. AHA. www. americanheart.org
SCD IN HEART FAILURE
Despite improvements in medical
therapy, symptomatic HF still confers
a 20-25% risk
of premature death in the first 2.5
years after
diagnosis.1,2
 50% of these premature deaths
are SCD
CORONARY HEART DISEASE
Coronary heart disease and its consequences
account for the majority of sudden cardiac
deaths.
5% Other*
15%
Nonischemic
Cardiomyopathy
80%
Coronary Heart
Disease
*ion-channel
abnormalities, valvular
or congenital heart
disease, other causes
MYOCARDIAL INFARCTION
• Prior myocardial infarctions are identified in as
many as 50-75% of SCA victims.
• Therapeutic innovations in the last decade* have
improved initial survival in patients with reduced
ejection fraction and may have altered the
epidemiology of post-MI risk.
*including early and
aggressive
revascularization and
effective pharmacologic
therapy
2006 ACC/AHA/ESC GUIDELINES FOR THE
MANAGEMENT OF VENTRICULAR
ARRHYTHMIAS: PRIMARY PREVENTION OF SCD
ICD Class I Recommendations:
• Patients with ischemic cardiomyopathy who are at least 40
days post-MI with an LVEF ≤ 35% and NYHA functional class II
or III
• Patients with NYHA Class II-III, LVEF ≤ 30 - 35%, non-ischemic
cardiomyopathy
• Patients who are at high risk of SCA due to genetic disorders
such as long QT syndrome, Brugada syndrome, hypertrophic
cardiomyopathy and arrhythmogenic right ventricular
dysplagia (ARVD).
ICD Class II Recommendation:
• Ischemic and non-ischemic patients with NYHA functional
class I, LVEF ≤ 30-35%
Zipes, DP, et al. 2006 ACC/AHA/ESC Practice Guidelines 5. Circulation. 2006;114;385-484
PRIMARY PREVENTION
ADVANCED HEART DISEASE
SECONDARY PREVENTION AFTER SCA
...patients who have already
experienced a life-threatening
ventricular tachyarrhythmia
event...
SCD TREATMENT OPTIONS
AED & 911 EMS Response
The success of community-based resuscitation is low, with a
median survival of 6.4% in communities with defibrillatorequipped EMS.22
Implantable Defibrillators
Limitations
• Medicare Waiting Periods
• Potential Scheduling Delays
• “Not Covered” Indications such as NYHA Class IV
patients
SCA RESUSCITATION SUCCESS VS.
TIME*
Chance of success reduced
100
90
7-10% each minute
80
70
60
%
Success
*Non-linear
50
40
30
20
10
0
1
2
3
4
5
6
Time (minutes)
Cummins RO. Annals Emerg Med. 1989;18:1269-1275.
7
8
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SCD TREATMENT OPTIONS
Wearable Defibrillator
• Non-invasive
• No Clinical intervention required
• Reduces Time to Treatment (< 60 Secs)
• 98% First Shock Success Rate
• 92% Survival to ER
• Covered During ICD “Waiting Periods”
• Post MI – 40 Days
• Post PCI/CABG – 90 Days
• NICM/DCM – 90 – 270 Days
LIFEVEST SYSTEM
ECG Electrodes
• Dry & nonadhesive
• 4 electrodes
providing 2
channels of
monitoring
Self-Gelling
Defibrillation
Electrodes
Response
Buttons
Monitor
• 1.8 lbs.
• 150 joule biphasic
shock
• Stores ECG, daily
use, etc.
LIFEVEST BY THE NUMBERS
• Over 50,000 patients have worn the LifeVest
• Currently Saving a Patient every 2 Days
• 700 Patients have been saved by the LifeVest
• 98% first shock success rate
• 92% shocked event survival
(conscious to ER arrival or stayed at home)
• Average duration of use is 2 to 3 months
• Median daily use is 94% (22.4 hours/day)
LIFE VEST
QUICK REFERENCE GUIDE
Sustained VT
(> 30
Seconds)
- or -
Low EF (35% or
less)
- or -
with
Previous MI
or
NICM/DCM
ICD Explant
CONCLUSIONS
• Pharmacologic and device therapies are
effective in preventing SCD and overall
mortality in high risk post-MI and HF patients:
– Beta-blockers
– ACE inhibitors
– Aldosterone Receptor Blockade Drugs
(HF)
– ICD therapy
• Prophylactic use of ICD therapy prevents
SCD and saves lives in patients with CAD and
LV dysfunction, who are also on optimal
pharmacologic therapies.
QUIZ
1)
Initial evaluation of heart failure should include all but the following:
a)echocardiogram b) heart cath c)clinical presentation d)Lab data
2) Heart failure patients are at a higher risk for sudden cardiac death ? True or False
3)The main underlying cause of fatal arrhythmias is
a) Long QTS, Brugada synd, congenital problems
b) Cardiomyopathy
c) Coronary Disease
d) Electrolyte Abnormalities
4 )Patients with an Acute MI and low ef (<35%) qualify immediately for ICD? True or
False
Thank you