Transcript available now - Grand Strand Advanced Practice Nurse Association

Systolic or Diastolic: What’s
the Difference?
Cynthia MacDonald, MSN, RN,CS, APRN
Adult Nurse Practitioner
Low Country Lung & Critical Care
Hospitalist – Trident Health System
Statistics
• 40-60% pts w/ HF have nl
LV function, but have
diastolic dysfunction
• Estimated 15% have mildly
abnl sys fx (EF 45-54%) w/
dias dysfunction
Public Health Impact
• HF w/ preserved EF
– better prognosis
– 8-9 % mortality 1 yr
vs 19% for systolic
dysfunction
Patient: JS, 70 yo white female
CC: SOB
Hx: HTN, HLP, GERD
Ht: 5’4” Wt: 170 lbs
BP: 176/98 Pulse: 112 RR: 16
Meds: atenolol 50mg qday,
Zocor 40 mg q hs, omeprazole 40 mg
PE: NAD, S1 S2 2/6 murmur LSB,
lungs CTA, Abd taut, +HJR, 2+ LE
edema
Heart Failure
Definition
• Clinical syndrome
• Heart not able to
pump blood to meet
body’s needs
Heart Failure
•Systolic
– Decreased pumping
ability
•Diastolic
– Relaxation abnormality
Systolic Dysfunction
• Impaired forward output
caused by decreased LV
contraction.
• Damaged or weakened
heart muscle
• Hallmark -  EF
</= 40%
Diastolic Dysfunction
• Normal EF
• Noncompliant, stiff LV
• Less able to relax
• Interferes with adequate
filling;
• Raises filling pressures
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Coronary Artery Disease
Valvular Heart Disease
High Blood Pressure
Tachycardia induced CMP
Myocarditis
Sarcoidosis
Cocaine abuse
Noncardiac Causes
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Thyroid Disease
OSA
Alcohol Abuse
Infection
Drugs
Diabetes
Rheum D/O - lupus
Diastolic Heart Failure
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Preserved LV function
Signs & Symptoms of HF
Abnormal LV Filling
Elevated Filling Pressures
Impaired response to stress
Difficulty tolerating hemodynamic
stress
– Afib, tachycardia, elevated BP
DIASTOLE
• 2/3 cardiac cycle
• Tachycardia – decrease
filling/relaxation time/filling
• Afib – lose atrial contraction,
reduce LA emptying, LV
filling & LV stroke volume
Diastolic HF
• Ischemia raises LA & pulm venous
Pressure; worsens diastolic dysf
• Respiratory sx (wheezing, SOB,
inability to take a deep breath, &
pulm edema “Angina equivalents”
• BP Elevation - abrupt, severe, or
refractory elevation of BP
• Increases LV wall stress 
decreases myocardial relaxation
PATHOPHYSIOLOGY
of
HEART FAILURE
Neurohormonal Model
Nl Cardiac Function
Cardiac
Insult
LV Dysfunction
NPS Activation
LV Remodeling
 Responsiveness
Aldosynthesis
to NPS
RAAS Activation
Sympathetic Act.
Natriuretic Peptides
ANP - atria
BNP - ventricles
• Triggered by stretch
• Vasodilator, diuretic,
natriuretic properties
• Inhibits RAAS – suppresses
aldosterone, ADH,
epinephrine
NP System Overwhelmed in
Acutely Decompensated Heart
Failure
Angiotensin II
Epinephrine
Norepinephrine
Endothelin
Aldosterone
ANP
BNP
Renin-AngiotensinAldosterone System
(RAAS)
• Activated by hypoperfused
kidneys
• Leads to vasoconstriction &
volume retention
• Renin released by kidney
SNS Activation
Diuretics
 Na Diet
Angiotensinogen
RENIN
 Renal
Artery
Pressure
Angiotensin I
ACE
Angiotensin II
Angiotensin II
 SNS
ADH
Aldosterone
Activity
Release
Secretion
Vasoconstriction
Water
Na
retention
retention
Assessment &
Evaluation
• Patient History
• Physical Exam
• Diagnostic
Tests
Patient: JS, 70 yo white female
CC: SOB
Hx: HTN, HLP, GERD
Ht: 5’4” Wt: 170 lbs
BP: 176/98 Pulse: 112 RR: 16
Meds: atenolol 50mg qday,
Zocor 40 mg q hs, omeprazole 40 mg
PE: NAD, S1 S2 2/6 murmur LSB, lungs
CTA, Abd taut, +HJR, 2+ LE edema
==========================
Other Questions/Information needed
Labs/Tests to order
Patient History
Symptoms
SOB – exertion, nocturnal,
orthopnea – sleeps recliner
• Fatigue, ↓ exercise tolerance
• Edema – LE, abdominal –
bloating, pants tight, ↓ appetite
• Symptoms of OSA
PHYSICAL EXAM
• Cardiac exam
Heart sounds
Heart rhythm
• JVD/HJR
• Lungs clear/crackles/rhonchi
• Abdomen-bloating, taut
• Peripheral edema
Diagnostic Tests
• ECG
• CXR
• CBC
• Electrolytes
(Mg)
• TSH
Echocardiogram
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Evaluate EF, valves, chamber sizes
LVH
Relaxation abnormality
Diastolic Dysfunction
Reduced EF
Elevated RVSP
Pulmonary HTN
Wall motion abnormality
Treat
Sx
Meds
Low
Na
Diet
Lifestyle
Changes
Treatment Goals
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Relieve Symptoms
Control BP
Reduce LV afterload
Improve cardiac function
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slow/reverse deterioration in myocardial
function; slow pathologic remodeling
Decrease mortality/extend survival
Improve QOL
Cost effective treatment
Improve self-mgmt skills
Treatment Goals
• decrease risk of hospitalization
• Titrate as tolerated to medication
target ranges for optimal clinical
benefit
• Treatment beyond clinical
congestion may improve outcomes
• Prevent end organ dysfunction
PROLONG PATIENT
SURVIVAL
• Diuretics
• Beta blockers
• ACE Inhibitors
• ARB
• Hydralazine + nitrate
• Aldosterone Antagonists (AA)
Additional Pharm Therapy
• Prevention of arrhythmias
• Prevention embolic events
• Treatment of Anemia
Proven Therapies for Chronic
Systolic Heart Failure
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Diuretics
ACE Inhibitors
Angiotensin receptor blockers (ARBs)
Beta-blockers
Aldosterone antagonists
Implantable cardiac defibrillators (ICDs)
Cardiac resyncronization therapy (CRT)
Bi-ventricular pacemakers
• Patient education
Systolic Dysfunction
• Loop Diuretics (usually double
home po dose, give IV
• ACE
• Beta Blockers
• ARBs
• Spironolactone
• Nitrates
• Digoxin (use less)
Diastolic Dysfunction
Treatment Recommendations
• Treat known risk factors (HTN, DM, OSA)
• Ventricular rate control for all patients
• Drugs for all patients:
– Diuretics
• Drugs for appropriate patients:
– ACEI
– ARBs
– Beta-Blockers, CCB
• Coronary revascularization in selected patients
• Restoration/maintenance of sinus rhythm
Diastolic Dysfunction
• Diuretics -  LV filling
pressure
• Na Restriction
• Beta blockers
• ACE
• ARB
• CCB - Verapamil & diltiazem
 HR & promotes vent. relax
Treat Underlying Cause
• HTN
 HR =
• Ischemia
 Filling time
• Arrhythmias
?OTC meds w/
• Anemia
Ephredrine/
• Fever
pseudoephredrine
• Tachycardia
• Caffeine, Nicotine
Clues to Uncontrolled BP
• ASYMPTOMATIC
• Sx – headache, feels bad, hears
heartbeat in ears
• Echo findings – LVH, pulm HTN,
elevated RVSP, diastolic dysfunction
or relaxation abnormality
• CXR – Cardiomegaly (CMG)
• Look at trends if pt in hospital or if
monitoring at home; different times
Causes of Inadequate Response
Associated conditions
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smoking
Obesity
High salt/sodium intake
sleep apnea
insulin resistance
Alcohol intake
anxiety/panic attacks
chronic pain
Low Sodium Diet
• No salt or high Na seasonings
• Accent, MSG, Nature’s seasoning
– Meat Tenderizer
– Lemon Pepper
• Processed foods
• Canned goods
• Fast Foods
• 1.5 - 2 Gm sodium (Na diary)
Screen for Sleep Apnea
• Epworth sleepiness scale
• Do you sleep through the night?
• Nocturia
• Wakes up tired; Daytime drowsiness
• Palpitations (especially at night)
• Sleepy when driving
• Snoring, gasps, snorts, choking
• Ask family members
• Irritability
• Car accidents/work injuries
• Restlessness; Toss & Turn, restless legs
Clues to sleep apnea
• “Roller Coaster BP” (pt self monitor –
take BP at different times)
• 3, 4, 5 meds – BP not controlled
• Fluid retention problems
• Body habitus (don’t be fooled by thin
people); Class 3-4 Palate
• BS difficult to control
• Too tired to exercise
• Caffeine, nicotine (diet soda, tea)
Mallampati
score
Health Conditions & OSA
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Hypertension (roller coaster BP)
Palpitations; dysrhythmias
A Fib; PAF; A Flutter
↑ risk MI, CVA, SCD, blood clots
GERD
DM; difficult to control BS
Memory, concentration, focus
Irritability; depression; bipolar D/O
Fibromyalgia
Patient: JS, 70 yo white female CC: SOB
Hx: HTN, HLP, GERD Ht: 5’4” Wt: 170 lbs
BP: 176/98 Pulse: 112 RR: 16
Meds: atenolol 50mg qday, HCTZ 25mg Zocor 40
mg q hs, omeprazole 40 mg
PE: NAD, S1 S2 2/6 murmur LSB, lungs CTA, Abd
taut, +HJR, 2+ LE edema
Na 130, K 2.5, Mg 1.5
Echo – EF 60%. LVH, relaxation abnormality (grade
1 diastolic dysfunction, 1+ MR
EKG – NSR, LVH
Freq nocturia, wakes up tired, daytime sleepiness,
restlessness, no dreaming, memory probs
MEDICATIONS
TREATMENT
OF HEART FAILURE
Treatment
• Loop Diuretic
• ACE
• BB - carvedilol, metoprolol
succinate, bisoprolol
• titrate these up first
• add on AA
• add hydralazine + nitrate in African
Amer - persistent Class III, IV & EF
< 40%
MEDICATION
• Hydralazine - start at 25mg tid &
isosorbide dinitrate 20 mg tid
target 75mg tid & isosorbide
dinitrate 40 mg tid
• Women & AA don't benefit as much
from ACE
• Women benefit same from BB
AA may not benefit as much from
BB except for carvedilol
• CCB - no direct role in treatment of
Systolic HF
can add on vasoselective CCB such
as amlodipine & felodipine neutral effect on mortality
Don't recommend ACE, ARB, & AA
(as well as no Direct Renin
Inhibitor)
Oral Agents
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Diuretics (thiazide, loop, K+-sparing)
Beta Blockers
Calcium channel blockers
Angiotensin-converting enzyme inhibitors
(ACE I)
Angiotensin II receptor blockers (ARB)
Adrenergic inhibitors (peripheral, central
alpha-antagonists
Direct vasodilators (hydralazine, minoxidil,
nitrates)
Direct Renin Inhibitor (tekturna-aliskiren)
DIURETICS
• Loop diuretics
• Appropriate dosing
• Monitor Wt, K, Mg, Na,
BUN/Cr
• Zaroxolyn – 30 min before
loop diuretic
• Loop diuretic + HCTZ
© CMacDonald 3/00
DIURETICS
Thiazides
Inhibit active exchange of Cl-Na
in the cortical diluting segment of the
ascending loop of Henle
Cortex
K-sparing
Inhibit reabsorption of Na in the
distal convoluted and collecting tubule
Medulla
Loop diuretics
Inhibit exchange of Cl-Na-K in
the thick segment of the ascending
loop of Henle
Loop of Henle
Collecting tubule
Adverse effects
• Postural
•
↑
SNS
activation
hypotension
•
neuro• hypokalemia
hormonal
• hyperglycemia activation (↑
• hyperuricemia
renin production
& RAAS
• Rash
• hypomagnesem activation
• azotemia
ia
Electrolyte Replacement
• Monitor K, Mg, Na, Cr closely
• Careful w/ CRI
• Check Mg if hard to get
K up
•K - > 4
• Mg ≥ 2.0
© CMacDonald 3/00
ACE Inhibitors
• Inhibits ACE; Prevents Angiotensin I
to Angiotensin II (potent
vasoconstrictor)
•  afterload;  BP;
•  Cardiac output;  Renal blood flow
• Reduces TPR
• Correct volume status
• Reverse/limit remodeling
• Start low dose; split dose
ACE Inhibitors
Increases Cardiac Output by
decreasing afterload; makes
it easier for heart to pump
• Suppresses Aldosterone
secretion (some)
• Still underutilized
• Maximize dose
•
Adverse Effects
• Hypotension
• Worsening of renal function
• Hyperkalemia
• Cough
• Angioedema
• Rash
• Neutropenia
Beta-Blockers
Drug
Initial Dose
Bisoprolol
1.25 mg/day
(Zebeta)
Carvedilol* 3.125mg BID
(Coreg)
Metoprolol* 25 mg/day
(Toprol XL)
Target Dose
5mg/day (< 85 kg)
10 mg/day (> 85 kg)
25 mg BID (<85kg)
50 mg BID (> 85 kg)
150 – 200 mg/day
Beta Blockers
 HR -  filling time
•  Blood Pressure
•  Mortality HF & MI
•  risk of another heart attack
• Reverse remodeling; improve
function
• Caution – asthma, reactive
airway disease; not COPD
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 sensitivity to catacholamines
Prevent LV dilation
Negative inotrope
Warn pt – will feel worse before
feeling better
Titrate up slowly; monitor BP &
HR
Contraindications
• Bronchospasm
• Advanced heart block
• Sinus bradycardia
• Cardiogenic shock
• Acute pulmonary
edema
Titration and Adverse
Effects
• Begin at low
doses,  if
tolerated (2
wk
intervals).
• Monitor pts.
closely
–hypotension
–edema
–worsening
heart failure
–bradycardia
–heart block
–bronchospasm
Considerations
• Stabilize pts. on standard therapy
before initiation of beta-blocker
• Use with caution in pts. with
bradycardia
• Careful review of pt. before uptitration of dose
• Decrease dose or discontinue if
pt. develops worsening heart
failure
Angiotensin II Receptor
Blockers (ARBs)
• Blocks Angiotensin II at
receptor sites
• Dilates blood vessels
• Lowers BP
• Don’t use before ACE
© CMacDonald 3/00
ARBs
•  SVR
•  aldosterone &
epinephrine secretion
• Correct hypovolemia prior
to initiating therapy
Calcium Channel Blockers
• Use Diastolic Dysfunction; not for tx
LVSD
• Dilates blood vessels & helps to
decrease angina
•  BP
• Slow HR in LVDD
• Negative inotropy
• Diltiazem, verapamil -  HR,  BP
• Amlodipine –  BP
Calcium Channel Blockers
• Diltiazem start 30mg q 6hrs to slow
HR & lower BP; titrate up as tolerate
& then can change to long acting
(120 , 180, 240, 300, 360mg)
• Verapamil – 40, 80, 120 mg; tid
– Max 480mg/day
Aldosterone antagonists
• Helps to limit remodeling & fibrosis
• Aldactone/spironolactone (start
12.5 to 25 mg/day)
• Contraindications:
– serum creatinine > 2.5 m/dL
– serum K+ > 5.0 mmol/L
• Adverse Effects:
– worsening renal function, GI upset,
hyperkalemia, gynecomastia, rash
Spironolactone/Eplerenone
• Aldosterone inhibitors
• Prevents aldosterone from
attaching to receptors
• Promotes Na excretion
•  excretion of K
• Decrease/discontinue K
• Monitor K, Cr closely
• Prevents fluid retention
• Used to treat chest
discomfort & other
symptoms of angina
• Dilates blood vessels
• More blood flows through
coronary arteries to heart.
Hydralazine/ Isosorbide
Alternative in patients with
contraindications or intolerance
to ACE Inhibitors
• Monitor for side effects
• Hydralazine – H/A, tachycardia,
fluid retention, lupus, N/V/D
• Nitrates - H/A, dizziness,
nausea, hypotension
•
Digoxin
  force of contraction
• blocks sympathetic stimulation
(slower HR – treat Afib w/ RVR)
• EF < 40-45%
• Not used - diastolic dysfunction
• Used less for systolic dysfunction
• Draw blood 12 hrs after dose
• Don’t stop if already on dig
Contraindications
• Significant sinus or AV block
• Bradycardia
• Dosing 0.25 mg/day, lower for
elderly, renal dysfunction, or
potential drug interactions
• Monitoring of serum level is
controversial
Tekturna (Aliskiren)
• Direct Renin Inhibitor
• Cautious in renal dz, high K
• Should not be on ACE, ARB, Renin
inhibitor (can be on 2 of these)
• Watch Cr
• Diarrhea, GERD, hyper K, Elev Cr,
BUN, angioedema, hypotension
• Not used much now
Patient: JS, 70 yo white female CC: SOB
Hx: HTN, HLP, GERD Ht: 5’4” Wt: 170 lbs
BP: 176/98 Pulse: 112 RR: 16
Meds: atenolol 50mg qday, HCTZ 25mg Zocor 40
mg q hs, omeprazole 40 mg
PE: NAD, S1 S2 2/6 murmur LSB, lungs CTA, Abd
taut, +HJR, 2+ LE edema
Na 130, K 2.5, Mg 1.5
Echo – EF 60%. LVH, relaxation abnormality (grade
1 diastolic dysfunction, 1+ MR
EKG – NSR, LVH
Freq nocturia, wakes up tired, daytime sleepiness,
restlessness, no dreaming, memory probs
• Stop HCTZ, replete K & Mg
• Chg atenolol to 100 mg bid or
change to coreg 6.25-12.5 mg bid
or Toprol or diltiazem
• Add ACE – Lisinopril (bid dosing if
bid dosing w/ BB or CCB)
• Daily wts – prn loop diuretic
• Can add AA
• Refer for sleep eval/study
• HR target – 60-70s
Patient: JS, 70 yo white female CC: SOB
Hx: HTN, HLP, GERD Ht: 5’4” Wt: 170 lbs
BP: 176/98 Pulse: 86 RR: 16
Meds: atenolol 50mg qday, HCTZ 25mg Zocor 40
mg q hs, omeprazole 40 mg
PE: NAD, S1 S2 2/6 murmur LSB, lungs CTA, Abd
taut, +HJR, 2+ LE edema
Na 130, K 2.5, Mg 1.5
Echo – EF 30%, 1+ MR
EKG – NSR w/ PACs
Freq nocturia, wakes up tired, daytime sleepiness,
restlessness, no dreaming, memory probs
• Stop HCTZ, replete K & Mg
• Diurese w/ loop diuretic
• Chg atenolol to coreg 6.25-12.5 mg
bid
• Add ACE – Lisinopril (bid dosing)
• Daily wts – prn loop diuretic
• Add AA
• Refer for sleep eval/study
• HR target – 60-70s
Cardiac Resynchronization
Therapy (CRT)
• Criteria QRS >/= 130 msec
• Sinus rhythm
• EF ≤ 30%
• Dysynchony of RV & LV
• Improved LV function
• Decrease LV volume
BiV Pacer
• Atrial synchronized biventricular
pacing
• Correction of electrical =
correction of mechanical
• Improved coordination of
contraction
• Improved timing - valve opening &
closing
BiV Pacer
• Pacing leads placed
in RA & RV
• Specially designed
pacing lead passed
through coronary sinus
into a cardiac vein on
left lateral freewall
ICD (implantable cardioverter
defibrillator)
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EF < 35 - 40%, cardiac arrest, SCD
V Tach or V Fib
Inherited heart abnormality
Acts as pacemaker if slow HR
Defibrillate chaotic rhythm (V Fib)
Saves lives
What every heart failure
patient should know:
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Symptoms of heart failure
medications names/doses
Obtain daily weights
Eat a low sodium diet
Diagnose OSA/CSA
Exercise
Weight Loss
• Low Na Diet
• Fluid
Restriction
Sodium
holds
onto
fluid
Lifestyle changes
• Stop Smoking
• Lose Weight
• Avoid alcohol
• Control HTN,
Lipids, DM
Regular Exercise
• Progress slowly;
Start with short,
frequent intervals
• Improved
conditioning
• Feels better
• Perform ADLs
END OF LIFE ISSUES
• Educate both pt & family
– Expected course of illness
– Final treatment options
• Hospice services
• Planning undertaken before
pts become too ill to
participate in decisions