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5/24/2017 5/24/2017 1 11 Heart Failure 101 out of the lab, into the clinic 5/24/2017 1 2 Objectives today Provide an overview of clinical aspects of heart failure diagnosis assessment management clinical pearls from the trenches—front line HF care 5/24/2017 1 3 Definition of heart failure state in which the heart cannot pump a sufficient supply of blood to meet the physiological requirements of the body, or requires elevated filling pressures to do so a pathological condition leading to a debilitating illness characterized by poor exercise tolerance, chronic fatigue, along with high morbidity and mortality Rosens ER medicine 6th ed 5/24/2017 5/24/2017 1 44 Some truths about HF HF is a chronic, progressive condition that is life limiting HF is a terminal condition—eventually it leads to the patient’s death There is no “cure” HF is common HF prevalence is on the rise 5/24/2017 5/24/2017 1 55 Implications for the patient HF symptoms range from none to an inability to complete basic ADLs HF patients may not appear ill, but have profound symptoms; unable to function in the way family members feel they should HF clinical progression is cyclical, and unpredictable—patients have no control over what they can and cannot do on any given day 5/24/2017 1 6 “I wish I looked worse, and felt better!!” George J- HF patient 5/24/2017 1 7 What is your risk? 1 in 5 will develop heart failure 5/24/2017 1 Lloyd-Jones et al, Lifetime Risk for Developing Congestive Heart 8 Failure Circulation 2002; 106: 3068 - 3072. Heart failure: not going away 5/24/2017 1 Arnold Can J Cardiol 2007 9 The cost of heart failure Total Cost $2.96 billion Hospitalization $15.4 52% $3 billion 13% 7% 9% Physicians/Other Professionals $2.0 Drugs/Other Home Healthcare Medical Durables $2.4 $3.1 Lost Productivity/ Mortality* $2.8 *Lost future earnings of persons who will die in 2006, 5/24/2017 discounted by 3% Nursing Home $3.9 8% 10% 1 10 AHA. 2006 Heart and Stroke Statistical Update Heart failure: the numbers Prevalence 600,000 Canadians Incidence 50,000 / year Hospitalization #1 cause Average stay 7 days 1.4 million days Death in hospital 30 days post discharge 1 year 32% 2-22% 10% 5 year 50% J. Ezekowitz 2008 CMAJ 2009, EJHF 2008 5/24/2017 5/24/2017 1 11 11 Modes of death in HF 50% of HF patients “DROP” sudden 50% cardiac death of HF patients “DROWN” progressive 5/24/2017 5/24/2017 congestion 1 12 12 HF etiology ISCHEMIC (2/3 HF) CAD-ischemia+/-MI NON ISCHEMIC (1/3 HF) Dilated Hypertrophic Restrictive Valvular 5/24/2017 5/24/2017 1 13 13 HF rarely exists in a Vacuum Diabetes COPD Renal disease Thyroid disorder Cancer It is not uncommon for the heart failure patient to have one or all of the above 5/24/2017 5/24/2017 1 14 14 Mechanisms of heart failure myocardial injury mechanical abnormalities electrical disorders left ventricular dysfunction loss of pump Rosa Gutierrez 2006 5/24/2017 1 15 Compensatory mechanisms loss of pump (CO) neurohormonal activation BNP SNS vasopressin AT I - II aldosterone Rosa Gutierrez 2006 5/24/2017 5/24/2017 1 16 Chemical mediators of HF Angiotensin I / II Aldosterone ADH-antidiuretic hormone Epinephrine / Norepinephrine Vasopressin Endothelins Natiuretic peptides Atrial NP B-type NP C-type NP 5/24/2017 1 17 A toxic brew… 5/24/2017 1 18 myocardial injury neurohormonal activation hypertrophy-dilation “remodeling” vasoconstriction Na+ + H2O retention by the kidney heart failure Rosa Gutierrez 2006 5/24/2017 1 19 Compensatory mechanisms the heart will attempt to maintain perfusion in response to any increased burden of output loss of functioning myocytes by a variety of mechanisms… these mechanisms all worsen HF—by provoking further pump failure over time 5/24/2017 5/24/2017 1 20 20 MVO2 MVO2-myocardial oxygen demand a measure of cardiac workload: MVO2 increases with heart size, HR, contraction, and resistance to contraction in the healthy heart, MVO2 can be easily met with most workload demands in HF—MVO2 increases as the hearts ability to supply itself decreases 5/24/2017 5/24/2017 1 21 21 Compensated heart failure the patient appears normal but: the exercise capacity is decreased there is an increase in CO and BP there is an increase in the work of the heart further decrease in cardiac function …causing decrease in the force of the contraction and CO over time 5/24/2017 5/24/2017 1 Rosa Guterriez 2006 22 22 Types of heart failure compensated if the force of the contraction is moderately decreased the heart can meet the metabolic demands temporary improvement CO decompensated occurs when the force of the contraction is decreased further resulting in the appearance of clinical signs & symptoms Rosa Guterriez 2006 5/24/2017 5/24/2017 1 23 23 Diagnosing HF More difficult than you’d think 5/24/2017 1 24 Diagnosis of HF-CCS 2006 5/24/2017 5/24/2017 1 25 25 Diagnostic accuracy of traditional HF work-up 5/24/2017 1 26 Dao Q et al J Am Coll Cardiol 2001;37:379-85 Modes of heart failure Systolic Diastolic pumping dysfunction filling dysfunction Right sided HF Left sided HF A HF patient can have one or several of these It gets complicated…. 5/24/2017 5/24/2017 1 27 27 HF TESTING ECHO anyone? 5/24/2017 1 28 Echocardiogram WHY in HF: useful for assessing chamber size volume of cavity thickness of walls assessing pumping function (systolic) assessing filling function (diastolic) determining LVEFx within 10% 5/24/2017 1 29 Echo… determines chamber size and function, thickness of the walls of the heart, and how well each wall moves evaluates the function of valves and myocardium by looking at blood flow with doppler can be viewed live, and stored digitally or on tape 5/24/2017 1 30 Echo… valve function / movement structure, thickness, movement of valves identify scars / calcifications / infection vegetations assessing valve repairs / prosthetic valves pericardial fluid congenital defects thrombus 5/24/2017 1 31 ECHO 5/24/2017 1 32 Echo… WHEN: excellent first line test for determining / confirming HF as diagnosis ----also for re-assessing patient response to therapy, and improvements or decline of heart function yearly check of valve disease, prosthetic valve function assessment of LA in patients with atrial fibrillation recheck for thrombus resolution post anticoagulation Tx 5/24/2017 1 33 Additional testing in HF ECG BNP MUGA MIBI Thallium (viability scan) Coronary Angiogram 24 hour Holter monitor VO2 Max 5/24/2017 1 34 BNP -CCS 2007 BNP / NT-proBNP … should be measured to confirm or rule out a diagnosis of heart failure in the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt (class I, level A) currently the most practical use of this test under cut-off point—HF unlikely above cut-off point—HF very likely 5/24/2017 5/24/2017 1 1 35 35 BNP (CCS 2007) Heart failure is unlikely Heart failure possible but other diagnoses must be considered Heart failure is very likely All < 100 pg/ml 100-500 pg/ml > 500 pg/ml < 50 < 300 pg/ml 300-450 pg/ml > 450 pg/ml 50 - 75 < 300 pg/ml 450-900 pg/ml > 900 pg/ml > 75 < 300 pg/ml 900 - 1800 pg/ml > 1800 pg/ml Age (years) BNP NT-proBNP 5/24/2017 5/24/2017 1 1 36 36 MUGA WHY in HF: this test is the current “gold standard” for determining EFx to within 1-2% accuracy, and highly reproducible (little variation with serial testing) 5/24/2017 1 37 MUGA WHEN: can be used following any ECHO to narrow the range of EFx (particularly if EFx is in question), should be considered when assessing / re-assessing patients for device therapy often used during chemotherapy to monitor cardiotoxic effects 5/24/2017 1 38 HF Signs & Symptoms 5/24/2017 1 39 Forward flow HF symptoms “Out of gas”—related to O2 delivery fatigue weakness lack of energy cognitive dysfunction decreased exercise tolerance 5/24/2017 5/24/2017 1 40 40 Backword flow HF symptoms “Plumbing”—related to congestion shortness of breath orthopnea paroxysmal nocturnal dyspnea (PND) edema fluid retention / weight gain decreased exercise tolerance 5/24/2017 5/24/2017 1 41 41 Uncommon HF presentation Cognitive impairment* Altered mentation Delerium* Nausea Abdominal discomfort Oliguria Anorexia Cyanosis *May be more common presentation in elderly ccs-2006 5/24/2017 5/24/2017 1 42 42 HF Management 5/24/2017 1 43 HF treatment goals Slow progression of syndrome Control 5/24/2017 symptoms 1 44 Cardiac output– 4 components PRELOAD force stretching the ventricle before contraction AFTERLOAD tension against which the ventricle must pump to eject this volume HEART RATE CONTRACTILITY 5/24/2017 5/24/2017 ability of the myocardial cells to produce forceINOTROPY 1 45 45 How do we do this? “Get with the Guidelines”-CCS 2006 5/24/2017 1 46 CCS on Systolic Heart Failure Medical Therapy ACE inhibitors Beta-blockers Spironolactone Diuretics Digoxin Nitrates Statins ASA, Warfarin 5/24/2017 5/24/2017 Device Therapy ICD CRT Other Therapy Multidisciplinary clinics Exercise rehab Dietary referral Review of co-morbidity Review of other drugs LIFESTYLE! 1 www.hfcc.ccs.ca 47 47 CCS on HFPSF Guideline based medications should be considered in HF with preserved EF** (diastolic HF) for: relief of HF symptoms Pulmonary congestion Peripheral edema treatment of HF risk factors HR, atrial fibrillation BP (as per HTN guidelines) **overall lower level of evidence associated with HFPSF 5/24/2017 1 48 HF treatment is guided by… EFx-ejection ventricular NYHA systolic function functional class symptom 5/24/2017 5/24/2017 fraction status 1 49 49 Ejection Fraction EFx—its all about the LV how much blood is ejected per ventricular contraction is measured by percentage and is indicative of pump efficiency the normal heart will pump out 60-70% of the blood that enters the left ventricular chamber ---never 100% the LV’s normal shape is the perfect pump 5/24/2017 5/24/2017 1 50 50 New York Heart Association Functional Classification-NYHA NYHA I: no physical activity limitation NYHA II: slight limitation of physical activity NYHA III: marked limitation of physical activity NYHA IV: unable to carry out any physical activity or HF symptoms at rest 5/24/2017 5/24/2017 1 51 51 “You are not your EFx” Patients who have an EFx of 10% may have NYHA FC I symptoms an asymptomatic patient may be at risk for a sudden cardiac death, or arrhythmic event if their EFx is low HF diagnosis may be missed if patient asymptomatic Patients with a normal or near normal EFx may have NYHA FC II-III symptoms 5/24/2017 5/24/2017 a patient can have HF with a normal EFx (preserved LV function) 1 1 52 52 Medications for HF morbidity / mortality reduction ACE inhibitors Beta Blockers Aldosterone antagonists Goal: to target or maximally tolerated doses 5/24/2017 1 53 Medications for HF symptom control Diuretics Nitrates Digoxin 5/24/2017 1 54 Medications for HF risk factor reduction ASA Statins Warfarin 5/24/2017 1 55 Medications to avoid in HF NSAIDS (ibuprofen, indocid, high dose ASA) COX 2 inhibitors (Celebrex®) Thiazolidendiones (Avandia®, “glitizones”) Corticosteroids Tricyclic anti-depressants Antiarrhythmics* Calcium channel blockers** Herbals *exception: amiodarone (Cordarone) **exception: amlodipine (Norvasc) 5/24/2017 1 56 ICD-internal cardiac defibrillator many HF patients at risk for sudden cardiac death primary / secondary prevention quantity of life selection criteria: 5/24/2017 EFx NYHA functional class prognosis medications maximized 1 57 CRT-cardiac resynchronization mechanical dyssynchrony impacts pump function third lead attempts to improve synchrony quality of life selection criteria: 5/24/2017 EFx QRS width on ECG NYHA functional class medications maximized 1 58 HF patients in trouble …and into the hospital 5/24/2017 5/24/2017 1 59 59 A fine balance… 5/24/2017 1 60 HF de-compensation triggers Dietary indiscretion #1 (with a bullet) salt / fluid lapse Medications new / dose stopped / changed / forgotten / skipped OTC / PRN Infection Co-morbidity interplay Ischemia Arrhythmia Disease progression 5/24/2017 5/24/2017 1 61 61 Nutrition management of HF Limit Sodium Intake Avoid 5/24/2017 Excessive Fluids Daily Morning Weights 1 Liz Woo MHI HFC 62 62 Salt / Sodium restriction: Less than 3 Gm NA/day most HF patients Less than 2 Gm NA/day severe edema do not add salt remove the salt shaker from the table avoid pickles, luncheon meats, can soup, can tomatoes read labels for “hidden salt” less than 5% of total Rosa Gutierrez 2006 5/24/2017 5/24/2017 1 63 63 Sodium sources Liz Woo MHI HFC 2009 5/24/2017 1 64 Fluid restriction: 2 liters / day if clinically stable 1-1.5 liters / day with severe edema Fluid is: “anything wet” tea, juice, coffee, milk, water, watermelon, ice keep a diary adjust for hot weather, illness Rosa Gutierrez 2006 5/24/2017 5/24/2017 1 65 65 Daily weights weigh immediately after voiding upon rising in the morning no clothes on same scale every day keep a record bring the diary to the clinic appointments Rosa Gutierrez 2006 5/24/2017 5/24/2017 1 66 66 Medications YES & NO ACE inhibitors Beta blockers Aldosterone antagonists Diuretics Digoxin Nitroglycerin 5/24/2017 1 NSAIDS Thiazolidendiones Corticosteroids Tricyclic antidepressants Antiarrythmics* Calcium channel blockers** herbals 67 Remember… HF medications require close monitoring: electrolytes (K+) creatinine at initiation pre up-titration ongoing Coumadin INR 2.0-3.0 2.5-3.5 5/24/2017 1 68 Infection URTI flu pneumonia UTI cellulitis 5/24/2017 1 69 HF co-morbidity Diabetes COPD Renal disease HTN Thyroid disorder Cancer HF rarely exists in a vacuum 5/24/2017 5/24/2017 1 70 70 Ischemia 5/24/2017 1 71 Arrhythmia 5/24/2017 1 72 Disease progression 5/24/2017 1 73 Self care in HF “YOU have the most power over your condition” “AVOID behaviors that make heart failure worse” “PAY ATTENTION, act EARLY” “you can ignore your heart failure…” 5/24/2017 1 74 5/24/2017 1 75 HF ASSESSMENT Details, details, details 5/24/2017 1 76 HF assessment Thorough patient history & physical exam Establish baseline data and monitor trends Appropriate surveillance ongoing 5/24/2017 1 77 HF treatment is guided by… EFx-ejection ventricular NYHA systolic function functional class symptom 5/24/2017 5/24/2017 fraction status 1 78 78 Patient history Symptom status / most limiting factor: SOB Fatigue NYHA FC 5/24/2017 We use patient specific activities to measure—link to frequently done tasks ie. vacuuming, stairs Patient may avoid activities that provoke symptoms— helpful to ask “what are you not doing now that you would like to, or could do before?” 1 79 history cont… New or changed: 5/24/2017 Palpitations Dizziness Lightheadedness Syncope Angina Depression GI / appetite 1 80 history cont… Review of: Medications Lifestyle / risk factors Co-morbidity Recent admits to Hospital, ER Testing—current EFx? Bloodwork 5/24/2017 1 81 Physical exam Weight Edema JVP Heart rate / rhythm Blood pressure HS auscultation Lung auscultation 5/24/2017 1 82 Fluid balance assessment Weight increase Edema Orthopnea / PND (Paroxysmal nocturnal dyspnea) HS cough JVP elevation + Hepatojugular reflex Respiratory auscultation-crackles, rales CXR Heart auscultation-S3 5/24/2017 1 83 Weight “is that water, or is it you?” 5/24/2017 1 84 Weight accuracy compare home / prior clinic weight same scale shoes / no shoes does this number make sense? what is the ideal, “dry weight”? **NEW PTs: record discharge wt on chart if admission if within 2-3 months of initial clinic visit 5/24/2017 1 85 Weight assess if up or down? how much? over what period of time? what is long term trend for wt? compare current clinic weight to patient baseline, last clinic to assess fluid balance 5/24/2017 1 86 when the “tank’s too full”… The longer the fluid took to come on, the longer it takes to come off The more fluid the patient has gained, the longer it takes to come off 5/24/2017 1 87 Edema “where do you keep your water?” 5/24/2017 1 88 5/24/2017 1 89 Edema swelling in legs, feet, ankles? bloating in abdomen—ascites? swelling anywhere else? pitting / non-pitting? 5/24/2017 1 90 Edema cont… assess feet, ankles, legs for edema equal both sides how much pitting assess above knee, track to sacral area if edema severe compare edema to patient baseline, last clinic, plus weight to assess fluid balance 5/24/2017 1 91 JVP “up, down, up, down….” 5/24/2017 1 92 Jugular Venous Pressure JVP reflects pressure and volume changes in the right atrium most proximal location to view 10 cm column of blood supported to clavicle from right atrium when upright observe at 90 degrees, 30-45 degrees measured in cm ASA 5/24/2017 1 93 Jugular Venous Pressure elevated JVP indicates high right atrial pressure, fluid overload, TR should not be > 4cm ASA or > 1cm above R clavicle when patient upright jugular venous distension at 90 degrees suggests substantial congestion baseline values key 5/24/2017 1 94 5/24/2017 1 95 5/24/2017 1 96 Tips for patient placement 90 degrees look at eye level point on opposite wall relax ! wiggle chin 30-45 degrees remove pillow turn head slightly to the left (2 inches) tell patient why you are looking 5/24/2017 1 97 Jugular Venous Pressure cont… observe on right side of neck--- if not apparent, check left note external jugular position supine to upright position may “pop” JVP tricuspid regurgitation— “V” 5/24/2017 wave may not obliterate venous wave venous wave may be pulsatile baseline JVP to chin when euvolemic 1 98 VENOUS vs CAROTID venous is a biphasic, undulating wave, carotid is a monophasic wave assess in several positions from supine to upright (venous pulse will change with position) venous wave can usually be obliterated with firm finger pressure at base of neck venous wave can not usually be palpated as carotid can occasionally, venous will overlay carotid venous wave may descend with inspiration 5/24/2017 1 99 Look up…. way up! 5/24/2017 1 100 **Hepatojugular reflex: gentle abdominal pressure causing further distension of jugular veins suggests central congestion/volume overload **Kussmauls: paradoxical rise in JVP with inspiration compare JVP to patient baseline, last clinic, plus weight, edema to assess fluid balance 5/24/2017 1 101 What can mislead you… 5/24/2017 1 102 Lung auscultation crackles throughout expiratory wheezes decreased AE bases quiet breath sounds who is wet? who is euvolemic? 5/24/2017 1 103 Blood Pressure 79/40 mm/Hg 185/98 mm/Hg 121/83 mm/Hg who has heart failure? who is wet / dry? 5/24/2017 1 104 Creatinine 385 umol/L 110 umol/L 150 umol/L who is wet? who is dry? 5/24/2017 1 105 S3 heart sound normal HS S3 S4 summation gallup (Y.E Kocabasolglu, R.H. Henning) 5/24/2017 1 106 Cachexia muscle mass water weight daily weights? unchanged 5/24/2017 1 107 How much water? 15 kg 5 kg 10 kg 20 kg or none? 5/24/2017 1 108 Take home…wet or dry? Weight, edema, JVP = MVP compare to additional clinic findings account for specific patient factors We don’t know where the patient is, if we don’t know where he came from BASELINE-BASELINE-BASELINE 5/24/2017 1 109 Patient assessment in HF simple things methodically done multiple findings Baseline data = Monitor trends= 5/24/2017 1 110 What’s the plan? Self care teaching / reinforcement Guideline based treatment options What has or could de-stabilize this patient’s HF? Medications ICD / CRT Interventions ie. Angiogram, Sx Follow up 5/24/2017 What surveillance level does this patient require? 1 111 HF treatment goals Slow progression of syndrome Control 5/24/2017 symptoms 1 112 Why do we need specialty clinics in HF? 5/24/2017 1 113 HF patients take time Readmission rates are high Patients are complicated 9 visits to GP/year 8 visits to a specialist Multiple co-morbid conditions (average 5) Need time beyond 8-10 minutes of visit Titrate medications Further diagnosis Potential for huge benefits! 5/24/2017 JAE 2008 1 114 Heart failure: do specialists matter? Collaborative care GP alone McAlister et al JACC 2004 5/24/2017 1 Ezekowitz et al CMAJ 115 2005 Heart Function Clinic est. 1989 Missions: 1. 2. 3. Multidisciplinary 5/24/2017 Clinical Care Research Education 6 MDs 4 Nurses with expertise in heart failure Dietician Pharmacist 1 116 MHI Heart Function Clinic Clinic #s: 700 active patients 25 new referrals/month 120 patient visits/month 83000 minutes on the telephone 66000 minutes in clinic 45000 minutes reviewing test results support for this clinic is backed by extensive local data collection, clinical trials and ongoing quality improvement 5/24/2017 1 117 Future of HF care HF patients are complex in every aspect HF has a huge impact on quality and quantity of life, morbidity and mortality—particularly when not treated successful treatment requires: 5/24/2017 timely diagnosis close assessment & surveillance guideline based treatment regimes lifestyle support 1 118 Thank you! 5/24/2017 1 119