Download Systolic Heart Failure

4/5/2011
My Patient Has HEART FAILURE!!! Now WHAT???
Robin Harris MSN, ANP‐BC
,
Wellmont Cardiology Services
Cardiovascular Associates
Heart Failure Clinic
SYSTOLIC HEART FAILURE
Edvard Munch
The Scream
Definition of Heart Failure
 “Heart failure exists when the heart is unable to pump sufficient blood to meet the metabolic needs of the body at normal filling pressures provided the venous return to the pressures, provided the venous return to the heart is normal” – Braunwald, The Heart 1
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Significance of problem
Mortality Data
 6 million Americans have been diagnosed with  High rates of morbidity and mortality


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

HF
550,000 new cases each year
Number one diagnosis for hospital admissions
Only cardiovascular disorder on the increase
Estimated cost 33.2 billion in 2007
Incidence – 10 out of every 1000 people over age 65
 4 to 5 year mortality rate is 45% (women) and 60% (men)
 2 year mortality rate for advanced HF is 35‐50%
2 year mortality rate for advanced HF is 35 50%
 Within 8 years 80% of men of 70% of women will die usually from SCD (450,000 SCD yearly)
(Wu. Moser, Lennie & Burkhart, 2008)
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What’s the Problem?
 Annual Mortality
 Class I: 5%
 *Class II: 5‐15%
 Class III: 20‐50%
 Class IV: 30‐70%
 Sudden Cardiac Death
 Class I:
Common
none
Complex
 *Class II: 50‐80%
50 80%
 *Class III: 30‐50%
 Class IV: 5‐30%
Costly
Primary modes of death include pump failure and sudden cardiac death.
Uretsky, B. & Sheahan, G. Primary Prevention of Sudden Cardiac Death in Heart Failure: Will the solution be shocking? J Am Coll Cardiology, 1997, 30, 1589‐1597.
Heart Failure
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Projected Economic Impact of CVD 2010  Total CVD: $485.6 Bil
 CHD: $311.1 Bil
 HF: $38.6 Bil
 Direct: $35.1Bil
 Hospital: $20.1 Bil
 Physician Svc: $2.4 Bil
 Prescription Drugs: $3.4 Bil
 Nursing Home $5.1 Bil
Source: NHLBI.NIH Source Book.gov 9.22.20
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HF Hospitalization & Outcomes 1990‐2010 Pathophysiology
 Length of Stay
p
y
 In
In‐‐Hospital Mortality
 Readmission
 Use of Nursing Home & Chronic Care Facilities
Heart Failure
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Heart Failure
Cardiac Physiology
 CHF can develop rapidly (acute) OR gradually  Cardiac Output is a product of the heart rate and stroke volume (the amount of blood that is ejected with each heart beat).
 Ejection Fraction is the Ej ti F ti i th percentage of blood in the ventricle at the end of diastole and is ejected during systole. Normal EF is 60%‐65%.
(chronic).
 Acute cardiac failure has a sudden onset with no compensatory mechanisms.
t h i
 Chronic cardiac failure has a more gradual onset with compensatory mechanisms resulting in structural changes in the heart.
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 Signs/Symptoms of Decreased Cardiac Output:
 Cerebral: decreased LOC, restlessness
 Cardiac: tachycardia, hypotension
 Respiratory: decreased oxygen saturation, dyspnea
 Kidney: decreased Urinary Output (UOP)
 Skin: cool, weak peripheral pulses
Heart Failure
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Heart Failure
Compensatory Mechanisms
 1. Sympathetic Nervous System: peripheral  The progression of congestive heart failure vasoconstriction, elevates BP
occurs as a consequence of complex  Sympathetic overactivity
 Cellular
 Release of catecholamines
e ease o catec o a
es
 Metabolic
M t b li
 2. Renin‐angiotensin‐aldosterone system (RAAS)
 Neurohormonal mechanisms
 3. Tachycardia: increases myocardial oxygen demand
 Attempt to compensate for injury.
 4. Ventricular hypertrophy
Current focus is on blocking neurohormonal compensatory mechanisms.
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Ventricular Remodeling
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Normal Morphology of the Heart
Cardiac Cells (Myocytes)
 Change in the size, shape, and function of the ventricle in response to injury.
 Accelerated cell death (apoptosis)
 Interstitial fibrosis causing breakdown of extracellular matrix
 Myocyte hypertrophy causing heart to have a spherical shape
 Ventricular dilation and hypertrophy (dimensions are important)
Capillaries
Interstitium
Fibroblasts
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Heart Failure
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RAAS System
Morphological Changes of Cardiomyopathy
Intimal Hyperplasia due to
enlargement of the
endothelial cells and smooth
muscle cell proliferation
Interstitial Fibrosis and
Fibroblast Proliferation
Hypertrophy and
Enlargement of
Cardiac Myocytes
Perivascular Fibrosis wth
increased vascular resistance
and capillary closure
Microaneurysm of Cardiac
Blood Vessels
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Heart Failure
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Causes of Heart Failure
 Coronary Artery Disease
 Valvular heart disease
 Hypertension
 Thyroid dysfunction
 Fluid overload from non‐cardiac causes
 Sleep Apnea
 Cardiac Arrhythmias
 Exposure to Cardiotoxic Agents
 Chest Irradiation
 Illicit Drug Use/ETOH
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Precipitating Causes of Decompensated Heart Failure
CONGESTIVE HEART FAILURE:
AHA/ACC Stages of Heart Failure
 Excessive dietary sodium intake
 A. High risk for CHF but no identified structural  Excessive fluid intake
 Medication nonadherence
 Myocardial Infarction
 Dysrhythmias
 Uncontrolled hypertension
 Adverse Drug Effects (NSAIDs, TZDs, Ca++ Channel blockers)
 Comorbidities (fever, infection, sepsis, anemia, pulmonary disease, renal insufficiency)
or functional impairment.
 B. Structural disease but no clinical manifestations of CHF.
 C. Current or prior S/S of CHF associated with underlying structural heart disease.
 D. Advanced structural heart disease and clinical manifestations of CHF at rest despite aggressive treatment. Heart Failure
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Symptoms of Heart Failure
 Dyspnea with exertion
 Dyspnea at rest
 Orthopnea
 Paroxysmal Nocturnal Dyspnea
 Fatigue
 Decreased exercise tolerance
 Unexplained cough, particularly at night
 Mental status changes
 Abdominal bloating
 Decreased appetite
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Physical Findings of Heart Failure
Differential Diagnosis
 Tachycardia
 Cardiac:
 Third heart sound (S3)
 Increased Jugular Venous Pressure
 Positive hepatojugular reflux
 Rales – bilateral
 Peripheral edema not due to venous insufficiency
 Laterally displaced apical impulse
 Weight gain
 Abdominal distention
 MI
 Heart block
 Valvular Disease
 Pulmonary:
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COPD
Asthma
Pulmonary Embolism
Pulmonary Hypertension
 Pleural Effusion
 Cirrhosis
Heart Failure
Laboratory Tests
Diagnostic Tests
 CBC
 EKG
 BMP
 Chest X‐Ray
 BNP
 Echocardiogram
 TSH
 Stress Test
 LFTs
 Cardiac MRI
 Fasting Lipid Profile
 Cardiac Catheterization
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 Serum Electrolytes
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ACC Stages of Heart Failure
Stage A Heart Failure Management
At risk for development of heart failure
Stage A – High risk for developing heart failure
Stage B – Asymptomatic LV dysfunction
• Treat known risk factors
• Evaluation for S/S heart failure
• Rhythm control
• Echocardiogram to assess LV control
• Treat Lipid disorders
Heart Failure
Stage C – History of heart failure/current sx.
Stage D – End stage heart failure
• Control diabetes
Stage B Heart Failure Management
Stage C Heart Failure Management
• Same general measures as Stage A
 Same general measures as Stage A and B
• Medications: ACE Inhibitors, ARBs, Beta  Medications: ACE Inhibitors, ARBS, Beta blockers
• Implantable Cardioverter Defibrillator – EF < 35% on optimal medical therapy
• Treat structural disorder: CABG, PTCA/PCI, valve repair/replacement
• Avoid use of calcium channel blockers with negative inotropic effects
blockers, Diuretics
 Other Medication that may be indicated:
Aldosterone Antagonists, Digitalis, Hydralazine/nitrates
 Implantatable Cardioverter Defibrillator
 Cardiac Resynchronization (biventricular PM)
• Lifestyle modifications
• Medications: ACE Inhibitors, ARBs
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Stages in the Development of Heart Failure/Recommended Therapy by Stage
Stage D Heart Failure Management
 Control/Prevent fluid retention
 Heart Failure Clinic Program/Specialist
 Discuss end‐of‐life care
 Discuss deactivation of defibrillator
 Cardiac transplant
 Drug Therapy – continuous inotrope infusion
J Am Coll Cardiol 2009;53:1343-1382
Prognostic Significance of Heart Failure Stages
Applying Classification of Recommendations
and Level of Evidence
C lass I
C lass IIa
C lass IIb
C lass III
Benefit >>> Risk
Benefit >> Risk
A dditional studies with
focused objectives
needed
Benefit ? Risk
A dditional studies with
broad objectives needed;
A dditional registry data
would be helpful
Risk ? Benefit
No additional studies
needed
P rocedure/
T reatment SHO U L D
be performed/
administered
IT IS RE A SO NA B L E to
perform
procedure/administer
treatment
P rocedure/T reatment
MA Y B E C O NSIDE RE D
Procedure/T reatment
should NO T be
performed/administered
SINC E IT IS NO T
HE L PF U L A ND MA Y
B E HA RMFU L
Level of E vidence:
L ev el A :
Data derived from multiple randomized clinical trials or meta-analyses
Multiple populations evaluated
L ev el B :
Data derived from a single randomized trial or nonrandomized studies
Limited populations evaluated
L ev el C :
O nly consensus of experts opinion, case studies, or standard of care
V ery limited populations evaluated
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Circulation. 2007;115:1563-1570
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Recommendations for the Initial Clinical Assessment
of Patients Presenting With Heart Failure
Coronary Revascularization
I IIa IIb III
I IIa IIb III
Coronary arteriography is reasonable for patients
presenting with HF who have chest pain that may
or may not be of cardiac origin who have not had
evaluation of their coronary anatomy and who
have no contraindications to coronary
revascularizations. NO CHANGE
Coronary arteriography is reasonable for patients
presenting with HF who have known or suspected
coronary artery disease but who do not have angina
unless the patient is not eligible for revascularization
of any kind.
Patients With Reduced Left Ventricular
Ejection Fraction
I IIa IIb III
I IIa
II IIb III
Measuring LVEF
Angiotensin-converting enzyme (ACE) inhibitors are
recommended for all patients with current or prior
symptoms of HF and reduced LVEF, unless
contraindicated .
Use of 1 of the 3 beta blockers proven to reduce
mortality (i.e., bisoprolol, carvedilol, and sustained
release metoprolol succinate) is recommended for all
stable patients with current or prior symptoms of HF and
reduced LVEF, unless contraindicated.
J Am Coll Cardiol 2009, 53: 1343-82
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J Am Coll Cardiol 2009, 53: 1343-82
Mortality Findings in Large Placebo-Controlled ACEI Trials
J Am Coll Cardiol 2001;37:1456-1460
Lancet 1999;353:9-13. JAMA 2000;283:1295-302. N Engl J Med 2001;344:1651-8. N Engl J Med
2001;344:1659-67.
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Patients With Reduced Left Ventricular
Ejection Fraction
I IIa IIb III
I IIa IIb III
CHARM-Alternative: Candesartan in Place of ACEI
Angiotensin ll Receptor Blockers
Angiotensin II receptor blockers are recommended inpatient with current or prior symptoms of HF and
reduced LVEF who are ACE- inhibitor intolerant (see
full text guidelines).
Drugs known to adversely affect the clinical status of
patients with current or prior symptoms of HF and
reduced LVEF should be avoided or withdrawn
whenever possible (e.g., nonsteroidal antiinflammatory drugs, most antiarrhythmic drugs, and
most calcium channel blocking drugs).
NO CHANGE
J Am Coll Cardiol 2009, 53: 1343-82
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Patients With Reduced Left Ventricular
Ejection Fraction
Lancet 2003; 362: 772-76
Val-HeFT: Valsartan in Heart Failure
ARB and Conventional Therapy
I IIa IIb III
The addition of an ARB may be considered in persistently
symptomatic patients with reduced LVEF who are already
being treated with conventional therapy.
I IIa IIb III
Routine combined use of an ACE inhibitor
inhibitor, ARB
ARB, and
aldosterone antagonist is not recommended for
patients with current or prior symptoms of HF and
reduced LVEF.
I IIa IIb III
Calcium Channel Blocking Drugs
Calcium channel blocking drugs are not indicated as
routine treatment for HF in patients with current or prior
symptoms of HF and reduced LVEF.
J Am Coll Cardiol 2009, 53: 1343-82
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N Engl J Med 2001;345:1667-75
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RALES: Spironolactone Plus Usual Therapy
Patients With Reduced Left Ventricular
Ejection Fraction
I IIa IIb III
The Risks of Aldosterone Antagonists
Addition of an aldosterone antagonist is recommended
in selected patients with moderately severe to severe
symptoms of HF and reduced LVEF who can be carefully
monitored for preserved renal function and normal
potassium concentration
concentration. Creatinine 2.5
2 5 mg/dL or less
in men or 2.0 mg/dL or less in women and potassium
should be less than 5.0 mEq/L. Under circumstances
where monitoring for hyperkalemia or renal dysfunction
is not anticipated to be feasible, the risks may outweigh
the benefits of aldosterone antagonists.
J Am Coll Cardiol 2009, 53: 1343-82
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N Engl J Med 1999; 341:709-17
Patients With Reduced Left Ventricular
Ejection Fraction
Patients With Reduced Left Ventricular
Ejection Fraction
Hydralazine and Nitrate Combination
Recommendations for Hydralazine and Nitrates
I IIa IIb III
I IIa IIb III
The combination of hydralazine and nitrates is
recommended to improve outcomes for patients selfdescribed as African-Americans, with moderate-severe
symptoms on optimal therapy with ACE inhibitors, beta
blockers, and diuretics.
I IIa IIb III
The addition of a combination of hydralazine and a
nitrate is reasonable for patients with reduced LVEF
who are already taking an ACE inhibitor and beta
blocker for symptomatic HF and who have persistent
symptoms.
J Am Coll Cardiol 2009, 53: 1343-82
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A combination of hydralazine and a nitrate
might be reasonable in patients with current
or prior symptoms of HF and reduced LVEF
who cannot be given an ACE inhibitor or ARB
because of drug intolerance, hypotension, or
renal insufficiency.
J Am Coll Cardiol 2009, 53: 1343-82
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A-HeFT: Isosorbide Dinitrate Plus Hydralazine in Black Patients
Patients With Reduced Left Ventricular
Ejection Fraction
Recommendations for Atrial Fibrillation and Heart Failure
I IIa IIb III
It is reasonable to treat patients with atrial
fibrillation and HF with a strategy to maintain
sinus rhythm or with a strategy to control
ventricular rate alone.
J Am Coll Cardiol 2009, 53: 1343-82
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N Engl J Med 2004;351:2049-57
Patients With Reduced Left Ventricular
Ejection Fraction
Patients With Reduced Left Ventricular
Ejection Fraction
Recommendations for Atrial Fibrillation and Heart Failure
The Benefits of Digitalis
I IIa IIb III
I IIa IIb III
It is reasonable to treat patients with atrial
fibrillation and HF with a strategy to maintain
sinus rhythm or with a strategy to control
ventricular rate alone.
J Am Coll Cardiol 2009, 53: 1343-82
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Digitalis can be beneficial in patients with
current or prior symptoms of HF and
reduced LVEF to decrease hospitalizations
p
for HF.
J Am Coll Cardiol 2009, 53: 1343-82
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Patients With Reduced Left Ventricular
Ejection Fraction (Continued)
DIG Trial: Digoxin in Heart Failure
Infusion of Positive Inotropic Drugs
I IIa IIb III
Long-term use of an infusion of a positive inotropic
drug may be harmful and is not recommended for
patients with current or prior symptoms of HF and
reduced
d
d LVEF,
LVEF exceptt as palliation
lli ti for
f patients
ti t with
ith
end-stage disease who cannot be stabilized with
standard medical treatment.
J Am Coll Cardiol 2009, 53: 1343-82
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N Engl J Med 1997; 336: 525-33
Patients With Reduced Left Ventricular
Ejection Fraction
Treatment of Special Populations
Primary Prevention: Implantable Cardioverter-Defibrillator
I IIa IIb III
I IIa IIb III
ICD therapy is recommended for primary
prevention of sudden cardiac death to reduce
total mortality in patients with nonischemic
dilated cardiomyopathy or ischemic heart
disease at least 40 days post-myocardial
infraction, have an LVEF less than or equal to
35%, with NYHA functional class II or III
symptoms while receiving chronic optimal
medical therapy, and who have reasonable
expectation of survival with a good functional
status for more than 1 year.
Evidence Based Therapy for HF
It is recommended that evidence-based
therapy for HF be used in the elderly patient,
with individualized consideration of the
elderly
ld l patient’s
i ’ altered
l
d ability
bili to metabolize
b li
or tolerate standard medications.
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J Am Coll Cardiol 2009, 53: 1343-82
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J Am Coll Cardiol 2009, 53: 1343-82
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The Hospitalized Patient
I IIa IIb III
I IIa IIb III
The Hospitalized Patient
Reconciling and Adjusting Medications
I IIa IIb III In patients hospitalized with HF with reduced ejection
fraction not treated with oral therapies known to improve
outcomes, particularly ACE inhibitors or ARBs and betablocker therapy, initiation of these therapies is
recommended in stable patients prior to hospital
discharge.
g
Medications should be reconciled in every patient
and adjusted as appropriate on admission to and
discharge from the hospital.
IIn patients
ti t with
ith reduced
d
d ejection
j ti fraction
f ti experiencing
i
i
a symptomatic exacerbation of HF requiring
hospitalization during chronic maintenance treatment
with oral therapies known to improve outcomes,
particularly ACE inhibitors or ARBs and beta-blocker
therapy, it is recommended that these therapies be
continued in most patients in the absence of
hemodynamic instability or contraindications.
J Am Coll Cardiol 2009, 53: 1343-82
I IIa IIb III
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Initiation of beta-blocker therapy is recommended after
optimization of volume status and successful
discontinuation of intravenous diuretics, vasodilators, and
inotropic agents. Beta-blocker therapy should be initiated
at a low dose and only in stable patients. Particular
caution should be used when initiating beta-blockers in
patients who have required inotropes during their hospital
course.
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J Am Coll Cardiol 2009, 53: 1343-82
OPTIMIZE-HF Registry: Effect of Continuing or Withdrawing BB
The Hospitalized Patient
Reconciling and Adjusting Medications
I IIa IIb III
Comprehensive written discharge instructions for all
patients with a hospitalization for HF and their
caregivers is strongly recommended, with special
emphasis on the following 6 aspects of care: diet,
discharge medications, with a special focus on
adherence, persistence, and uptitration to
recommended doses of ACE inhibitor/ARB and betablocker medication, activity level, follow-up
appointments, weight monitoring, and what to do if
HF symptoms worsen.
J Am Coll Cardiol 2009, 53: 1343-82
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J Am Coll Cardiol 2008; 52: 190-9
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The Hospitalized Patient
Multidisciplinary Management
Effective Outpatient Care
 CVA offers a multidisciplinary HF clinic, I IIa IIb III
including HF physicians, EP physicians, specially trained nurse practitioners
Post-discharge systems of care, if available,
should be used to facilitate the transition to
effective outpatient care for patients
hospitalized with HF.
J Am Coll Cardiol 2009, 53: 1343-82





Dx & w/u of systolic HF & HF w/ preserved EF
Medication titration Education & reinforcement about compliance Referral for device therapy when appropriate
Rapid access to clinic for volume management & rapid outpt f/u after hospital discharge
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The Future of Heart Failure Research
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