Acute vs. Chronic Heart Failure

1. Acute vs. Chronic Heart Failure Pharmacological Objectives and Treatment Karen Crespo ARNP Integris HF/Advanced Cardiac Care

3. Heart Failure Definition of Heart Failure: Heart failure is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid accumulation; both ventricles are usually involved to some extent. Diagnosis is clinical, supported by chest x-ray and echocardiography. Initial Treatment may include diuretics, ACE-I, BBs, and correction of the underlying disorder. The Merck Manual 18th Edition. May 2005.

4. Systolic Coronary Artery Disease Myocardial infarction Hypertension Valvular disease Congenital heart disease Viral infection Toxins (EtOH, chemoRx) Diastolic Hypertension Diabetes mellitus Restrictive cardiomyopathy (amyloidosis) Aging Obesity Primary Causes of Heart Failure (US)

5. Heart Failure: Significant Clinical and Economic Burden • Persons with HF in the US 5.8 million • Overall prevalence 2.3% • Incidence 670,000 new cases each year • Mortality 864,480 deaths in 2008. Reference: American Heart Association. Heart Disease and Stroke Statistics – 2005 Update.

6. Heart Failure: Epidemic & Expensive • 1.106 million hospital discharges for HF in 2006, up from 877,000 in 1996. • Outpatient visits for HF: 3.434 million • Direct cost for care of patients with HF estimated to be $39.2 billion. • Likely underestimated because estimates based on data for HF as primary diagnosis or cause of death. • 1992 – 2002 • Deaths increased 35.3% • As a population ages, the number of patients with HF is expected to double in 30 years American Heart Association. Heart Disease and Stroke Statistics – 2010 Update.

7. Hospitalization Due to Heart Failure Continues to Rise • Progression of disease inevitable • Incidence of HF rising • Population of US is aging • Survival is improving with AMI* and revascularization • HF not treated appropriately during hospitalization • Patients do not adhere to diet and drugs * AMI=acute myocardial infarction

8. A Growing Medical Challenge Compliance • 50% have three or more comorbidities • Average of six medications • 78% had at least two admissions per year • Only 10% completed their annual prescription regimen • One-third never refilled any heart failure prescription English M, Mastream M. Congestive heart failure: public and private burden. Crit Care Nurs Q. 1995;18:1-6.

9. Complications of Heart Failure • The most serious and life-threatening complications of heart failure are: • Arrhythmias (irregular beating of the heart) • Acute pulmonary edema (fluid in the lungs) • Weight Issues (cardiac cachexia) • Impaired Kidney Function • Congestion/edema • Left Bundle Branch Block • Depression • Death

10. ACC Heart Failure Stages and Classification Refractory End-Stage HF: Marked symptomsat rest despite maximal medical therapy D Symptomatic HF: Known structuralheart disease, shortness of breath and fatigue, reduced exercise tolerance C Asymptomatic LVD: Previous MI, LV systolic dysfunction, asymptomatic valvular disease B High Risk: Hypertension, coronary artery disease, diabetes, family history of cardiomyopathy A Reference: Adapted from Jessup M et al. NEJM. 2003;348:2007-18.

11. NYHA –Classification of Heart Failure • Class 1 • Class 2 • Class 3 • Class 4

12. Our Approach to Heart Failure • Cause • Determine if cause can be corrected • Lifestyle modifications • Medications • Progression of Disease-consider advanced treatment options

13. Treatable Risk Factors for HF • Hypertension • Hyperlipidemia • Diabetes • Physical Inactivity • Obesity • Excessive alcohol intake • Smoking • Dietary Sodium intake

14. Recommended Medications for Heart Failure • Diuretics • Beta Blockers • Ace inhibitors or ARB • Aldosterone inhibitors • Hydralazine and Nitrates • Digoxin Anissa Bouzamondo*, Jean-Sébastien Hulot, Paola Sanchez , Philippe Lechat (June 11, 2002). Beta-blocker benefit according to severity of heart failure, volume 5(issue 3). Retrieved from http://eurjhf.oxfordjournals.org/content/5/3/281.full

15. Why all the Confusion with Heart Failure? • May be classified as one disease process, really 2 stages of the same disease process (acute and chronic) • Acute – the exacerbation • Chronic – preventing the exacerbation • The large direct costs with chronic heart failure are largely attributable to hospitalization Heart Disease and Stroke Statistics 2007 Update: A Report from the AHA Statistics Committee and Stroke Statistics Subcommittee. Circulation 2007;115(5):e69-e171. 2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.

16. Heart Failure - Distinctions Acute Heart Failure • “The exacerbation” • Goal of therapy is symptomatic and hemodynamic improvement • Few studies • Studies in small populations of patients (hundreds) • Often requires hospitalization • Often requires IV therapy • First Guidelines in 2006 (HFSA) 2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.

17. Heart Failure - Distinctions Chronic Heart Failure • Treat to prevent the exacerbation • Goal of therapy is to reduce morbidity and mortality • Many studies • Studies in large populations of patients (thousands) • Often managed in the outpatient setting • Often managed with oral medications and/or devices

18. Treatment Objectives Chronic Heart Failure2 • Survival •  Mortality •  Exercise capacity •  Quality of life • Neuro-hormonal changes •  Progression of CHF •  Symptoms Acute Heart Failure1 • Improve symptoms • Optimize volume status • Identify etiology • Identify precipitating factors • Optimize chronic oral therapy • Minimize side effects • Identify patients who might benefit from revascularization • Educate (medications/self assessment of HF) 1 2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e. 2 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.

19. Pharmacological & Treatment Objectives in Acute Heart Failure • Oxygen • Diuretic • Vasodilators • Ace Inhibitors/ARB • Aldosterone blocking agent • Digoxin • Anticoagulation

20. Pharmacological & Treatment Objectives in Chronic Heart Failure • ACE inhibitors/ARB • Beta Blockers • Digitalis • Aldosterone antagonist • Diuretics • Appropriate treatment of co-morbidities

21. Summary • Heart Failure is a continuum that has 2 distinct phases, Acute and Chronic. • The goal for Acute Heart Failure is symptomatic and hemodynamic improvement, whereas the goal for managing Chronic Heart Failure is to reduce morbidity and mortality. • Acute Heart Failure is often managed in the hospital setting and often requires IV therapy. Patients with Chronic Heart Failure may often be managed in an outpatient setting with oral medications and/or devices. • Lack of research in Heart Failure therapy leads to discrepancy in treatment 2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.

22. What Happens if All Else Fails ? • Mechanical circulatory Support • Heart Transplantation • Hospice