Transcript Outpatient management of heart failure

Outpatient management of
heart failure
Dr. Rob Wu
Feb 2008
Case
• 86 year old woman recently discharged from Team with
heart failure arrives at clinic for follow up
• Echo done in hospital – EF 58%, normal valves
• PMH: HTN, osteoporosis, osteoarthritis, DM2
• Meds: ASA, tylenol, ramipril 5 mg daily, metoprolol 25
mg po bid *, spironolactone 25 mg po daily *, furosemide
40 mg po bid *, arthrotec 75mg po bid, diabeta 5mg bid,
avandia 4mg daily , fosamax
• Currently, feels ok, no orthopnea, PND or ankle swelling
* - new medications, started in hospital
Case cont
• Exam: BP 130/68 HR 72
– Chest – clear, no crackles
– CV JVP 2 cm ASA, normal HS
– Extremities – no pedal edema
• Labs on discharge:
– CBC Normal, Na 140 K 5.5 Cl 108 Cr 140
• How would you manage her ?
Some questions
• LVEF>50%! Was it really heart failure?
– Maybe not. But diagnosis of HF is clinical
• including symptoms (PND, orthopnea), signs
(elevated JVP, S3, crackles), investigations (CXR,
BNP)
– If so, likely diastolic dysfunction or preserved
systolic function
• How would you optimize the meds?
• Further investigations?
• When to see her back?
Resources
• CCS Heart failure guidelines 2007, 2006
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Definition
Epidemiology
Diagnosis
Management
Quality
Some terminology
What is Heart Failure (HF)?
• HF is a complex syndrome in which abnormal
heart function results in, or increases the
subsequent risk of, clinical symptoms and signs
of low cardiac output and/or pulmonary or
systemic congestion
• HF is common and reduces quality of life,
exercise tolerance and survival
NB: calling it CHF is considered inaccurate and
uncool
Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.
Heart Failure Mortality
• Canada’s average annual in-hospital
mortality rate is:
– 9.5 deaths/100 hospitalized patients >65
years of age
– 12.5 deaths/100 hospitalized patients >75
years of age
• HF patients have a poor prognosis, with
an average 1-year mortality rate of 33%
Lee DS et al. Can J Cardiol 2004;20(6):599-607.
HF – An epidemic ?
Projected number of incident hospitalizations for CHF
patients, using high, medium and low population growth
projections in Canada 1996-2050
Johansen et al. Can J Cardiol 2003;19(4):430-5.
HF Readmissions
• Hospital readmission rates are high, and
mainly due to recurrent heart failure
Rate per 100 cases
Canadian Hospital Readmission Rates for Any Heart Failure
23.6
25
20
14.1
15
10
8.7
5
0
30 days
Lee DS et al. Can J Cardiol 2004;20(6):599-607.
90 days
1 year
Management Overview
• Management of HF requires
• an accurate diagnosis
• aggressive treatment of known risk factors
(e.g. hypertension, diabetes)
• rational combination drug therapy
• Care should be individualized for each patient based on:
• symptoms
• clinical presentation
• disease severity
• underlying cause
Diagnosis and investigations
• Clinical history, physical examination and
laboratory testing
– BNP (available at UHN, cost $65, ~2d turnaround)
• Transthoracic echocardiography (ventricular size
and function, valves, etc.)
• Coronary angiography in patients with
known/suspected CAD
• NYHA classification should be used to document
functional capacity in all patients
Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.
Management
CCS HF guidelines 2006. Can J Cardiol 2006;22(1):23-45.
Non pharmacologic therapy
• I am supposed to counsel what again ?
– Diet
• How much salt – no added or low salt
• Is that 1gm, 2gm?
• Is fluid restriction necessary ?
– Symptoms of heart failure
– Self care including daily weights
Salt and Fluid
• Salt
– All patients with heart failure
• No added salt diet (2-3 gm / day)
– If difficult to control, low salt diet 1-2 gm/day
• May just need some educational literature for ~ 2gm/day
• Likely needs to see a dietitian (TWH referral) for <2gm/day
• Fluid restriction
– Not necessarily all patients, just those with difficult to
control HF or sodium issues (1.5 – 2 L / day)
Medications
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ACE
ARB
BB
Spironolactone
Digoxin
Diuretics
ACE
• All HF patients with LVEF <40% should be
treated with an ACE-I and a beta-blocker,
unless a specific contraindication exists
(Class I, Level A)
Practical Tips for ACE-I/ARB Use
• Check supine and erect BP for symptomatic
hypotension
• If symptomatic hypotension persists, separate
timing of dose from other medications that could
also lower BP
• Reduce dose of diuretic if patient stable and
reassess need for other vasodilators (e.g., longacting nitrates)
• An increase in creatinine of up to 30% is not
unexpected after introduction of an ACE-I/ARB
• Adding spironolactone to an ACE-I plus an ARB
is discouraged, unless followed closely in a
specialist HF clinic
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
When to Use Beta-blockers?
• All HF patients with LVEF 40%
(use clinically proven beta-blocker)
(Class I, Level A)
• In stabilized HF patients with NYHA Class IV symptoms
(Class I, Level C)
MERIT-HF Study Group. Lancet 1999;353:2001-7.
CIBIS II Investigators. Lancet 1999;353:9-13.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Packer M et al. Circulation 2002;106:2194-9.
Practical Tips for BB Use
• Dose of BB should be increased slowly, e.g., double dose
every 2-4 weeks if stable
• If bradycardia or AV block is present, reduce or stop digoxin or
amiodarone (where appropriate)
• If hypotensive, consider reducing other medications or change
timing of doses
• Objective improvement in LV function may not be apparent for
6-12 months or longer
• Major reduction of BB dose or abrupt withdrawal should
generally be avoided
• Consider using beta blocker proven effective in HF trials
– Bisoprolol, carvedilol (or long-acting metoprolol but not available in
Canada)
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
When to Use Aldosterone Blockers?
Spironolactone:
• Patients with LVEF 30% and severe symptoms
despite optimized other therapies (and Creat <200, K
<5.2)
(Class I, Level B)
Pitt B et al. N Engl J Med 1999;341:709-17.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
When To Use Digoxin?
• To relieve symptoms and reduce hospitalizations in
patients in sinus rhythm who have persistent moderateto-severe symptoms despite optimized HF medical
therapy
(Class I, Level A)
The Digitalis Investigation Group. N Engl J Med 1997;336:525-33.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
When To Use Nitrates +
Hydralazine?
• Other HF patients unable to tolerate ACE inhibitors
and ARBs
(Class IIb, Level B)
• African-Americans with systolic dysfunction in
addition to standard therapy
(Class IIa, Level A)
Cohn et al. N Engl J Med 1986;314:1547-52.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Taylor AL et al. N Engl J Med 2004;351:2049-57.
Drug Interactions and Additive Adverse
Effects of Common Medications
(Class I, Level B)
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
HF with Preserved Systolic Function
• Diagnosis is generally based on typical signs and
symptoms of HF in patient with normal LVEF and no
valvular abnormalities
• Important to control comorbidities, such as hypertension
and diabetes, which are often associated with HF with
PSF
• Systolic and diastolic hypertension should be controlled
according to published guidelines
(Class I, Level A)
• The ventricular rate should be controlled in patients with
atrial fibrillation at rest and during exercise
(Class I, Level C)
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
HF with Preserved Systolic Function
• Diuretics should be used to control pulmonary congestion
and peripheral edema
(Class I, Level C)
• ACE inhibitors, ARBs, and beta-blockers should be
considered for most patients
(Class IIa, Level B)
• Coronary revascularization may be considered for patients
with symptomatic or demonstrable ischemia that is judged
to have an adverse effect on cardiac function
(Class IIa, Level C)
• Excessive diuresis should be avoided as this can easily
lead to reduced CO and renal dysfunction
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Remainder of Slides are
Optional….
Review if time permits….
Heart Failure and Renal
Dysfunction
A Caution (and a recommendation)
• Routine use of ACE-I, ARBs or spironolactone
in the setting of severe renal dysfunction
(serum creatinine >250 µmol/L or an increase
of > 50% from baseline) is not recommended
due to a lack of evidence for efficacy in HF
patients
(Class IIa, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
Geriatric HF
• (this is us)
• Frailty score
– predicts
• Death
• Need for
institution
Other evidence-based therapies
• Multidisciplinary heart failure clinics
– Reduces readmissions and mortality
– Most have RNs doing monitoring, counselling
– But…
– Most only see systolic dysfunction
– Many wont see older patients who may not
benefit from devices
Which Patients Should be Referred to
a Heart Failure Specialist?
• New onset HF
• Recent HF hospitalization
• HF associated with ischemia, hypertension, valvular
disease, syncope, renal dysfunction, other multiple
comorbidities
• HF of unknown etiology
• Intolerance to recommended drug therapies
• Poor compliance with treatment
• First degree family members if family history of
cardiomyopathy or sudden cardiac death
(Class I, Level C)
CCS HF guidelines, Can J Cardiol 2006;22(1):23-45.
Practically, which referrals will be
accepted by a Heart Failure Specialist?
Definitely pre-transplant candidates
Age <60
Candidates for devices (AICD, biventricular pacer, LVAD)
LV systolic dysfunction (LVEF <40%)
Conclusions
• Make an accurate and timely diagnosis
• Initiate treatment to
• Reduce HF risk factors
• Reduce HF symptoms
• Reduce hospitalizations
• Improve quality of life
• Prolong survival
• Refer patients at higher risk to specialist or HF clinic
• Continue to translate new knowledge into practice
• Combine available healthcare resources to improve
delivery of best care and practices to HF patients
• Improve HF outcomes in Canada
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Case
• 86 year old woman recently discharged from team with
heart failure arrives at clinic for follow up
• Echo done in hospital – EF 58%, normal valves
• PMH: HTN, osteoporosis, osteoarthritis, DM2
• Meds: ASA, tylenol, ramipril 5 mg daily, metoprolol 25
mg po bid *, spironolactone 25 mg po daily *, furosemide
40 mg po bid *, arthrotec 75mg po bid, diabeta 5mg bid,
avandia 4mg daily , fosamax
• Currently, feels ok, no orthopnea, PND or ankle swelling
* - new medications, started in hospital
Case cont
• Exam: BP 130/68 HR 72
– Chest – clear, no crackles
– CV JVP 2 cm ASA, normal HS
– Extremities – no pedal edema
• Labs on discharge:
– CBC Normal, Na 140 K 5.5 Cl 108 Cr 140
• How would you manage her ?
Some answers?
• Management
– Etiology – consider ischemia
– Counseling – daily wts, NAS diet, symptoms, meds
– Meds – D/C NSAID, rosiglitazone, spironolactone, try
titrate down diuretic
• Further investigations
– Lytes, Creat, ECG
• When to see her back?
– High risk of readmission (elderly, recent admit)
• 1-2 weeks would be reasonable
web resources
• www.heartfunction.com
– Counseling info
– HF guidelines
– Flow sheets for your hf patients