Outpatient Heart Failure Management Common Problems Elaine Winkel, M.D. University of Wisconsin Heart Failure and Transplant Program
Who takes care of heart failure patients? • 75% -primary care • 20%-cardiology • 5%-heart failure cardiologist
Heart Failure LV systolic dysfunction with an ejection fraction of < 40%
Heart Failure A syndrome characterized by left ventricular dysfunction, reduced exercise tolerance, impaired quality of life, and reduced life expectancy. Cohn
Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure
New Approach to the Classification of Heart Failure Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.
Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class ACC/AHA HF Stage1 NYHA Functional Class2 A At high risk for heart failure but without structural heart disease or symptoms of heart failure (eg, patients with hypertension or coronary artery disease) None B Structural heart disease but without symptoms of heart failure I Asymptomatic II Symptomatic with moderate exertion C Structural heart disease with prior or current symptoms of heart failure III Symptomatic with minimal exertion IV Symptomatic at rest D Refractory heart failure requiring specialized interventions 1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113. 2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.
Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure
Common Diagnostic Errors LV systolic dysfunction commonly a missed diagnosis No symptoms Symptoms attributed to other diseases Symptoms ignored Signs ignored (CXR)
Why screen for LV dysfunction? May be asymptomatic Mortality related to degree of LV dysfunction, not symptoms High mortality once symptoms appear
Heart failure is worse than most cancers. -The Fat Man The House of God
Patients at risk for developing HF(Stage A) • Coronary disease or CAD equivalent (DM) • Hypertension • Hyperlipidemia • Congenital heart disease • Valvular heart disease • Stroke or other vascular disease –30% w/LVD • Arrhythmias
High risk patients • Drug abuse (cocaine, anabolic steroids) • Alcohol use • Family members with heart failure • Sickle cell disease • Sarcoidosis/amyloidosis • Muscular dystrophies • Collagen vascular diseases • Immigrant population-Chagas
High risk patients • End stage renal disease • Chronic lung disease-(long time beta-agonist use) • Certain malignancies (multiple myeloma) • History of cardiotoxic drugs (adriamycin)
High risk populations Good history, including family history Screen with echocardiography
Diagnostic errors LV systolic dysfunction not completely evaluated No cardiac cath Incomplete echo study Role of endomyocardial biopsy
Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure
Common presentations of HF • Fatigue • SOB • GI distress (anorexia, early satiety, abdominal bloating, nausea, vomiting) • Chest pain/pressure • Lightheadedness/dizziness/palpitations • No symptoms
Physical Exam • Often unhelpful especially in chronic or slowly progressive LV dysfunction • Physical signs frequently absent • History most important
Causes of SOB in patients with known LVD • New or worsening CAD • New or worsening valve disease • Unappreciated arrhythmia • Anemia • Lung disease • Deconditioning
Other causes of edema • Cirrhosis • Severe renal insufficiency • Nephrotic syndrome • Venous insufficiency • Lymphedema
Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure
Current medical therapy • ACE inhibitors/ARB’s/direct vasodilators • Digoxin • Diuretics • Beta-blockers • Aldosterone blockers
ACE Inhibitors-common errors • Short vs. long acting agent • Dose too low • ARB substituted- (cough, creatinine rise, etc.) • Asymptomatic patient w. LVD
Digoxin • Not given • Wrong dose • Dig level • Effect of amiodarone, spironolactone • Digoxin in women
Diuretics • Too much • Too little • Generic vs. brand name • Timing
Beta Blockers • Wrong time (concomitant w/ACE, decompensated, volume overloaded) • Wrong agent (atenolol, acebutelol, pindolol, carvedilol vs. metoprolol) • Wrong dose • Using BB alone • Asymptomatic patient w/LVD
Aldosterone Blockers • Spironolactone vs. eplerenone • Too much • Wrong patient (nl-hi K+, DM, Type IV RTA, renal insufficiency, non-compliant) • No follow-up
Drug management • Drugs/doses used in clinical trials • Generic vs. brand name drugs • Short vs. long acting agents • Pill bottles each visit • Timing to avoid lightheadedness
Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure
Non-pharmacologic therapy • Sodium restriction-2000 mg/day • Fluid restriction • Avoid alcohol • Small, frequent meals • Energy conservation
Deleterious drugs • Calcium blockers-nefedipine, diltiazem, verapamil • Antiarrhythmics • NSAID’s, COX-2 inhibitors (inc OTC) • Herbal agents (hawthorn, gingko, St. John’s wort) • Grapefruit juice • Inotropic agents-(milrinone, dobutamine)
Common Problems • Diagnosis • Physical assessment • Drug therapy • Non-pharmacologic therapy • Education & follow-up • Other therapies for heart failure
Education and follow-up • Disease • Treatment • Diet/fluids • Exercise/rest • Avoid deleterious agents • Involve family • Close follow-up
Other therapies • Coronary intervention (PCI, CABG) • Ventricular reconstruction (aneurysm resection or Dor procedure) • Valve repair or replacement • Correction of arrhythmias-especially AF • Pacing (DDD, BiV) • ICD
“Genius is the infinite capacity for taking pains.” Sherlock Holmes
