Transcript Management of CHF on Hospice - Washington State Hospice

Management of CHF on Hospice
David Kregenow, MD
Evergreen Health
Hospice and Palliative Care
Disclosures
• I have no relevant financial conflicts of interest
• My background is in Pulmonary and Critical
Care Medicine
• The material that follows comes from:
Consensus Statement: End-of-Life Care in
Patients with Heart Failure. J Cardiac Failure
2014;20:121-134 on behalf of the Quality of
Care Committee for the Heart Failure Society of
America.
Outline
•
•
•
•
•
•
•
•
•
Classification and Prognosis in HF
Case #1
Diastolic vs. Systolic Failure
Connections to Renal and Respiratory Physiology
Symptom Inventory #1
Case #2
Systolic Failure and Therapies
Symptoms Inventory #2
Mechanical Circulatory Support (LVAD)
Prognosis of Heart Failure, NYHA
Classification
Class
Symptoms
I
Cardiac disease, but no symptoms and no limitation in ordinary physical
activity. Ordinary physical activity does not cause undue fatigue,
palpitation, dyspnea (shortness of breath).
II
Mild symptoms (mild shortness of breath and/or angina) and slight
limitation during ordinary activity. Comfortable at rest. Ordinary physical
activity results in fatigue, palpitation, dyspnea (shortness of breath).
III
Marked limitation in activity due to symptoms, even during less-thanordinary activity, e.g. walking short distances (20–100 m).
Comfortable only at rest. Less than ordinary activity causes fatigue,
palpitation, or dyspnea.
IV
Severe limitations. Experiences symptoms even while at rest. Mostly
bedbound patients. Unable to carry on any physical activity without
discomfort. Symptoms of heart failure at rest. If any physical activity is
undertaken, discomfort increases.
Prognosis of Heart Failure, Objective
Assessment
Class
Description
A
No objective evidence of cardiovascular disease. No symptoms and no
limitation in ordinary physical activity. Risk factors but no structural heart
disease.
B
Objective evidence of minimal cardiovascular disease. Mild symptoms and
slight limitation during ordinary activity. Comfortable at rest. Structural heart
disease but minimal symptoms.
C
Objective evidence of moderately severe cardiovascular disease. Marked
limitation in activity due to symptoms, even during less-than-ordinary
activity. Comfortable only at rest. Symptomatic heart failure.
D
Objective evidence of severe cardiovascular disease. Severe limitations.
Experiences symptoms even while at rest. Refractory symptoms despite
guideline-directed medical therapy.
Prognostic Tool
Seattle Heart Failure Model
www.seattleheartfailuremodel.org/
Hospice Eligibility
• Models may help
• Guidelines help
– NYHA Class IV Symptoms
– Symptoms despite maximal therapy
– Persistent resting tachycardia
• Physiology helps
– Combination of heart failure and renal impairment is
medically very challenging
• HF Survival on Hospice is 81 days longer on average than
without Hospice. J Pain Symp Mgmt 2007; 33(3): 238-46.
Case 1 Presentation
• Phyllis is an 87 year old woman hospitalized four times
this year with shortness of breath and fluid overload.
• She has a long history of hypertension, with moderate
chronic kidney disease, macular degeneration, and
paroxysmal atrial fibrillation, and a history of TIAs.
• She has recurrent difficulty with falls complicated by
persistent lower extremity edema, and chronic bilateral
pleural effusions.
• Her ECHO shows LVH, EF 65%, Biatrial Enlargement,
and Mod-Severe Pulmonary Hypertension.
• She is widowed and lives in a AFH.
The Picture of CHF
Two Main Paths to CHF
HFnEF
Normal
HFrEF
HFpEF and HFrEF
HFpEF
• Older
• F>M
• Hypertension
• Few Treatment Options
• Maintain Euvolemia
HFrEF
• Younger
• M>F
• Ischemia
• Medical Therapies
• Inotrope Infusions
• Implantable Devices
• Mechanical Circulatory
Support
• Cardiac Transplantation
Normal Echocardiogram
https://www.youtube.com/watch?feature=pla
yer_detailpage&v=7TWu0_Gklzo
Normal Echocardiogram
HFpEF ECHO
Sensation of Dyspnea
Sensation of Dyspnea
Treatments for Dyspnea
• Maintenance of euvolemia
– Sodium and fluid restrictions
– Diuretics
– Leg elevation above the atrium
• Digoxin (Narrow therapeutic window)
• When near EOL:
–
–
–
–
Opioids (Careful of impaired renal excretion)
Oxygen if hypoxemia is present
Benzodiazepines
Elevation of the Head of the Bed, Fan
Leg Elevation
Sleep Disorders in CHF
• Approximately 50% of HF patients have sleep disordered
breathing
–
–
–
–
–
Orthopnea
Nocturia
Obstructive Sleep Apnea
Central Sleep Apnea
Cheynes-Stokes Respirations
• Sleep Maintenance vs. Insomnia
• Treatments:
–
–
–
–
Sleep Hygiene
CPAP
Nocturnal Oxygen
Nocturnal urination aids
Kidney Physiology
Diuretics
• Loop of Henle: Furosemide, Torsemide
• Distal Tubule: Metalazone, Thiazides
• Potassium Sparing/Neurohumoral:
Spironolactone
Kidney Physiology
Thiazide Diuretics
Loop Diuretics
Fatigue and Weakness in CHF
• Multifactorial
– Cardiac insufficiency
– Muscle loss
– Deconditioning
– Other: anemia, sleep disorders, depression,
hypothyroidism
• Optimize what you can
• Stimulants?
Causes of Confusion and Delirium in
CHF
• Impaired cerebral blood flow and micro
emboli
• Medications (e.g.. Sleep aids)
• Sleep-wake cycle disturbance
• Low BP associated with high doses of ACE
Inhibitors and Beta Blockers
Case 2 Presentation
• Paul is a 54 year old man with ischemic
cardiomyopathy living at home on hospice
hoping for a heart transplant
• He has a family history of early death from MI,
and suffered his first heart attack at age 45,
presenting initially with a large anterior MI
• He’s had an ICD placed for syncope for
paroxysmal ventricular fibrillation
Case 2 Presentation Continues
• His CHF progressed over the last 9 years
• He has been felt to be a good candidate for
heart transplant, but deteriorated before a
suitable organ became available
• He has been placed on mechanical circulatory
support (LVAD) and a milrinone infusion
• However, he has developed a chronic strep
infection associated with his device and is no
longer able to have a transplant
Dilated Cardiomyopathy ECHO
https://www.youtube.com/watch?v=37KDMNi
V3AU&feature=player_detailpage
Dilated Cardiomyopathy ECHO
Diuretics
Potassium
Sparing
Diuretics
Beta Blockers
ACE Inhibitors
Diuretics
Pain in CHF
• Common in advanced CHF
• Angina
– Nitrates
• Other types of pain
– Opiates
– Avoid NSAIDs
GI Disorders in CHF
• Cardiac cachexia
– Anorexia
– Increased catabolism
• Nausea
– Medications (e.g.. ASA)
– Reduced Intestinal Perfusion
• Constipation
– Decreased intake and activity
– Medications (e.g.. Opioids)
Depression and Anxiety in CHF
• 1/3 of patients with advanced HF have clinical
depression
– Higher symptom burden
– Increased adverse outcomes
• Spiritual Care
• Cognitive Behavioral Therapy
• Medications
– SSRIs at low dose, watch for fluid retention and
hyponatremia (mental status changes with edema)
– TCAs can prolong the QTc
– Psychostimulants
Cough
• Often worse at night
– Pulmonary Congestion
– Pneumonitis
– Bronchitis
• ACE Inhibitors
– Transition to ARBs
• Secretions
Discontinuing Medications for CHF on
Hospice
• Medical management of CHF (that has helped
raise life expectancy in the last 40 years) truly
pushes the limits of low BPs and low HRs
• On Hospice, the Goals of Care are more
nuanced than survival so expectations and
therapies need adjusting
– ACE Inhibitors
– Beta Blockers
Conclusion
• Heart Failure is common and often chronic
• Salt and water retention produce much of the
morbidity so understanding diuretics helps
management
• Preserved EF vs. Reduced EF are significantly
different entities that can look alike clinically
• There is a high symptom burden, but many tools
• Often less is more for the patient
• “The LVADs are coming!”