Transcript Congestive Heart Failure: Mechanical Cardiac

Heart Failure
Margaret Barnett ANP AACC
Alaska Heart Institute
September 2016
Heart Failure Facts
1. Approximately 5.7 million adults in the US have heart failure
2. One in 9 deaths in 2009 included HF as a contributing cause
3. Half the people who develop heart failure die within 5 years of
diagnosis
4.
Annual cost estimated $30.7 billion dollars each year
CDC 2016 Heart Failure Facts
Definition
1. Clinical syndrome results from any structural or functional CV disorder
which causes inadequate perfusion
2. Most common symptoms include dyspnea, fatigue and fluid retention
3. Often misdiagnosed as bronchitis or URI
4. No specific diagnostic test for CHF predominately a clinical diagnosis
based on careful history and physical examination – although BNP
may be helpful
NYHA Classification of Severity of HF
1. Class I NYHA - patients with heart disease without resulting
limitations of physical activity
2. Class II NYHA – patients with heart disease resulting in slight
limitation of physical activity
3. Class III NYHA – patients with heart disease resulting in
marked limitation of physical activity.
4. Class IV NYHA - patients with heart disease resulting inability
to carry on any physical activity without discomfort
Stages in Heart Failure
Stage A – At high risk for HF but without structural heart
disease or symptoms of HF
Stage B - Structural heart disease but without symptoms of
HF.
Stage C - Structural heart disease with prior or current
symptoms of HF
Stage D - Refractory HF requiring specialized interventions
Categories of Disease
1. HF caused by variety of disorders including those that affect
the pericardium, myocardium, endocardium, valves,
vasculature or metabolism
2. Mechanism that causes reduced cardiac output and HF:
systolic and diastolic dysfunction
3. Challenge is to find correct etiology to determine the cause
4. Often missed are cardiac sarcoidosis, myocarditis,
arrhythmogenic right ventricular dysplasia , hypertrophic
cardiomopathy and non compaction
Systolic Dysfunction
1. HF with reduced ejection fraction of less than 40%
2. Most common causes are coronary artery (ischemic) disease,
idiopathic dilated cardiomyopathy (DCM), hypertension and
valvular disease
3. Relative Frequency includes:
Idiopathic 50 %
Myocarditis 9%
Ischemic heart disease 7%
Infiltrative disease 5%
Peripartum CM 4%
Hypertension
4%
Connective Tissue disease 3%
Substance abuse 3%
Doxorubcin 1%
Other
10%
Diastolic Dysfunction
1. Major cause of HF with preserved ejection fraction EF > 50-60%
2. Patients with EF between 41 – 49% may be categorized with
Diastolic Dysfunction
3. Most common causes include: hypertension, ischemic heart
disease, HCOM and restrictive cardiomyopathy
4. Caution: patients with Sx of SOB, ankle edema or PND with
preserved EF may not have DD but may be related to obesity, lung
disease or occult coronary ischemia
Clinical presentation
1. History and clinical presentation
- Classical angina usually indicated ischemic heart disease
- Acute HF with antecedent flu-like illness suggest viral
myocarditis
- Family history of unexplained CM , amyloidosis, low voltage
on EKG, LVH without HTN and proteinuria - strongly
consider cardiac amyloidosis
- Long standing hypertension or alcohol use suggests
hypertensive or alcoholic CM
- Worsened by antiarrhythmic agents such as Norpace,
Flecainide, CCB especially Verapamil, BB and NSAID
Physical examination
1. Cardiac murmur – consider primary valvular dysfunction
2. Periorbital purpura – pathognomonic for amyloid CM
3. Triad of cirrhosis, diabetes mellitus, and skin pigmentation
– suggests late stage hemochromatosis
4. Evidence of volume overload – JVD, presence of rales,
S3, S4, ascites, peripheral edema
Diagnostic workup
1. EKG – assess for evidence of ischemia, prior or acute MI,
LVH, loss of R waves (amyloid), Low voltage in limb leads
with LVH may indicate idiopathic DCM, heart block
(cardiac sarcoid), tachycardia – tachycardia mediated CM
2. Lab work: CBC (rule out infection), check for anemia,
CMP checks electrolytes include magnesium, renal
function, sodium, LFTs to check for hepatic congestion,
glucose, TSH since hypo or hyperthyroidism can
precipitate HF, troponin – r/o ischemia
3. BNP - less than 100 normal, 100 - 400 can be caused by
multiple etiologies, over 400 usually HF
Diagnostic Workup
1. Echocardiography – performed on all patients with new onset HF
Regional wall motion abnormalities compatible with CAD but
occur in 50 – 60% IDCM
Dobutamine Stress echo can be used to distinguish between
these
Pericardial thickening suggestive of constrictive pericarditis
Valvular structure and function can be assessed
Interatrial and interventricular shunts
Access of myocardial texture – infiltrative CM
Assessment of PCWP, PAP and flow
Diagnostic Workup
1. Exercise stress testing – part of initial workup used for risk
stratification, evaluate presence of ischemic heart disease,
provoke arrhythmias, determine exercise capacity
2. Coronary arteriography – if ischemia is contributing to HF, right
heart catheterization to measure pressures, cardiac output,
endomyocardial biopsy, asses for shuts and severity of pulmonary
hypertension
3. Non invasive coronary angiography = CT, CMR
4. Additional laboratory workup includes: HIV, Iron studies, ANA,
viral serologies, evaluation for pheochromocytoma, thiamine
levels, genetic testing and counseling
Management
1. Goals of therapy with patients with reduced ejection fraction are to
reduce morbidity, reduce symptoms, improving health-related
quality of life and functional status, decreasing hospitalization and
readmissions and to reduce mortality
2. Multiple guidelines from the American College of Cardiology
Foundation/American Heart Association guidelines 2013, the
Canadian Cardiovascular Society guidelines, the European
Society of Cardiology guidelines, the 2010 Heart Failure Society of
America guidelines, and the 2010 National Institute for Health and
Care Excellence chronic heart failure guidelines.
3. Mainstay of therapy includes: management of contributing factors
and associated conditions, lifestyle modifications, pharmacologic
therapy, device therapy, cardiac rehabilitation and preventive care
Life Style Management
1. Cessation of smoking
2. Restriction or abstinence of alcohol consumption
3. Salt restriction commonly recommended but insufficient data to
support any specific level of sodium intake. Most experts
recommend less than 3 grams per day in symptomatic patient
4. Fluid restriction 1.5 to 2 liters per day helpful in refractory HF patients
especially with hyponatremia
5. Avoidance of obesity
6. Daily weight monitoring
Pharmacologic Therapy
1. Improvement in symptoms can be achieved with
diuretics, beta blockers, ACE-I, ARBs, hydralazine plus
nitrate, digoxin, ARNI, and aldosterone antagonists
2. Prolongation of survival documented with beta blockers,
ACE-I, hydralazine plus nitrate and aldo-blockers. More
limited evidence of survival benefit with diuretics and
none with digoxin
3. All drugs and supplements the patient is taking should be
reviewed and the patient should avoid : NSAID,
antiarrhythmic drugs (unless prescribed by cardiology),
calcium channel blockers, thiazolidines
Device Therapy
1. ICD – implantable cardioverter-defibrillator for primary and
secondary prevention of sudden cardiac death. Criteria
include: life threatening ventricular arrhythmias, reduced
ejection fraction, class III or IV heart failure.
2. CRT- Biventricular pacing can improve symptoms and survival
in select patients who are in NSR with a reduced EF and
prolonged QRS duration who are expected to survive at least
one year. Most patients who meet CRT criteria may also
candidates for CRT-D
3. Left Ventricular Assist Device – discuss during case
presentation
Heart Failure Therapies
1. Cardiac Rehab – HF is covered diagnosis for reimbursement and
recommended for Class III and IV HF patients without advanced
arrhythmias. Benefits of exercise can be seen as early as 3 weeks
2. Multidisciplinary Care – HF educator, HF follow up clinics, hospital
discharge planning, close follow up that monitors ability to perform
ADLs, volume status, weight, use of tobacco, alcohol, illicit drugs,
alternative therapies, diet and sodium intake and assessment for
depression
3. Refractory HF - Cardiac transplantation referral: Dr. Ankie Amos
(Alaska Heart Institute 561-3211), palliative care and Hospice
Case Study # 1
Case # 1

Mr. A is a 56yo male who comes in for HF
follow up. No Sx or complaints.
 EF 25%, Class II HF
 Vitals: BP 128/65, P 72
 PE: No JVD, 1+ LE edema at feet only, NO
crackles. Ext warm
 Meds: Coreg 6.25mg BID, Lisinopril 10mg
BID, Lasix 10mg a day
What therapy changes would you recommend?

1. Add digoxin 0.25mg a day

2. Increase Coreg to 12.5mg BID

3. Add spironolactone 25mg a day

3. No changes recommended
Mortality Reduction of Evidence Based Management

ACE Inhibitors 17-36%

β-blockers 20-35%

Aldactone 25-30%

Inotropic Drugs 36-50% increase
Pharmacology

Ace-I:
 All Stages of HF with
or without symptoms

ARB:
 If Ace-I intolerant

Beta-Blockers:
 Class II-IV NYHA and
beyond

Diuretics:
 For symptoms only.

Digoxin:
 For symptoms in Class IIIV

Aldosterone Antagonists:
 Lasix dependent, post-MI

Hydralazine/Nitrates:
 Class II-IV
(Red: Mortality Reduction)
Target Doses: Important!
Goal SBP: As low as they can tolerate!
Benefit of Heart Failure Medications
ACE-I or ARB
17% RRR in RCT
NNT 77
RRR Meta-analysis 20%
Beta blockers (Toprol, Zebeta, Coreg)
34% RRR in RCT
NNT 28
RRR Meta-analysis 31%
Aldo blockers
30% RRR in RCT
NNT 18
RRR Meta-analysis 25%
Hydralazine plus Nitrates
43% RRR in RCT
NNT 21
Not available
CRT
36% RRR in RCT
NNT 24
RRR Meta-analysis 29%
ICD
23% RRR in RCT
NNT 70
RRR Meta-analysis 26%
Newer medications available
Neprilysin inhibitor and an ARB – Entresto works by relaxing the
blood vessels and reducing the build up of sodium and fluid retention
Combination of Valsartan and Sacubritil which blocks the enzyme
neprilysin. Fast track FDA release July 2015.
Corlanor (Ivabradine) Ir channel blocker – indicated in patients who
can not tolerate beta blocker or contraindicated. Heart rate above 70
with low EF. Contraindicated in decompensated HF, BP < 90, any
heart block. Released April 2015
Case Study # 2
Case # 2

Mr. M is a 47yo without insurance or money who comes
in with sob, le edema, and increased abd girth. Weight
up 35lbs over month.
 He cannot afford and refuses imaging
 He cannot afford and refuses hospitalization.
 PE: BP 159/95, P 100, O2sat 90%
 JVD 20cm, Lungs- crackles, abd – ascites, ext 2+ edema
– warm
 Meds: none – he will take meds
 Labs: (1 mo prior for health fair) nl Cr and K

What will you put him on?
Case # 2

1) Toprol XL 50mg a day

2) Lisionpril 10mg a day

3) Spironolactone 50mg BID

4) Lasix 80mg a day

5) Torsemide 80mg a day

6) Metolazone 5mg a day
Diuretics
Diuretics
Diuretic Resistance Challenges

Restrict Na/H2O intake.

Increase dose, frequency, iv

Combine loop diuretic with thiazide
/spironolactone

Try inotrope or dopamine to increase CO

Ultrafiltrate

Consider Stage D Treatments
Thiazides, Loop Diuretics: Adverse Effects

Lowers K+, Mg+ (15 - 60%)
 (sudden death ???)

Lowers Na+

Stimulation of the neurohormonal activity

Hyperuricemia (15 - 40%)

Hypotension. Ototoxicity. Gastrointestinal. Alkalosis.
Case Study # 3
Case # 3

A 80yo female presents with SOB, LE edema.
 EKG with LBBB (QRS duration 145)
 EF 25%, Cath with nl cors
 Meds: Ramipril 2.5 mg BID, Toprol XL 100 mg
BID, Lasix 20mg a day
 BP 125/80, P 58, BMI 18
 Labs: Cr 1.2, K 5.1
Case # 3

After diuresis, what can be offered to avoid
decompensation again?
 1) Add Digoxin 0.25mcg Po daily
 2) Increase Ramipril by 2.5mg a day
 3) Add spironolactone 12.5mg a day
 4) Refer for CRT
Significance of MADIT-CRT Study for Women

Women CRT-D had a 72% reduction in risk of HF or
Death

Greater reductions in mortality with patients
with QRS> 150 ms or LBBB (82% & 78%,
respectively)

Benefits showed consistent evidence of greater
reverse cardiac remodeling in women than men
via echo

Bottom Line: Screen all women with low EF for
LBBB.
Case Study # 4
Case Study # 4

59yo with an ICM who has been in the hospital 9 times over a
year for heart failure – he presents with SOB.





Last cath 2 years ago – Prior stents in LAD and RCA patent.
LCX non-dominant.
Echo: 6 mo ago: EF 30% (down from 45% 1 yr ago)
Meds: Coreg 20, Lisinopril 10 BID, Lasix 80 qd, Kcl 40 qd
Vitals: BP 95/62, P 100, RR 29, O2sat 95% RA. JVD 8cm,
Lungs – decreased BS at bases, CV – tachy, RR, pmi
displaced, SEM at LLSB 3/6, Ext – cool,trace edema
Labs: Na 128, K 5, Cr 1.9, Hct 29,
Case # 4

What would you do first?
 1) Increase lisinopril by 2.5mg a day
 2) Re-echo
 3) Cath or stress MRI
 4) Give Lasix 80mg IV in clinic
It is important to Define the Cause of
Worsening Left Heart Failure
Non-Ischemic
Ischemic
32%
68%
Nonischemic causes

Valvular disease

Myocardial toxins

Myocarditis

Hypertension

Other
CAD Causes
Gheorghiade M, Bonow RO. Circulation. 1998;97:282–289.

History of MI

Hemodynamic CAD
Causes of Heart Failure

Without treating the underlying cause,
progress will be limited.

Examples:
 Coronary disease: Revascularization
 Valve Disease: Surgery
 Chemotherapy: Re-thinking chemo
 Lupus: Immunosuppression
 Amyloid: BMT

Labs: HIV, Ferritin, ESR/ANA, TSH
MRI is a great tool to define the cause of
Heart Failure: can see valves, ischemia, new infarct,
& define EF.
Amyloid
Infarct
Valvular Disease
Cardiac MRI:
Gives it all, PLUS viability
Anatomy
Function/Valves
Perfusion
Viability
Hemodynamics

Perfusion:
 CI: Digoxin, Inotropes
 SVR: Ace-I, ARBS, Nitrates/Hydralazine

Volume:
 PCW: Diuretics only work if RA pressure
high!
 RA=JVD: Diuretics/ultrafiltration

Normal #’s: PCW 12, RA 5-10, CI >2, CO >4,
SVR 900-1000.

Interrogate Device!! Many have Impedance
Measures (Volume estimations)
Back to Case # 4

59yo with an ICM who has been in the hospital 9 times
over a year for heart failure – he presents with SOB.
 Last cath 2 years ago – Prior stents in LAD and RCA
patent. LCX non-dominant.
 Echo: 6 mo ago: EF 30% (down from 45% 1 yr ago)
 Meds: Coreg 20, Lisinopril 10 BID, Lasix 80 qd, Kcl 40
qd
 Vitals: BP 95/62, P 100, RR 29, O2sat 95% RA. JVD
8cm, Lungs – decreased BS at bases, CV – tachy, RR,
pmi displaced, SEM at LLSB 3/6, Ext – cool,trace
edema
 Labs: Na 128, K 5, Cr 1.9, Hct 29,
Case # 4

What would you do first?
 1) Increase lisinopril by 2.5mg a day
 2) Re-echo
 3) Cath or stress MRI
 4) Give Lasix 80mg IV in clinic
Case # 4

MRI without ischemia. Moderate MR. What
would you do medically?
 1) Increase lisinopril by 2.5mg a day
 2) Add Digoxin
 3) Give up and call hospice
 4) Give Lasix 80mg IV in clinic
Definition of Heart Failure: Staging
At risk for HF-------------------> Heart Failure
Stage A
At High risk for HF
But without structural
Heart disease or
Symptoms of HF.
Stage B
Structural heart
Disease but without
Signs or symptoms.
Stage C
Structural heart disease
With prior or current
Symptoms.
Stage D
Refractory HF
Requiring specialized
Interventions.
Patients with:
-HTN
-CAD
-DM
-Obesity
-Metabolic Syndrome
Patients with:
-Previous MI
-LV remodeling
-LVH
-Low EF
-Valvular disease
Patients with:
-Structural Heart Ds
-SOB/Fatigue
-Reduced Exercise
Tolerance
Patients with:
-Rest Symptoms
-On maximal med
Therapy
-Recurrent hosp.
Structural Hrt Ds
Symptoms
Refractory Rest Sx
Advanced Heart Failure: Definition

Low doses of HF meds
due to hypotension

Hct <35%

QRS >140ms

Can’t walk 1 block without
SOB

Diuretic dose >1.5 mg/kg/d

Hyponatremia, Na <136

Cr >1.5 / BUN >40

EF<30%; NYHA III/IV on
standard therapy

Peak VO2 <14ml/kg

Pulmonary HTN

Intermittent Inotropic
Dependence
Markers for Advanced Heart Failure

Functional Assessment
 Walk <1 block due to dyspnea
 Heart Failure Meds are not at target
due to hypotension
 Lasix dose 1.5mg/kg/d (>100mg/day
in most patients)
 CHF admit in last 6 mo
 CRT non-responder

Lab Evalutation
 Hct <35% (Hb around
11.6)
 Na <136
 BUN >40 and/or Cr >1.8
Stuart Russell, Congestive Heart
Failure; Volume 14, Issue 6, pages
316–321, November/December 2008
Highest Risk Indicators

Drug Intolerance

Lasix > 1.5mg/kg/day

BUN > 40
64% 1-year Mortality
Adapted from Russell SD, et al. in press.
Recognize Stage D Heart Failure:
Options

Options:
 1. Hospice
 2. Inotropes
 3. Mechanical support
 4. Transplant
Worldwide HeartMate II Clinical Experience
More than 14,000 patients worldwide have now been implanted with the
HeartMate II® LVAS.
Over 6,000 patients on ongoing support

Patients supported ≥ 1 year: 1,634

Patients supported ≥ 2 years: 963

Patients supported ≥ 5 years: 143
As of April 2013
*Based on clinical trial and device tracking data
HeartMate II VAD
Factors that worsen Heart Failure
1. Superimposed ischemia or infarction
2. Uncontrolled hypertension
3. Unrecognized primary valvular disease – or worsening mitral
regurgitation
4. New onset or uncontrolled atrial fibrillation or excessive
tachycardia
5. Pulmonary embolism
6. Inappropriate medications
7. Non compliance
Factors that worsen heart failure
8. Super imposed infections
9. Electrolyte disorders
10. Pregnancy
11. Medication non compliance
12. Dietary indiscretion
13. Polysubstance abuse
Conclusion
1. HF diagnosis often missed
2. Heart Failure is a progressive disease
3. Serial assessment and close follow up of patients required
4. Refer advanced heart failure or refractory patients
5. Multidisciplinary approach preferred for heart failure patients