Transcript "Living With Heart Failure" (Nov 2012)

Living with Heart Failure
Ayesha Hasan MD, FACC
Advanced Heart Failure and Transplantation Program
Medical Director Cardiac Transplant Program
Contact information: 614-293-6081 (heart failure office)
What is Heart Failure?
Heart failure is NOT a heart attack
Heart failure means the heart is:


Weakened
Cannot pump enough blood to supply the
body’s needs
. . . It does not mean the heart has stopped
working!
Heart Failure is Very Common

Heart failure affects nearly 5 million Americans


50% men and 50% women
An estimated ½ million new cases are diagnosed each year
Expected to rise to 750,000 new cases by 2040
 Related to aging population, better treatment of heart disease
and risk factors, awareness


Over one million heart failure hospitalizations annually
Rising over past few decades
 Accounts for over 20% admissions in people 65 and over

Types of Heart Failure: Difference Between
Systolic and Diastolic Heart Failure
Aorta
LA
LV
Normal
Normal ejection (squeeze)
=Systolic function
Normal relaxation (filling)
=Diastolic function
Dilated
Systolic Heart Failure
Thickened or stiff
heart walls
Diastolic Heart Failure
Weakened pump
Normal ejection
Relaxation ± abnormal
Abnormal relaxation: Stiff or scarred
 Blood backs up
and overloads the heart
Won’t allow enough blood to fill the
heart before it squeezes
Pg 238, Lilly 3rd edition
Simplified View of Heart Failure
Normal Heart
Development of
Heart Failure
What Causes Heart Failure?
Heart failure results after injury to the heart
High blood pressure
Heart attack
Damage to heart valves
Diabetes
High cholesterol
Heart muscle disease: damage
from drugs, alcohol, or
infections
Congenital heart disease
What Are The Symptoms of Heart Failure?
Think FACES...
• Fatigue Constant lack of energy
• Activities limited Difficulty with everyday activities
• Chest congestion Dry cough or producing white or pink bloodtinged phlegm
• Edema or ankle swelling Swelling of the feet, ankles,
legs, abdomen, or unexplained weight gain
• Shortness of breath Breathlessness during activity, at rest, or
while sleeping
Additional symptoms: Lack of appetite, nausea, increased
heart rate, irregular heart rhythm
How Severe is A Patient’s Heart Failure?
 We measure the “ejection fraction” by echo
 The fraction of blood that the heart pumps with every
beat
 We assess the patient’s symptoms
 No or mild symptoms
 Do symptoms limit activity? If so, how much?
Treatment…Begins with Prevention!
Symptomatic Heart Failure
Coronary
Artery Disease
Risk Factors
Left Ventricular
Hypertrophy
Family History
Diabetes
Smoking
High cholesterol
Obesity
High Blood
Poor Diet Pressure
Lack of Exercise
How Do We Treat Heart Failure?
Lifestyle Changes
 Quit smoking
 Monitor diet: low-fat, low sodium
 Exercise regularly
 Lose weight
 Avoid alcohol
 Limit caffeine intake
Limiting Sodium or Salt Will Improve Your
Heart Failure Symptoms
Sodium is a component of salt
Naturally occurring in many foods
Sodium attracts
fluid
Added during processing
In most foods eaten away from home
Your body needs only a small amount of sodium to
keep a normal fluid balance.
Fluid build-up in body
Extra work on heart &
kidneys to get rid of fluid
Higher BP often results
Too much sodium causes your body to hold onto fluid
and cause symptoms of weight gain, shortness of breath,
Heart failure symptoms,
heart attack, stroke
and fatigue.
The more sodium (salt) you take in, the more fluid your body holds on to
Patients Should Follow a 2000 mg Sodium Diet
In addition to heart failure patients, the
American Heart Association recommends
1) All adults older than 51
2) All African Americans
3) Anyone with high blood pressure
limit their daily intake to 1500 mg
Plan your meals for 2000 mg intake
MEAL
Breakfast
Lunch
Dinner
mg Sodium
600mg
600mg
600mg
Snack
200mg
Use alternative seasonings!
Basil
Chives
Dill weed
Garlic
Tarragon
Thyme
Parsley
Paprika
Pepper
Sage
Mrs. Dash
Lemon, lime juice
How It Shakes Out
¼ tsp salt = 600 mg sodium
½ tsp salt = 1200 mg sodium
1 tsp salt = 2300 mg sodium More than daily recommendation
Even a small amount of salt counts!
½ tsp salt
= 1 serving
pretzels
= 3 slices of ham =2 packets of
soy sauce
= 3 pickles
= 14 green
olives
Some common high sodium foods
 Frozen meals
 Pickles
 Canned foods
 Bacon
 Breads, baked goods
 Anchovies
 Lunch & smoked meats
 Soy sauce
 Cheese
 Seasoning mixes
 Condiments (salad dressing)
 Gravy
 Olives
 Salted crackers
 Pretzels
 FAST FOOD
Rule of thumb: the more processed the food, the more sodium it contains
First step: Learn how to read sodium labels
on all food
1. Look for Sodium
Listed as milligrams or mg
2. Next, look at serving size
If you eat 2 servings of a food
you need to double what you
see on the label
3. Reduced-sodium products still
contain sodium
Always read the label
Sodium Guidelines
< 140 mg = low sodium
140-400 mg = medium sodium
> 400 mg = high sodium
Enjoy these foods!
Use food in moderation
Use this food sparingly
Low sodium
140 mg or less sodium per serving
Very low sodium
35 mg or less sodium per serving
Sodium-free
Less than 5 mg sodium per serving
1. Use salt substitute or other spices when cooking (watch for
high potassium in some substitutes)
2. Don’t add salt at the table
Fluid intake & Daily Weights
Limiting fluid intake: important in managing heart failure
REMEMBER: Anything liquid at room temperature is considered a fluid
Daily weights: every morning at the same time using the same scale
Keep track of daily weights
REMEMBER: You might not see swelling until you are 8-15# up
Exercise: Get Off the Couch!
Exercise Will Improve Your Quality of Life
 Pick a simple aerobic activity that you enjoy
 Start slowly and increase gradually
 Need to move large muscle groups
 Walking is a great first choice
 Resume activities you stopped (gardening, bowling, fishing)
 Work your way up to 30 minutes most days
 Doesn’t have to be 30 minutes in a row
 Warm up and cool down
 Check with your physician first if
 You are really out of shape, uncertain about your abilities, or have
shortness of breath with very mild activity
Exercising & Precautions
 Find an indoor location along with a partner
 Build muscle (stretching, elastic bands,
light weights)
 Overexertion
 Shortness of breath that prevents you from completing a
sentence or doesn’t get better with rest
 Dizziness, chest pain, nausea, vomiting, severe sweating,
unusual fatigue (extreme)
What Medications Do We Use in Heart Failure and
Why?






Diuretics
Digitalis
Beta-blockers
ACE inhibitors
Hydralazine/nitrates
Spironolactone
1. To reduce symptoms
2. To prevent disease
progression
3. Keep patients out of the
hospital
4. Improve survival
Be careful about alternative therapy (chinese herbs, hawthorne, ginseng):
No evidence they help & associated with some negative effects
Why Do We Use These Treatments?
Heart failure limits a patient's ability to perform the
routine activities of daily living…
Diuretics, ACE Inhibitors
Reduce the number of sacks on
the wagon (or load on the heart)
ß-Blockers
Limit the speed, thus saving energy
Spironolactone, Cardiac Resynchronization Therapy
Increase the heart’s efficiency
What if the Heart is Still Weak After Medications?
Risk of death from cardiac arrest
 Defibrillators can protect the heart from these
abnormal rhythms
Based on the ejection fraction
History of Pacemakers & Defibrillators
What if the Heart is Still Weak After Medications?
The heart “pump” worsens
Newer devices can be implanted to
help the heart’s contraction
1. Pacemakers (resynchronization)
2. Ventricular assist devices
3. Clinical trials: investigational
devices
Heart transplant
Pace both ventricles of the heart
to make it stronger & more efficient
Ventricular Assist Devices
Try to be as active as possible with
the following limitations:
 No driving
 No contact sports
 No high “bounce” activities like
running, jumping, or jumping jacks
 No submerging in water. Stay out of
bathtubs, hot-tubs, swimming
pools, lakes & ponds
 Do not drive or operate heavy
machinery
Continue to follow heart failure
recommendations: sodium and
fluid restriction, daily weight
Indications for Mechanical Circulatory Support in
Advanced HF
 Bridge to Transplant (BTT)
 Non-reversible left heart failure
 High mortality risk
 Candidate for cardiac transplantation
 Destination Therapy (DT)
 Not a candidate for cardiac transplantation
 Bridge to Recovery
 Potentially reversible (post-heart attack, postpregnancy, myocarditis)
ADULT HEART TRANSPLANTATION
% OF PATIENTS BRIDGED WITH MECHANICAL CIRCULATORY
SUPPORT* (Transplants: 1/2000 – 12/2009)
50
% of patients
40
30
20
10
0
2000
2001
2002
2003
2004
2005
Year
2006
2007
* LVAD, RVAD, TAH
Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
2008
2009
History of Heart Transplantation at Ohio State
University
 Heart transplant program started in 1986
 To date, have performed 382 transplants
 Includes a joint heart/kidney transplant program
 Average 15 transplants per year
 Around 2000-2500 transplants in the nation per year
 Approximately 3500 reported worldwide per year
Cardiac Transplantation:
Are There Gender Differences in Transplant Rates?
Of total reported transplants, what % patients are women?
a. 25-30%
b. 50-60%
c. 70-75%
International Statistics (ISHLT registry)

Of 22,387 reported heart transplants between 2002-2010, 77% were
men

Improved to 31% women for Jan 2011 to Dec 2011
Is the OSU transplant program similar?
11 of 37 transplants are women – 27% (Past 3 yrs - 1/2010 to present)
Current waitlist – around 20% are women
Taylor DO, et al. JHLT 2009;28:1007-22
ISHLT online registry www.ISHLT.com
The Heart-Kidney Relationship in Heart Failure
Dysfunction of one affects the other
Increased load
on the heart
Decreased output
from the heart
Neurohormonal
Activation
Increased water
& sodium retention
Diminished blood
flow to the kidney
Neurohormonal
Activation
Impaired kidney
function
Poor absorption of drugs
and drug delivery to kidney
Ultrafiltration for Acute Heart Failure
 Mechanical removal of excess
volume
 Safe and effective
 Patients on high dose diuretic
(diuretic-resistance)
 Caution: Not a substitute for
dialysis as waste products are not
removed with this method
Costanzo MR et al. JACC 2005;46:2047-2051.
Clinical Trials at OSU:
Measuring Pressures in the Heart Invasively for Heart
Failure Management
Left Atrial Pressure Sensor
Modified PDA
Powers through clothing
Alerts patient to monitor
‘DynamicRX®’ calculates
pressure and instructs patient
on management
RA
LA
 Meds
 Activity
 Clinician contact
Based on physician’s
prescription for specific values
obtained
Measure pressures as
an indication of fluid status
Clinical Trials at OSU:
Measuring Pressures in the Heart Invasively for Heart
Failure Management
15 mm
Measure pulmonary artery pressures
for assessment of fluid
No battery
No leads
Stem Cell Therapy and Heart Failure:
Still being studied
Sleep Apnea and Heart Failure
People with heart failure have a high risk for sleep
apnea
If not treated, sleep apnea can cause:






Drop in oxygen levels
The heart rate to speed up
A rise in the blood pressure
Changes to the heart rhythm
Stroke
Heart attack
or an episode of heart failure
Normal breathing pattern
Central sleep apnea: no breathing
(apnea) alternates with rapid
breathing
Friends and Family
 Emotional support helps a patient have a more positive outlook on life
 Allow the patient to make decisions regarding health care and lifestyle
behaviors
 Positive reinforcement
 Discuss fears about heart failure
 Discuss advanced care planning
 Don’t forget to take care of yourself: eat healthy, exercise, sleep
Advanced Care Planning
 Not giving up
 Focus is on caring for the patient in a way that meets your
wishes
 Key is communication
 Goal is to reduce stress on the patient
 Consists of





Advanced care directive
Do-not-resuscitate order
Power of attorney
Living will
Financial plan
Advanced Care Planning
 Palliative care
 Support program that focuses on comfort and reducing
symptoms, pain. The disease is no longer responsive to curative
treatment.
 Hospice care
 Support program for the patient and family through the dying
process. Focus is also comfort and to help with bereavement.
 Nurses, chaplains, therapists, bereavement counselors, social
workers and physicians
Conclusion: Call your healthcare provider for
these symptoms. . .

A change in shortness of breath,
fatigue, or swelling

Requiring more pillows than usual
to sleep comfortably at night or
needing to sleep in a recliner

Chest pain

Near fainting or fainting

Weight gain of 2 lbs in one day or 5
lbs in one week
Conclusion: Living with Heart Failure
 See your physician regularly
 Weigh yourself daily & call your RN/MD if gaining
 Limit salt and fluid intake
 Exercise at a level recommended by your physician
 Avoid smoking
 Keep your flu and pneumonia vaccines current
 Take your medications
 Take an active role in managing your health!
For More Information About Heart Failure…
The Heart Failure Society of America via their website:
Patients and caregivers– www.abouthf.org