Download Heart Failure - NMHIMA New Mexico

Mark Garcia, MD Chief Resident in Quality and Safety
Department of Internal Medicine
University of New Mexico Health Science Center
Heart Failure Overview
• UNM Hospital – Participates in American Heart Association (AHA) Get With The Guidelines (GWTG)
• Continuous quality improvement initiative to ensure the highest quality of care for heart failure patients
– Gold Performance Achievement Awards
– Target: HF member • Current quality improvement project – Discharge medication compliance and discharge instruction – Coding review and accuracy of documentation Epidemiology • In 2010, ~ 6.6 million American adults had HF • Lifetime risk for developing heart failure is 1:5
• ~1 million HF hospital discharges per year • ~50% of people diagnosed with HF will die within 5 years
Heart Disease and Stroke Statistics—2012 Update Circulation 2012
Case 1
82 y/o M evaluated in emergency department for shortness of breath progressive over 1 week and new onset lower extremity edema. On exam heart sounds reveal S1, S2, and S3, jugular vein is distended, he has mild lower extremity edema, and chest x‐ray shows moderate pulmonary edema. Labs reveal BNP 850. Echocardiogram shows reduced left ventricular ejection fraction of 30%. Is this heart failure and if so, what type?
Goals
• Become more familiar with:
– heart failure physiology – heart failure terminology
– clinical features of heart failure
– the causes and diagnosis of heart failure Physiology
• Diastolic – relaxation phase (filling of blood) • Systolic – contraction phase (ejection of blood) Contraction
(Ejection of blood) Relaxation
(Filling of blood)
Diastolic and Systolic Blood Pressure http://www.euroclinix.net/diastolic‐systolic‐blood‐pressure.html
Physiology
• Diastolic Heart Failure – relaxation problem • Systolic Heart Failure – contraction problem Relaxation problem –
diastolic dysfunction Contraction problem –
systolic dysfunction Heart failure in women http://www.health.harvard.edu/newsletters/Harvard_Womens_Health_Watch/2008/September/Heart_failure_in_women
Failure
• Problems with relaxation (filling) and/or contraction (ejection) => elevated intracardiac pressures => congestion (decompensation) Failure Terms
• Cardiomyopathy ‐ disease of the heart muscle manifested with structural and functional problems
• Heart Failure ‐ clinical syndrome that impairs the ability of the ventricle to fill or eject blood causing specific signs and symptoms.
• Congestive Heart Failure ‐ avoid using Heart Failure Terminology
• Heart failure with preserved ejection fraction “HFpEF” (diastolic dysfunction Æ filling problem)
– Preserved ejection fraction = EF > 40%
– Clinical signs and symptoms of failure
• Heart Failure with reduced ejection fraction “HFrEF” (systolic dysfunction Æ ejection problem)
– Reduced ejection fraction = EF < 40%
– Clinical signs and symptoms of failure
• Replacing Congestive Heart Failure (CHF) Diastolic dysfunction => Systolic dysfunction => relaxation (filling) problem =>
contraction (ejection) problem =>
Heart failure with preserved ejection Heart failure with reduced ejection fraction (HFpEF) fraction (HFrEF)
Heart failure in women http://www.health.harvard.edu/newsletters/Harvard_Womens_Health_Watch/2008/September/Heart_failure_in_women
Cardiac Assessment By: Close the Gap National Heart, Lung and Blood Institute; National Institutes of Health Heart Failure Terminology
• Heart failure with preserved ejection fraction “HFpEF” (diastolic dysfunction Æ filling problem)
– Preserved ejection fraction = EF > 40%
– Clinical signs and symptoms of failure
• Heart Failure with reduced ejection fraction “HFrEF” (systolic dysfunction Æ ejection problem)
– Reduced ejection fraction = EF < 40%
– Clinical signs and symptoms of failure
• Replacing Congestive Heart Failure (CHF) Ejection Fraction
Ejection Fraction (EF) How much blood the ventricle pumps out with each contraction
EF = amount of blood pumped out of the ventricle total blood in ventricle End diastolic volume http://www.hrsonline.org/Patient‐Resources/The‐Normal‐Heart/Ejection‐Fraction#axzz2NYzTQz9L
Ejection Fraction • EF = 60% means 60% of the blood is pushed out with each ventricular contraction • Normal EF = 55‐70%
• Ventricular dysfunction EF = 40‐50%
• Preserved EF > 40%
• Reduced EF < 40%
Heart Failure Terminology
• Heart failure with preserved ejection fraction “HFpEF” (diastolic dysfunction Æ filling problem)
– Preserved ejection fraction = EF > 40%
– Clinical signs and symptoms of failure
• Heart Failure with reduced ejection fraction “HFrEF” (systolic dysfunction Æ ejection problem)
– Reduced ejection fraction = EF < 40%
– Clinical signs and symptoms of failure
• Replacing Congestive Heart Failure (CHF) Heart Failure Terminology
• Heart failure with preserved ejection fraction “HFpEF” (diastolic dysfunction Æ filling problem)
– Preserved ejection fraction = EF > 40%
– Clinical signs and symptoms of failure
• Heart Failure with reduced ejection fraction “HFrEF” (systolic dysfunction Æ ejection problem)
– Reduced ejection fraction = EF < 40%
– Clinical signs and symptoms of failure
• Replacing Congestive Heart Failure (CHF) Congestion = Decompensated
heart_failure_symptoms_heart_currents_blogspot.jpg http://heartcurrents.blogspot.com/2008/11/using‐stem‐cells‐for‐heart‐failure.html
Clinical Symptoms of Congestion
(Patient complaints)
• Dyspnea/Short of breath (SOB)
• Orthopnea • Paroxysmal nocturnal dyspnea (PND)
• Swelling lower extremity
• Abdominal distention/fullness http://problemdefinitions.wikispaces.com/file/view/pink_puffer.jpg/1
11257483/269x236/pink_puffer.jpg
Clinical Signs of Congestion (Physical Exam) •
•
•
•
•
Pulmonary edema – fluid in lungs Jugular venous distention (JVD)
Peripheral Edema Abdominal distention Cardiac Auscultation:
– S3 (extra heart sound)
– Murmurs (mitral, tricuspid) – Displaced point of maximal impulse Left Sided Congestion Pulmonary edema Enlarged cardiac silhouette
Normal
Courtesy of Paul Stark, MD and Courtesy of Carol M Black, MD ‐ ©2013 UpToDate®
Right Sided Congestion Pitting edema Jugular venous distention James Heilman, MD ‐ http://en.wikipedia.org/wiki/File:Combinpedal.jpg and Courtesy of http://meded.ucsd.edu/clinicalimg/head_ejdistension1.htm Goals
• Become more familiar with:
– heart failure physiology – heart failure terminology
– clinical features of heart failure
– the causes and diagnosis of heart failure Diagnosis of Heart Failure
• “HF is defined as a clinical syndrome that is characterized by specific symptoms…and signs.” • “There is no single diagnostic test for HF”
2009 focused update
incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management
of heart failure in adults: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol 2009;53:e1–90.
Causes of Heart Failure
• Ischemic cardiomyopathy – Coronary artery disease leading to ischemia and infarctions – Most common Causes of Heart Failure
• Non‐ischemic
– Hypertension
– Valvular disease – Arrhythmias – Uncontrolled diabetes – Cardiotoxic agents (alcohol, cocaine, meth) – Hypo/hyperthyroidism
– Anemia – Many others http://www.sos03.com/files/styles/health_images/public/Arterial%20Hypertension.jpg
Review Process • Does the patient have congestion? • Did the patient respond to heart failure treatments? • If HF, then what type of HF is it? • Are there other possibilities for the congestion? Review Process • Review discharge summary – Diagnosis and hospital course • Review History and Physical – Symptoms – dyspnea, swelling, PND, orthopnea
– Signs – elevated JVD and LE edema • Ejection Fraction – Echocardiogram, cardiac catherization, MUGA scan, Nuclear medicine scan, cardiac MRI or CT scan Review Process • Chest x‐ray – pulmonary edema, enlarged cardiac silhouette • Labs – BNP elevation, renal failure, low sodium, others
• Cardiac catheterization – elevated intracardiac
pressures Common Pitfalls • Fluid overload
– Dialysis missed – Post‐op
– Sepsis/infection management – Blood transfusions • BNP eleva on ≠ Heart failure
– Can be useful if diagnosis is uncertain in the acute setting Http://upload.wikimedia.org/wikipedia/commons/d/d4/Iv1‐07_014.jpg and http://emdose.files.wordpress.com/2012/08/untitled.jpg Heart Failure Terminology
• Heart failure with preserved ejection fraction “HFpEF” (diastolic dysfunction Æ filling problem)
– Preserved ejection fraction = EF > 40%
– Clinical signs and symptoms of failure
• Heart Failure with reduced ejection fraction “HFrEF” (systolic dysfunction Æ ejection problem)
– Reduced ejection fraction = EF < 40%
– Clinical signs and symptoms of failure
Case 1
82 y/o M evaluated in emergency department for shortness of breath progressive over 1 week and new onset lower extremity edema. On exam heart sounds reveal S1, S2, and S3, jugular vein is distended, he has mild lower extremity edema, and chest x‐ray shows moderate pulmonary edema. Labs reveal BNP 850. Echocardiogram shows reduced left ventricular ejection fraction of 30%. Is this heart failure and if so, what type?
Case 1
• Heart Failure with reduced ejection fraction (HFrEF)
– Clinical signs and symptoms of HF • Shortness of breath, LE edema, elevated JVD, pulm
edema, S3
– Ejection fraction 30% (reduced) Case 2
53 y/o M with history of hypertension and diabetes presents to the emergency room with 1 week of progressive shortness of breath with dry cough and new onset lower extremity edema. On exam heart sounds reveal S1, S2, and S3, jugular vein is distended, he has mild lower extremity edema, and chest x‐ray shows moderate pulmonary edema. Labs reveal BNP 850. Echocardiogram shows normal ejection fraction with ventricular wall thickening. Is this heart failure and if so, what type?
Case 2
• Heart Failure with preserved ejection fraction (HFpEF)
=> Clinical signs and symptoms of HF • Shortness of breath, LE edema, elevated JVD, pulm
edema, S3
=> Ejection fraction >40% (preserved) Case 3
52 y/o M with history of end stage renal disease on hemodialysis, hypertension, and diabetes. He has missed dialysis for the past week due to his car being broken down. He now presents to the emergency room with 1 week of progressive shortness of breath with dry cough and worsening lower extremity edema. On exam heart sounds reveal S1, S2, and S3, jugular vein is distended, he has moderate lower extremity edema, and chest x‐ray shows moderate pulmonary edema. Labs reveal BNP 850. Echocardiogram shows normal ejection fraction with ventricular wall thickening. Is this heart failure and if so, what type?
Case 3
• Not likely heart failure
– Volume overload from missing dialysis
– Would this patient have these symptoms, if he did not miss dialysis? References
Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol 2009;53:e1–90.
Roger VL, Go AS, Lloyd‐Jones DM, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ, Sorlie PD, Sotoodehnia N, Turan TN, Virani
SS, Wong ND, Woo D, Turner MB; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2–e220.
John J.V. McMurray (Chairperson) (UK)*, Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Angelo Auricchio
(Switzerland), Michael Bo¨hm (Germany), Kenneth Dickstein (Norway), Volkmar Falk (Switzerland), Gerasimos Filippatos (Greece), Caˆndida Fonseca (Portugal), Miguel Angel Gomez‐Sanchez (Spain), Tiny Jaarsma (Sweden), Lars Køber (Denmark), Gregory Y.H. Lip (UK), Aldo Pietro Maggioni (Italy), Alexander Parkhomenko (Ukraine), Burkert M. Pieske (Austria), Bogdan A. Popescu (Romania), Per K. Rønnevik (Norway), Frans H. Rutten (The Netherlands), Juerg Schwitter (Switzerland), Petar Seferovic (Serbia), Janina
Stepinska (Poland), Pedro T. Trindade (Switzerland), Adriaan A. Voors (The Netherlands), Faiez Zannad (France), Andreas Zeiher
(Germany). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC, European Heart Journal (2012) 33, 1787–1847