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Heart Failure 101

Heart Failure 101. out of the lab, into the clinic. Objectives today. Provide an overview of clinical aspects of heart failure diagnosis assessment management Interacting with a HF patient. Definition of heart failure.

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Heart Failure 101

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  1. Heart Failure 101 out of the lab, into the clinic 1

  2. Objectives today Provide an overview of clinical aspects of heart failure • diagnosis • assessment • management • Interacting with a HF patient 1

  3. Definition of heart failure state in which the heart cannot pump asufficient 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 1 9/19/2014 3

  4. 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 1 9/19/2014 4

  5. 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 1

  6. What is your risk? 1 in 5 will develop heart failure 1 Lloyd-Jones et al, Lifetime Risk for Developing Congestive Heart FailureCirculation 2002; 106: 3068 - 3072.

  7. Heart failure: not going away 1 Arnold Can J Cardiol 2007

  8. $3-4 billion The cost of heart failure Hospitalization $15.4 Total Cost $40 billion 52% Nursing Home $3.9 13% 7% 9% Physicians/Other Professionals $2.0 Lost Productivity/Mortality* $2.8 8% 10% Drugs/Other Medical Durables $3.1 Home Healthcare $2.4 1 AHA. 2006 Heart and Stroke Statistical Update

  9. Heart failure: the numbers Prevalence 600,000 Canadians Incidence 50,000 / year Hospitalization #1 cause Average stay 7 days 1.4 million days Death in hospital 2-22% 30 days post discharge 10% 1 year 30% 5 year 50% J. Ezekowitz CMAJ 2009, EJHF 2008 1 9/19/2014 9

  10. Modes of death in HF 50% of HF patients “DROP” sudden cardiac death 40% of HF patients “DROWN” progressive HF 1 9/19/2014 10

  11. HF etiology • ISCHEMIC (50% HF) • CAD-ischemia+/-MI • HTN (diastolic and systolic HF) (25%) • NON ISCHEMIC (25 % HF) • Dilated • Hypertrophic • Restrictive • Valvular 1 9/19/2014 11

  12. Mechanisms of heart failure mechanical abnormalities myocardial injury electrical disorders left ventricular dysfunction loss of pump 1 Rosa Gutierrez 2006

  13. Chemical mediators of HF Angiotensin I / II Aldosterone ADH-antidiuretic hormone Epinephrine / Norepinephrine Endothelins Natiuretic peptides Atrial NP B-type NP C-type NP 1

  14. Modes of heart failure Systolic (pumping dysfunction) vs Diastolic (filling dysfunction) Compensated vs Decompensated Right sided HF vs Left sided HF Forward HF vs Backward HF A HF patient can have one or several of these 9/19/2014 14

  15. 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 • Rosa Guterriez 2006 1 9/19/2014 15

  16. Forward flow HF symptoms “Out of gas”—related to O2 delivery fatigue weakness/lack of energy cognitive dysfunction decreased exercise tolerance 1 9/19/2014 16

  17. Backword flow HF symptoms “Plumbing”—related to congestion shortness of breath orthopnea paroxysmal nocturnal dyspnea (PND) edema fluid retention / weight gain decreased exercise tolerance 1 9/19/2014 17

  18. Diagnostic accuracy of traditional HF work-up 1 Dao Q et al J Am Coll Cardiol 2001;37:379-85

  19. Diagnosis of HF-CCS 2006 1 9/19/2014 19

  20. Disease progression 1

  21. Echocardiogram • WHY in HF:useful for • assessing chamber size • volume of cavity • thickness of walls, valves • assessing pumping function (systolic) • assessing filling function (diastolic) • determiningLVEFxwithin 10% 1

  22. Additional testing in HF • BNP (and other biochemistry eg. TSH, Cr) • MIBI/Thallium (viability scan) • Coronary Angiogram • 24/48 hr Holter monitor; Event Monitors • VO2 Max 1

  23. 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 under cut-off point—HF unlikely above cut-off point—HF very likely 9/19/2014 1 1 23

  24. BNP (CCS 2007) 9/19/2014 1 1 24

  25. HF Management 1

  26. HF treatment goals (quality and quantity) • Slow progression of syndrome • Control symptoms • Prolong Life 1

  27. CCS on HFPSF (Diastolic HF) • Guideline based medications should be considered in HF with preserved EF** (diastolic HF) for: • relief ofHF symptoms • Pulmonary congestion • Peripheral edema • treatment ofHF risk factors • HR, atrial fibrillation • BP (as per HTN guidelines) **overall lower level of evidence associated with HFPSF 1

  28. CCS on Systolic Heart Failure Medical Therapy ACE inhibitors Beta-blockers Spironolactone Diuretics Digoxin Nitrates Statins ASA, Warfarin Device Therapy ICD CRT Other Therapy Multidisciplinary clinics Exercise rehab Dietary referral Review of co-morbidity Review of other drugs LIFESTYLE! 1 9/19/2014 www.hfcc.ccs.ca 28

  29. HF treatment is guided by… • EFx-ejection fraction • ventricular systolic function • NYHA functional class • symptom status • Patient/Family Perspectives !! 1 9/19/2014 29

  30. Ejection Fraction EFx—its all about the LV (and RV !) how much blood is ejected per ventricular contraction is measured by percentage and is indicative of pump efficiency the normal heartwill pump out 60-70% of the blood that enters the left ventricular chamber ---never 100% the LV’s normal shape is the perfect pump 1 9/19/2014 30

  31. 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 1 9/19/2014 31

  32. “You are not your EFx” Patients who have an EFx of 10% may have NYHA FC I symptoms 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 a patient can have HF with a normal EFx (preserved LV function) 1 1 9/19/2014 32

  33. many HF patients at risk for sudden cardiac death primary / secondary prevention quantity of life selection criteria: EFx NYHA functional class prognosis medications maximized ICD-internal cardiac defibrillator 1

  34. CRT-cardiac resynchronization • mechanical dys-synchrony impacts pump function • third lead attempts to improve synchrony • quality (and quantity) of life • selection criteria: • EF ( 30%) • QRS width on ECG (120 ms) • NYHA functional class (II-IV) • medications maximized 1

  35. Nutrition management of HF Limit Sodium Intake Avoid Excessive Fluids Daily Morning Weights Liz Woo MHI HFC 2009 1 35

  36. Salt / Sodium restriction:Less than 3 gm Na/day most HF patients Less than 2 gm Na/day severe edema 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 Rosa Gutierrez 2006 1 9/19/2014 36

  37. Fluid restriction: 2 liters / day if clinically stable1-1.5 liters / day with severe edema Fluid is: “anything wet” tea, juice, coffee, milk, water, watermelon, ice keep a diary adjust for hot weather, illness Rosa Gutierrez 2006 1 9/19/2014 37

  38. Weight • accuracy • same scale • shoes / no shoes • compare home / prior clinic weight • 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 1

  39. HF co-morbidity Diabetes COPD Renal disease HTN Thyroid disorder Cancer HF rarely exists in a vacuum 1 9/19/2014 39

  40. Self care in HF • “YOUhave the most power over your condition” • “AVOIDbehaviors that make heart failure worse” • “PAYATTENTION, actEARLY” “you can’t ignore your heart failure…” 1

  41. HF assessment • Thorough patient history & physical exam • Establish baseline data and monitor trends • Appropriate surveillance ongoing 1

  42. Patient history • Symptom status / most limiting factor: • SOB • Fatigue • NYHA FC • 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?” 1

  43. history cont… New or changed: • Palpitations • Dizziness • Lightheadedness • Syncope • Angina • Depression • GI / appetite 1

  44. HF de-compensation triggers 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 1 9/19/2014 44 1

  45. Physical exam • Weight • Edema • JVP • Heart rate / rhythm • Blood pressure • HS auscultation • Lung auscultation 1

  46. Fluid balance assessment • Weight increase • Edema • Orthopnea / PND (Paroxysmal nocturnal dyspnea) • HS cough • JVP elevation • + Hepatojugular reflex • Respiratory auscultation-crackles, rales • CXR • Heart auscultation-S3 1

  47. Edema “where do you keep your water?” 1

  48. 1

  49. Edema • swelling in legs, feet, ankles? • bloating in abdomen—ascites? • swelling anywhere else? pitting / non-pitting? 1

  50. Jugular Venous Pressure • JVP reflects pressure and volume changes in the right atrium • most proximal location to view • 9-10 cm column of blood supported to clavicle from right atrium when upright • observe at 90 degrees, 30-45 degrees • measured in cm ASA 1

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