Transcript Common Problems

Outpatient Heart Failure
Management
Common Problems
Elaine Winkel, M.D.
University of Wisconsin
Heart Failure and Transplant Program
Who takes care of heart failure
patients?
• 75% -primary care
• 20%-cardiology
• 5%-heart failure cardiologist
Heart Failure
LV systolic dysfunction with
an ejection fraction of
< 40%
Heart Failure
A syndrome characterized by left
ventricular dysfunction, reduced
exercise tolerance, impaired quality
of life, and reduced life expectancy.
Cohn
Common Problems
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Diagnosis
Physical assessment
Drug therapy
Non-pharmacologic therapy
Education & follow-up
Other therapies for heart failure
New Approach to the Classification of
Heart Failure
Stage
Patient Description
A
High risk for developing heart
failure (HF)
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B
Asymptomatic HF
• Previous MI
• LV systolic dysfunction
• Asymptomatic valvular disease
C
Symptomatic HF
• Known structural heart disease
• Shortness of breath and fatigue
• Reduced exercise tolerance
D
Refractory
end-stage HF
• Marked symptoms at rest despite
maximal medical therapy (e.g., those who
are recurrently hospitalized or cannot be
safely discharged from the hospital
without specialized interventions)
Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.
Hypertension
CAD
Diabetes mellitus
Family history of cardiomyopathy
Classification of HF: Comparison
Between ACC/AHA HF Stage and NYHA
Functional Class
ACC/AHA HF Stage1
A At high risk for heart failure but without
structural heart disease or symptoms
of heart failure (eg, patients with
hypertension or coronary artery disease)
B Structural heart disease but without
symptoms of heart failure
NYHA Functional Class2
None
I Asymptomatic
II Symptomatic with moderate exertion
C Structural heart disease with prior or
current symptoms of heart failure
D Refractory heart failure requiring
specialized interventions
1Hunt
SA et al. J Am Coll Cardiol. 2001;38:2101–2113.
York Heart Association/Little Brown and Company, 1964.
Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.
2New
III Symptomatic with minimal exertion
IV Symptomatic at rest
Common Problems
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Diagnosis
Physical assessment
Drug therapy
Non-pharmacologic therapy
Education & follow-up
Other therapies for heart failure
Common Diagnostic Errors
LV systolic dysfunction commonly a missed
diagnosis
No symptoms
Symptoms attributed to other diseases
Symptoms ignored
Signs ignored (CXR)
Why screen for LV dysfunction?
May be asymptomatic
Mortality related to degree of LV dysfunction,
not symptoms
High mortality once symptoms appear
Heart failure is worse
than most cancers.
-The Fat Man
The House of God
Patients at risk for developing HF
(Stage A)
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Coronary disease or CAD equivalent (DM)
Hypertension
Hyperlipidemia
Congenital heart disease
Valvular heart disease
Stroke or other vascular disease –30% w/LVD
Arrhythmias
High risk patients
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Drug abuse (cocaine, anabolic steroids)
Alcohol use
Family members with heart failure
Sickle cell disease
Sarcoidosis/amyloidosis
Muscular dystrophies
Collagen vascular diseases
Immigrant population-Chagas
High risk patients
• End stage renal disease
• Chronic lung disease-(long time betaagonist use)
• Certain malignancies (multiple myeloma)
• History of cardiotoxic drugs (adriamycin)
High risk populations
Good history, including family history
Screen with echocardiography
Diagnostic errors
LV systolic dysfunction not completely
evaluated
No cardiac cath
Incomplete echo study
Role of endomyocardial biopsy
Common Problems
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Diagnosis
Physical assessment
Drug therapy
Non-pharmacologic therapy
Education & follow-up
Other therapies for heart failure
Common presentations of HF
• Fatigue
• SOB
• GI distress (anorexia, early satiety,
abdominal bloating, nausea, vomiting)
• Chest pain/pressure
• Lightheadedness/dizziness/palpitations
• No symptoms
Physical Exam
• Often unhelpful especially in chronic or
slowly progressive LV dysfunction
• Physical signs frequently absent
• History most important
Causes of SOB in patients with
known LVD
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New or worsening CAD
New or worsening valve disease
Unappreciated arrhythmia
Anemia
Lung disease
Deconditioning
Other causes of edema
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Cirrhosis
Severe renal insufficiency
Nephrotic syndrome
Venous insufficiency
Lymphedema
Common Problems
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Diagnosis
Physical assessment
Drug therapy
Non-pharmacologic therapy
Education & follow-up
Other therapies for heart failure
Current medical therapy
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ACE inhibitors/ARB’s/direct vasodilators
Digoxin
Diuretics
Beta-blockers
Aldosterone blockers
ACE Inhibitors-common errors
• Short vs. long acting agent
• Dose too low
• ARB substituted- (cough, creatinine rise,
etc.)
• Asymptomatic patient w. LVD
Digoxin
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Not given
Wrong dose
Dig level
Effect of amiodarone, spironolactone
Digoxin in women
Diuretics
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Too much
Too little
Generic vs. brand name
Timing
Beta Blockers
• Wrong time (concomitant w/ACE,
decompensated, volume overloaded)
• Wrong agent (atenolol, acebutelol, pindolol,
carvedilol vs. metoprolol)
• Wrong dose
• Using BB alone
• Asymptomatic patient w/LVD
Aldosterone Blockers
• Spironolactone vs. eplerenone
• Too much
• Wrong patient (nl-hi K+, DM, Type IV
RTA, renal insufficiency, non-compliant)
• No follow-up
Drug management
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Drugs/doses used in clinical trials
Generic vs. brand name drugs
Short vs. long acting agents
Pill bottles each visit
Timing to avoid lightheadedness
Common Problems
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Diagnosis
Physical assessment
Drug therapy
Non-pharmacologic therapy
Education & follow-up
Other therapies for heart failure
Non-pharmacologic therapy
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Sodium restriction-2000 mg/day
Fluid restriction
Avoid alcohol
Small, frequent meals
Energy conservation
Deleterious drugs
• Calcium blockers-nefedipine, diltiazem,
verapamil
• Antiarrhythmics
• NSAID’s, COX-2 inhibitors (inc OTC)
• Herbal agents (hawthorn, gingko, St. John’s
wort)
• Grapefruit juice
• Inotropic agents-(milrinone, dobutamine)
Common Problems
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Diagnosis
Physical assessment
Drug therapy
Non-pharmacologic therapy
Education & follow-up
Other therapies for heart failure
Education and follow-up
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Disease
Treatment
Diet/fluids
Exercise/rest
Avoid deleterious agents
Involve family
Close follow-up
Other therapies
• Coronary intervention (PCI, CABG)
• Ventricular reconstruction (aneurysm
resection or Dor procedure)
• Valve repair or replacement
• Correction of arrhythmias-especially AF
• Pacing (DDD, BiV)
• ICD
“Genius is the infinite
capacity for taking pains.”
Sherlock Holmes