Transcript Rosa Gutierrez 2006

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Heart Failure 101
out of the lab, into the clinic
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Objectives today
Provide an overview of clinical aspects of heart failure

diagnosis
assessment
management

clinical pearls from the trenches—front line HF care
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Definition of heart failure

state in which the heart cannot pump a
sufficient supply of blood to meet the
physiological requirements of the body, or
requires elevated filling pressures to do so

a pathological condition leading to a
debilitating illness characterized by poor
exercise tolerance, chronic fatigue, along with
high morbidity and mortality
Rosens ER medicine 6th ed
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Some truths about HF
 HF
is a chronic, progressive condition
that is life limiting
 HF is a terminal condition—eventually
it leads to the patient’s death
 There is no “cure”
 HF is common
 HF prevalence is on the rise
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Implications for the patient

HF symptoms range from none to an inability
to complete basic ADLs

HF patients may not appear ill, but have
profound symptoms; unable to function in the
way family members feel they should

HF clinical progression is cyclical, and
unpredictable—patients have no control over
what they can and cannot do on any given day
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“I wish I looked worse,
and felt better!!”
George J- HF patient
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What is your risk?
1 in 5 will develop heart failure
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Lloyd-Jones et al, Lifetime Risk for Developing Congestive Heart
8 Failure
Circulation 2002; 106: 3068 - 3072.
Heart failure: not going away
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Arnold Can J Cardiol 2007
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The cost of heart failure
Total Cost
$2.96 billion
Hospitalization
$15.4
52%
$3
billion
13%
7%
9%
Physicians/Other
Professionals
$2.0
Drugs/Other
Home Healthcare Medical Durables
$2.4
$3.1
Lost Productivity/
Mortality*
$2.8
*Lost future earnings
of persons who will
die in 2006,
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discounted by 3%
Nursing Home
$3.9
8%
10%
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AHA. 2006 Heart and Stroke Statistical Update
Heart failure: the numbers
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Prevalence
600,000 Canadians
Incidence
50,000 / year
Hospitalization
#1 cause
Average stay
7 days
1.4 million days
Death
 in hospital
 30 days post discharge

1 year 32%
2-22%
10%
5 year 50%
J. Ezekowitz 2008
CMAJ 2009, EJHF 2008
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Modes of death in HF
 50%
of HF patients “DROP”
 sudden
 50%
cardiac death
of HF patients “DROWN”
 progressive
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congestion
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HF etiology

ISCHEMIC (2/3 HF)
 CAD-ischemia+/-MI

NON ISCHEMIC (1/3 HF)
 Dilated
 Hypertrophic
 Restrictive
 Valvular
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HF rarely exists in a Vacuum
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Diabetes
COPD
Renal disease
Thyroid disorder
Cancer
It is not uncommon for the heart failure
patient to have one or all of the above
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Mechanisms of heart failure
myocardial
injury
mechanical
abnormalities
electrical
disorders
left ventricular dysfunction
loss of pump
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Compensatory mechanisms
loss of pump (CO)
neurohormonal
activation
BNP
SNS
vasopressin
AT I - II
aldosterone
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Chemical mediators of HF
Angiotensin I / II
Aldosterone
ADH-antidiuretic hormone
Epinephrine / Norepinephrine
Vasopressin
Endothelins
Natiuretic peptides
Atrial NP
B-type NP
C-type NP
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A toxic brew…
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myocardial injury
neurohormonal activation
hypertrophy-dilation
“remodeling”
vasoconstriction
Na+ + H2O retention by
the kidney
heart failure
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Compensatory mechanisms

the heart will attempt to maintain perfusion in
response to any increased
 burden of output
 loss of functioning myocytes
by a variety of mechanisms…

these mechanisms all worsen HF—by
provoking further pump failure over time
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MVO2

MVO2-myocardial oxygen demand
 a measure of cardiac workload: MVO2
increases with heart size, HR, contraction,
and resistance to contraction
 in the healthy heart, MVO2 can be easily met
with most workload demands
 in HF—MVO2 increases as the hearts ability
to supply itself decreases
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Compensated heart failure
the patient appears normal but:
 the exercise capacity is decreased
 there is an increase in CO and BP
 there is an increase in the work of the
heart
 further decrease in cardiac function
…causing decrease in the force of the
contraction and CO over time
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Rosa Guterriez 2006
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Types of heart failure
compensated


if the force of the
contraction is
moderately
decreased the heart
can meet the
metabolic demands
temporary
improvement CO
decompensated
occurs when the force
of the contraction is
decreased further
resulting in the
appearance of clinical
signs & symptoms
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Diagnosing HF
More difficult than you’d think
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Diagnosis of HF-CCS 2006
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Diagnostic accuracy of traditional HF
work-up
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Dao Q et al J Am Coll Cardiol 2001;37:379-85
Modes of heart failure

Systolic
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Diastolic
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pumping dysfunction
filling dysfunction
Right sided HF
Left sided HF
A HF patient can have one or several of these
It gets complicated….
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HF TESTING
ECHO anyone?
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Echocardiogram
WHY in HF: useful for
 assessing chamber size
 volume of cavity
 thickness of walls
 assessing pumping function (systolic)
 assessing filling function (diastolic)
 determining LVEFx within 10%
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Echo…
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determines chamber size and function,
thickness of the walls of the heart, and how
well each wall moves
evaluates the function of valves and
myocardium by looking at blood flow with
doppler
can be viewed live, and stored digitally or
on tape
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Echo…
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valve function / movement
structure, thickness, movement of valves
identify scars / calcifications / infection
vegetations
assessing valve repairs / prosthetic valves
pericardial fluid
congenital defects
thrombus
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ECHO
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Echo…

WHEN:

excellent first line test for determining / confirming
HF as diagnosis ----also for re-assessing patient
response to therapy, and improvements or decline of
heart function
yearly check of valve disease, prosthetic valve function
assessment of LA in patients with atrial fibrillation
recheck for thrombus resolution post
anticoagulation Tx
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Additional testing in HF
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ECG
BNP
MUGA
MIBI
Thallium (viability scan)
Coronary Angiogram
24 hour Holter monitor
VO2 Max
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BNP -CCS 2007

BNP / NT-proBNP … should be measured to
confirm or rule out a diagnosis of heart failure in
the acute or ambulatory care setting in patients
in whom the clinical diagnosis is in doubt
(class I, level A)

currently the most practical use of this test

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under cut-off point—HF unlikely
above cut-off point—HF very likely
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BNP (CCS 2007)
Heart
failure is
unlikely
Heart failure
possible but other
diagnoses must be
considered
Heart failure
is very likely
All
< 100
pg/ml
100-500 pg/ml
> 500 pg/ml
< 50
< 300
pg/ml
300-450 pg/ml
> 450 pg/ml
50 - 75
< 300
pg/ml
450-900 pg/ml
> 900 pg/ml
> 75
< 300
pg/ml
900 - 1800
pg/ml
> 1800 pg/ml
Age
(years)
BNP
NT-proBNP
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MUGA
 WHY
in HF: this test is the current
“gold standard” for determining EFx to
within 1-2% accuracy, and highly
reproducible (little variation with serial
testing)
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MUGA
 WHEN:
can be used following any
ECHO to narrow the range of EFx
(particularly if EFx is in question),
should be considered when
assessing / re-assessing patients for
device therapy
 often used during chemotherapy to
monitor cardiotoxic effects

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HF Signs & Symptoms
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Forward flow HF symptoms
“Out
of gas”—related to O2
delivery

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fatigue
weakness
lack of energy
cognitive dysfunction
decreased exercise tolerance
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Backword flow HF symptoms
“Plumbing”—related to congestion
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shortness of breath
orthopnea
paroxysmal nocturnal dyspnea (PND)
edema
fluid retention / weight gain
decreased exercise tolerance
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Uncommon HF presentation
Cognitive impairment*
Altered mentation
Delerium*
Nausea
Abdominal discomfort
Oliguria
Anorexia
Cyanosis
*May be more common presentation in elderly
ccs-2006
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HF Management
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HF treatment goals
Slow
progression of syndrome
Control
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symptoms
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Cardiac output– 4 components

PRELOAD


force stretching the ventricle before contraction
AFTERLOAD

tension against which the ventricle must pump to
eject this volume
HEART RATE
 CONTRACTILITY


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ability of the myocardial cells to produce forceINOTROPY
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How do we do this?
“Get with the Guidelines”-CCS 2006
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CCS on Systolic Heart Failure

Medical Therapy
 ACE inhibitors
 Beta-blockers
 Spironolactone
 Diuretics
 Digoxin
 Nitrates
 Statins
 ASA, Warfarin
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Device Therapy
 ICD
 CRT
Other Therapy

Multidisciplinary clinics
Exercise rehab
Dietary referral
Review of co-morbidity
Review of other drugs

LIFESTYLE!
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www.hfcc.ccs.ca
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CCS on HFPSF

Guideline based medications should be
considered in HF with preserved EF**
(diastolic HF) for:

relief of HF symptoms
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Pulmonary congestion
Peripheral edema
treatment of HF risk factors

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HR, atrial fibrillation
BP (as per HTN guidelines)
**overall lower level of evidence associated with HFPSF
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HF treatment is guided by…
EFx-ejection
ventricular
NYHA
systolic function
functional class
symptom
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fraction
status
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Ejection Fraction
EFx—its all about the LV
how much blood is ejected per ventricular
contraction is measured by percentage and is
indicative of pump efficiency
 the normal heart will pump out 60-70% of the
blood that enters the left ventricular chamber
---never 100%
 the LV’s normal shape is the perfect pump

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New York Heart Association
Functional Classification-NYHA
NYHA I: no physical activity limitation
NYHA II: slight limitation of physical activity
NYHA III: marked limitation of physical
activity
NYHA IV: unable to carry out any physical
activity or HF symptoms at rest
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“You are not your EFx”

Patients who have an EFx of 10% may have
NYHA FC I symptoms

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an asymptomatic patient may be at risk for a sudden
cardiac death, or arrhythmic event if their EFx is low
HF diagnosis may be missed if patient asymptomatic
Patients with a normal or near normal EFx may
have NYHA FC II-III symptoms
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a patient can have HF with a normal EFx
(preserved LV function)
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Medications for HF
morbidity / mortality reduction
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ACE inhibitors
Beta Blockers
Aldosterone antagonists
Goal: to target or maximally tolerated doses
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Medications for HF
symptom control

Diuretics
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Nitrates
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Digoxin
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Medications for HF
risk factor reduction

ASA
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Statins
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Warfarin
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Medications to avoid in HF
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NSAIDS (ibuprofen, indocid, high dose ASA)
COX 2 inhibitors (Celebrex®)
Thiazolidendiones (Avandia®, “glitizones”)
Corticosteroids
Tricyclic anti-depressants
Antiarrhythmics*
Calcium channel blockers**
Herbals
*exception: amiodarone (Cordarone)
**exception: amlodipine (Norvasc)
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ICD-internal cardiac defibrillator

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many HF patients at risk
for sudden cardiac death
primary / secondary
prevention
quantity of life
selection criteria:
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EFx
NYHA functional class
prognosis
medications maximized
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CRT-cardiac resynchronization

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mechanical dyssynchrony impacts pump
function
third lead attempts to
improve synchrony
quality of life
selection criteria:
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EFx
QRS width on ECG
NYHA functional class
medications maximized
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HF patients in trouble
…and into the hospital
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A fine balance…
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HF de-compensation triggers
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Dietary indiscretion #1 (with a bullet)
 salt / fluid lapse
Medications
 new / dose stopped / changed / forgotten / skipped
OTC / PRN
Infection
Co-morbidity interplay
Ischemia
Arrhythmia
Disease progression
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Nutrition management of HF

Limit Sodium Intake
Avoid
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Excessive Fluids
Daily Morning Weights
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Liz Woo MHI HFC
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Salt / Sodium restriction:
Less than 3 Gm NA/day most HF patients
Less than 2 Gm NA/day severe edema
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do not add salt
remove the salt shaker
from the table
avoid pickles, luncheon
meats, can soup, can
tomatoes
read labels for “hidden
salt”
less than 5% of total
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Sodium sources
Liz Woo MHI HFC 2009
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Fluid restriction:
2 liters / day if clinically stable
1-1.5 liters / day with severe edema
Fluid is: “anything wet”
 tea, juice, coffee,
milk, water,
watermelon, ice
 keep a diary
 adjust for hot
weather, illness
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Daily weights
weigh immediately after
voiding upon rising in
the morning
 no clothes on
 same scale every day
 keep a record
 bring the diary to the
clinic appointments
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Medications YES & NO

ACE inhibitors
 Beta blockers
 Aldosterone
antagonists
 Diuretics
 Digoxin
 Nitroglycerin
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NSAIDS
Thiazolidendiones
Corticosteroids
Tricyclic antidepressants
Antiarrythmics*
Calcium channel
blockers**
herbals
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Remember…

HF medications require
close monitoring:
 electrolytes (K+)
 creatinine

at initiation
pre up-titration
ongoing


Coumadin INR
 2.0-3.0
 2.5-3.5
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Infection
 URTI
 flu
 pneumonia
 UTI
 cellulitis
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HF co-morbidity
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Diabetes
COPD
Renal disease
HTN
Thyroid disorder
Cancer
HF rarely exists in a vacuum
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Ischemia
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Arrhythmia
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Disease progression
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Self care in HF

“YOU have the most power over your condition”

“AVOID behaviors that make heart failure worse”

“PAY ATTENTION, act EARLY”
“you can ignore your heart failure…”
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HF ASSESSMENT
Details, details, details
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HF assessment

Thorough patient history & physical exam

Establish baseline data and monitor trends

Appropriate surveillance ongoing
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HF treatment is guided by…
EFx-ejection
ventricular
NYHA
systolic function
functional class
symptom
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fraction
status
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Patient history


Symptom status / most limiting factor:
 SOB
 Fatigue
NYHA FC
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We use patient specific activities to measure—link to
frequently done tasks ie. vacuuming, stairs
Patient may avoid activities that provoke symptoms—
helpful to ask “what are you not doing now that you
would like to, or could do before?”
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history cont…
New or changed:
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Palpitations
Dizziness
Lightheadedness
Syncope
Angina
Depression
GI / appetite
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history cont…
Review of:
 Medications
 Lifestyle / risk factors
 Co-morbidity
 Recent admits to Hospital, ER
 Testing—current EFx?
 Bloodwork
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Physical exam
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Weight
Edema
JVP
Heart rate / rhythm
Blood pressure
HS auscultation
Lung auscultation
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Fluid balance assessment
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Weight increase
Edema
Orthopnea / PND (Paroxysmal nocturnal dyspnea)
HS cough
JVP elevation
+ Hepatojugular reflex
Respiratory auscultation-crackles, rales
CXR
Heart auscultation-S3
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Weight
“is that water, or is it you?”
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Weight

accuracy
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compare home / prior clinic weight
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same scale
shoes / no shoes
does this number make sense?
what is the ideal, “dry weight”?
**NEW PTs: record discharge wt on chart
if admission if within 2-3 months of initial
clinic visit
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Weight



assess if up or down? how much?
over what period of time?
what is long term trend for wt?
compare current clinic weight to patient
baseline, last clinic
to assess fluid balance
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when the “tank’s too full”…

The longer the fluid took to come on, the
longer it takes to come off

The more fluid the patient has gained, the
longer it takes to come off
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Edema
“where do you keep your water?”
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Edema
 swelling
in legs, feet, ankles?
 bloating in abdomen—ascites?
 swelling anywhere else?
pitting / non-pitting?
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Edema cont…

assess feet, ankles, legs for edema


equal both sides
how much pitting
assess above knee, track to sacral area if
edema severe
compare edema to patient baseline, last
clinic, plus weight
to assess fluid balance
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JVP
“up, down, up, down….”
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Jugular Venous Pressure
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JVP reflects pressure and volume changes
in the right atrium
most proximal location to view
10 cm column of blood supported to
clavicle from right atrium when upright
observe at 90 degrees, 30-45 degrees
measured in cm ASA
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Jugular Venous Pressure

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elevated JVP indicates high right atrial
pressure, fluid overload, TR
should not be > 4cm ASA or > 1cm above
R clavicle when patient upright
jugular venous distension at 90 degrees
suggests substantial congestion
baseline values key
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Tips for patient placement

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90 degrees
look at eye level point on opposite wall
relax ! wiggle chin
30-45 degrees
remove pillow
turn head slightly to the left (2 inches)
tell patient why you are looking
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Jugular Venous Pressure cont…

observe on right side of neck--- if not
apparent, check left
note external jugular position
supine to upright position may “pop” JVP

tricuspid regurgitation— “V”

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wave
may not obliterate venous wave
venous wave may be pulsatile
baseline JVP to chin when euvolemic
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VENOUS vs CAROTID
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
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


venous is a biphasic, undulating wave, carotid is a
monophasic wave
assess in several positions from supine to upright
(venous pulse will change with position)
venous wave can usually be obliterated with firm
finger pressure at base of neck
venous wave can not usually be palpated as carotid
can
occasionally, venous will overlay carotid
venous wave may descend with inspiration
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Look up…. way up!
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**Hepatojugular reflex: gentle abdominal
pressure causing further distension of
jugular veins suggests central
congestion/volume overload
 **Kussmauls: paradoxical rise in JVP with
inspiration
compare JVP to patient baseline, last clinic,
plus weight, edema
to assess fluid balance
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What can mislead you…
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Lung auscultation



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

crackles throughout
expiratory wheezes
decreased AE bases
quiet breath sounds
who is wet?
who is euvolemic?
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Blood Pressure
 79/40
mm/Hg
 185/98 mm/Hg
 121/83 mm/Hg


who has heart failure?
who is wet / dry?
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Creatinine
 385
umol/L
 110 umol/L
 150 umol/L


who is wet?
who is dry?
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S3 heart sound

normal HS

S3

S4

summation gallup
(Y.E Kocabasolglu, R.H. Henning)
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Cachexia

muscle mass

water weight
 daily
weights?
unchanged
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How much water?
 15
kg
 5 kg
 10 kg
 20 kg
or none?
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Take home…wet or dry?
Weight, edema, JVP = MVP


compare to additional clinic findings
account for specific patient factors
We don’t know where the patient is, if we
don’t know where he came from
BASELINE-BASELINE-BASELINE
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Patient assessment in HF



simple things
methodically done
multiple findings
 Baseline
data =
 Monitor trends=
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What’s the plan?

Self care teaching / reinforcement


Guideline based treatment options



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What has or could de-stabilize this patient’s HF?
Medications
ICD / CRT
Interventions ie. Angiogram, Sx
Follow up

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What surveillance level does this patient require?
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HF treatment goals
Slow
progression of syndrome
Control
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symptoms
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Why do we need
specialty clinics in
HF?
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HF patients take time




Readmission rates are high
Patients are complicated
 9 visits to GP/year
 8 visits to a specialist
 Multiple co-morbid conditions (average 5)
Need time beyond 8-10 minutes of visit
 Titrate medications
 Further diagnosis
Potential for huge benefits!
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JAE 2008
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Heart failure: do specialists matter?
Collaborative care
GP alone
McAlister et al JACC 2004
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Ezekowitz et al CMAJ
115 2005
Heart Function Clinic est. 1989

Missions:
1.
2.
3.

Multidisciplinary




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Clinical Care
Research
Education
6 MDs
4 Nurses with expertise in heart failure
Dietician
Pharmacist
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MHI Heart Function Clinic

Clinic #s:







700 active patients
25 new referrals/month
120 patient visits/month
83000 minutes on the telephone
66000 minutes in clinic
45000 minutes reviewing test results
support for this clinic is backed by extensive local data
collection, clinical trials and ongoing quality
improvement
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Future of HF care



HF patients are complex in every aspect
HF has a huge impact on quality and quantity of
life, morbidity and mortality—particularly when
not treated
successful treatment requires:




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timely diagnosis
close assessment & surveillance
guideline based treatment regimes
lifestyle support
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Thank you!
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