Download Congestive Heart Failure

Chronic Management of Heart
Failure
Topic Discussion
Outline
•
•
•
•
Epidemiology
Etiology
Pathophysiology
Presentation
▫ Classification
• Treatment of chronic heart failure
▫ Monitoring
What is Heart Failure
• Heart can’t pump enough blood to meet the
metabolic needs of the body
▫ Clinically = loss of energy
• Systolic
▫ Reduced left ventricular ejection fraction (LVEF)
• Diastolic
▫ Disturbed relaxation
Epidemiology
• Five million Americans
• 550,000 new cases/year
• Most common hospital discharge diagnosis in
adults over 65
• Overall 5 year survival after diagnosis - 50%
Etiology
• Reduction in muscle mass
▫ Myocardial infarction (MI)
▫ Coronary Artery Disease
• Dilated cardiomyopathies
• Ventricular hypertrophy
▫ Pressure overload
 Hypertension
▫ Volume overload
Pathophysiology
• Decreased cardiac output
• Compensatory mechanisms
▫ Tachycardia and increased contractility
▫ Increase preload (sodium (Na) and H2O
retention)
▫ Vasoconstriction
• Ventricular hypertrophy and remodeling
Pathophysiology
• Neurohormonal model
▫ Angiotensin II
 Aldosterone
▫ Norepinephrine/catecholamines
▫ Endothelin
▫ Inflammatory cytokines
Pathophysiology
• Decreased left ventricular ejection fraction
(LVEF)
• Increased preload
▫ With minimal changes in stroke volume
• Increased afterload
▫ Slight change in afterload causes significant
changes in stroke volume
Presentation
• Fatigue
• Pulmonary congestion
– Dyspnea, orthopnea, paroxysmal nocturnal dyspnea,
cough
– Pulmonary edema, pleural effusion
– Rales, S3
• Systemic congestion
– Jugular Venous Distention (JVD)
– Peripheral edema/weight gain, cool extremities
– Nausea/vomiting
– Hepatojugular reflux, splenomegaly, hepatomegaly
Presentation
• New York Heart Association Classification
▫ Stage 1
 No limitations of activity
▫ Stage 2
 Slight, mild limitation of activity
▫ Stage 3
 Marked limitation of physical activity
▫ Stage 4
 Severe limitation of physical activities; symptoms at
rest
Presentation
• ACC/AHA staging
▫ Stage A
 Patients at high risk
▫ Stage B
 Patients with structural heart disease but no heart
failure (HF) signs or symptoms
▫ Stage C
 Patients with structural disease and symptoms
▫ Stage D
 Refractory HF
Treatment of Chronic Heart Failure
Treatment
• Goals
▫ Short-term
 Relieve symptoms and improve quality of life
▫ Long-term
 Slow progression of the disease and prolong survival
▫ Pharmacotherapeutic
 Disrupt neurohormonal mechanisms
 Decrease preload
 Decrease afterload
Treatment
• Non-drug
▫
▫
▫
▫
▫
▫
Treat the underlying cause
Restrict sodium (Na)<2g/day
Avoid overexertion
Avoid alcohol
Immunizations
Avoid drugs that worsen heart failure
Treatment: Drug Therapy
• Drugs that improve survival
– Angiotension converting enzyme inhibitor (ACE-I)
– Beta blockers
– Aldosterone antagonists
• Drugs that improve symptoms
– Diuretics
– Digoxin
• Alternatives
– Angiotension receptor blocker (ARB)
– Hydralazine/Isosorbide dinitrate (ISDN)
Treatment: General Approach
Stage
Treatment
A
Risk factor reduction
B (MI or LVEF<40%)
ACE-I + Beta
Blocker
ARB
C
ACE-I + Beta Blocker
+ Diuretic
+ Digoxin
+ Aldosterone
antagonist
ARB,
hydralazine/I
SDN
Fluid retention
Frequent hospitalizations
Severe + low LVEF or early
after MI
Alternative
s
Treatment: ACE-I
• Patients: stage A with other indications, stages B,C,D
• Benefit: alleviate symptoms, reduce risk of death and
hospitalization
• MoA: prevents conversion of angiotensin I to angiotensin II
– Reduce preload and afterload, interrupt neurohormonal cycle
• Dosing
– Start low and titrate to target
Drug
Initial Dose
Target Dose
Captopril
6.25mg TID
50 TID
Enalapril
2.5mg BID
10-20 BID
Lisinopril
5mg QD
20-40 QD
Ramipril
1.25-2.5mg QD
10 mg QD
Trandolapril
0.5mg QD
4 mg QD
Treatment: ACE-I
• Adverse events
▫ Hypotension
 Don’t use if systolic blood pressure (SBP) <80mmHg
▫ Angioedema
▫ Acute renal failure
 Risk increases: hypovolemic, high dose diuretics, renal artery
stenosis
▫ Cough
▫ Hyperkalemia
▫ Others: dysgeusia, rash
• Monitoring
▫ Potassium (K+), serum creatinine (Scr), after 1-2 weeks
▫ Blood pressure (BP)
Treatment: ARBs
•
•
•
•
Alternative when patient is ACE-I intolerant
Benefit: non inferior to ACE-I
MoA: block angiotensin receptor
Dosing
Drug
Initial Dose
Target Dose
Candesartan
4-8mg QD
32mg QD
Valsartan
20-40mg BID
160mg BID
Losartan
25-50mg QD
50-100mg QD
Treatment: ARBs
• Adverse events
▫ Hypotension
 Don’t use if SBP <80mmHg
▫ Angioedema
▫ Acute renal failure
▫ Hyperkalemia
• Monitoring
▫ K+, Scr, after 1-2 weeks
▫ BP
Treatment: Beta Blockers
• Patients: stages B, C, D
• Benefit: reduce risk of death and hospitalization,
improve symptoms
• Effects: inhibit effects of the sympathetic nervous
systems
• Agents and dosing
– Start when patient is stable
– Start low and go slow – 2 week intervals
– Expect transient discomfort: congestion, hypotension
Drug
Initial Dose
Target Dose
Bisoprolol
1.25 mg QD
10mg QD
Carvedilol
3.125mg BID
25mg BID
Carvedilol CR
10mg QD
80mg QD
Metoprolol succinate
12.5-25mg QD
200mg QD
Treatment: Beta Blockers
• Monitoring
– BP
– HR
– Weight daily and adjust diuretic
dose
• Adverse events
–
–
–
–
–
Fluid retention
Hypotension/bradycardia
Fatigue
Depression
Erectile dysfunction
• Disease state considerations
▫ Asthma/COPD
▫ Diabetes
▫ Peripheral Vascular
Disease/Raynauds
• Don’t stop abruptly
Treatment: Aldosterone Antagonists
• Patients: severe heart failure and low LVEF, or early
after MI
• MoA: compete with aldosterone
• Benefit: reduced risk of death and hospitalization,
symptom improvement
▫ Select patients carefully
 SCr <2.5mg/dl or <2.0mg/dl
 Don’t use in CrCl<30ml/min
 K+ < 5.0meq/L
• Dosing
Drug
Initial Dose
Target Dose
Spironolactone
12.5-25mg QD
50mg QD
Eplerenone
25mg QD
50mg QD
Treatment: Aldosterone Antagonists
• Monitoring
– BP
– SCr
• Renally adjusted
– K+ at 3 days, 1 week, monthly x 3 months
– Start series over if changes made to dose or changes to
ACE-I/ARB regimen
– Decrease dose or discontinue when k+ >5.5meq/l
• Adverse events
– Hyperkalemia
– Gynecomastia
• Less with eplerenone
Treatment: Loop Diuretics
•
•
•
•
•
Patients: with fluid overload
Benefit: rapid symptom relief
MoA: inhibit Na reabsorption in distal tubule
Effects: diuresis and dilation of veins (IV)
Dosing
▫ Use higher doses in renal insufficiency
▫ Oral loop equivalents
 1mg bumetanide=20mg torsemide=40mg furosemide
Treatment: Loop Diuretics
• Monitoring
▫ Weight
 Goal weight loss is 0.5-1kg/day
▫ Signs and symptoms of fluid overload
▫ BP
▫ Electrolytes
• Adverse events
▫
▫
▫
▫
▫
Electrolyte (K+, Mg2+, Ca2+) and fluid depletion
Hypotenstion
Azotemia
Rash
Ototoxicity
Weight Gain
• When to call a doctor
▫ 2-3 pounds in a day
▫ 5 pounds in 5 days
Treatment: Digoxin
• Patients: frequent hospitalizations, rate control in
atrial fibrillation
• Benefit: reduce symptoms, prevent hospitalization,
control rhythm, enhance exercise tolerance
• MoA: inhibit Na/K ATPase which results in
increased contractility
• Dosing
▫ 0.125-0.250mg QD
▫ Plasma concentration
▫ 0.5-1.0ng/mL
Treatment: Digoxin
• Monitoring
▫ HR and rhythm
▫ Levels at 5-7 days; 6-12 hours after dose
▫ Electrolytes and renal function
• Adverse events
▫ Cardiac arrhythmias
 PAT with block
▫ GI upset
▫ Neurological complaints
▫ Vision changes
Treatment: Digoxin
• Drug interactions
▫ Verapamil, quinidine, amiodarone
• Digoxin toxicity
▫ Predisposing factors: hypokalemia,
hypomagnesemia, hypothyroid, hypercalcemia
▫ Treatment
 Digoxin immune fab
Treatment: ISDN/Hydralazine
• Alternative for ACE-I/ARB
▫ African American
• MoA: arterial and venous dilation
• Dosing
▫ Nitrate-free interval
Drug
Initial Dose
Target Dose
Hyralazine
10-25mg T-QID
225-300mg/day
divided
ISDN
20mg T-QID
160mg/day divided
QID
Bidil ®
1 tablet TID
2 tablets TID
ISDN 20mg + hydrlazine 37.5 mg
Treatment: ISDN/Hydralazine
• Monitoring
▫ BP/HR
▫ ANA titer
• Adverse events
▫
▫
▫
▫
Headache
GI upset
Dizziness
Weakness
• Hard to tolerate/high pill burden
Treatment: Stage D
• Fluid overload:
▫ 2 Drug combination (i.e., loop + metolazone)
▫ Fluid restriction 2L/day
• Neurohormonal
▫ ACE-I’s and beta blockers
 Less likely to tolerate
• Other
▫ Cardiac transplant, left ventricular assist device
(LVAD)
Drugs that Worsen Heart Failure
• Negative inotropes
– Calcium channel blockers
– Beta blockers
– Antiarrhythmics:
disopyramide, flecainide,
propafenone, sotalol
• Exogenous Na
–
–
–
–
Sodium polystyrene sulfonate
Antibiotics
Antacids
Cough syrups
• Na-retaining products
– NSAIDs
– Glucocorticoids
– Androgens/estrogens
• Cardiotoxics
–
–
–
–
Ethanol
Doxorubicin
Trastuzumab
Infliximab
• Others
– Glitazones
Drugs that are Safe in Heart Failure
• Calcium channel blockers
▫ Amlodipine
▫ Felodipine
• Antiarrhythmics
▫ Amiodarone
▫ Dofetilide
Treatment: Heart Failure with Normal
LVEF
• Control underlying disease states
▫ BP
▫ Ventricular rate with A.fib
• Symptom control
▫ Diuretics for congestion
▫ Beta blockers, ACE-Is, ARBs, calcium channel
blockers might provide some symptom relief
Case
• 50 yom presents with a new diagnosis of heart
failure
• He takes hydrochlorothiazide 25mg daily for
hypertension and uses ibuprofen ~3x/week for
headaches.
• His LVEF is 50%
• He is currently experiencing peripheral edema
and significant shortness of breath
Case
• What stage of heart failure does the patient
have?
▫ Stage C
• What should we do with this patient’s
medications today?
▫ ACE-I
▫ Loop diuretic (d/c hydrochlorothiazide)
▫ Stop ibuprofen
• What dose should we start at?
▫ Start low
Case
• What should we monitor?
▫ Weight, symptoms
▫ K+, SCr
▫ BP
• What is the goal weight loss for this patient?
▫ 0.5-1kg/day
• What else do we want to tell the patient?
▫ Non-drug therapy
Case
• The patient returns in a few months and is stable on
lisinopril 30mg daily and furosemide 20mg daily.
• What do you want to do now?
▫ Add a beta blocker
• Which one?
▫ Metoprolol XL, bisoprolol, or carvedilol
• What dose?
▫ Start low and titrate!
• What do you want to tell the patient about his
symptoms?
▫ They might get worse initially
Case
• What might you consider if the patient’s LVEF
was low?
▫ Spironolactone
• What might you consider if the patient is having
frequent hospitalizations?
▫ Digoxin