Heart Failure Living with a Hurting Heart Outline

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Heart Failure: Living with a Hurting Heart

Heart Failure: Living with a Hurting Heart

Outline • Definitions and scope of problem • Diagnosing and classifying heart failure •

Outline • Definitions and scope of problem • Diagnosing and classifying heart failure • Approach to management of CHF Oral drug therapy (ACE-I, ARB, betablockers, aldosterone blockade, digoxin) • Device therapy • Biventricular (Bi. V) pacers • Intracardiac defibrillators (ICD’s) • • Future directions and exciting developments

Congestive Heart Failure • Heart (or cardiac) failure is the state in which the

Congestive Heart Failure • Heart (or cardiac) failure is the state in which the heart is unable to pump blood at a rate commensurate with the requirements of the tissues or can do so only from high pressures Braunwald 8 th Edition, 2001

Congestive Heart Failure • Symptoms: Shortness of breath • Leg swelling (edema) • Breathing

Congestive Heart Failure • Symptoms: Shortness of breath • Leg swelling (edema) • Breathing worsens with lying flat (orthopnea) • Fatigue •

Anatomy

Anatomy

A normal heart pumps blood in a smooth and synchronized way.

A normal heart pumps blood in a smooth and synchronized way.

Heart Failure Heart A heart failure heart has a reduced ability to pump blood.

Heart Failure Heart A heart failure heart has a reduced ability to pump blood.

Types of Heart Failure • Systolic (or squeezing) heart failure • Decreased pumping function

Types of Heart Failure • Systolic (or squeezing) heart failure • Decreased pumping function of the heart, which results in fluid back up in the lungs and heart failure • Diastolic (or relaxation) heart failure Involves a thickened and stiff heart muscle • As a result, the heart does not fill with blood properly • This results in fluid backup in the lungs and heart failure •

Risk Factors for Heart Failure • Coronary artery disease • Hypertension (LVH) • Valvular

Risk Factors for Heart Failure • Coronary artery disease • Hypertension (LVH) • Valvular heart disease • Alcoholism • Diabetes • Congenital heart defects • Other: • Infection (viral) • • • CAD=coronary artery disease; LVH=left ventricular hypertrophy. Obesity Age Smoking High or low hematocrit level Obstructive Sleep Apnea

Epidemiology of Heart Failure in the US Heart Failure Patients in US (Millions) 12

Epidemiology of Heart Failure in the US Heart Failure Patients in US (Millions) 12 10 10 8 • 550, 000 new cases/year 6 4 • More deaths from heart failure than from all forms of cancer combined 4. 7 • 4. 7 million symptomatic patients; estimated 10 million in 2037 3. 5 2 0 1991 2000 2037* *Rich M. J Am Geriatric Soc. 1997; 45: 968– 974. American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.

“Wow! Brazil is big. " —George W. Bush, after being shown a map of

“Wow! Brazil is big. " —George W. Bush, after being shown a map of Brazil by Brazilian president Luiz Inacio Lula da Silva, Brasilia, Brazil, Nov. 6, 2005

Classifying Heart Failure: Terminology and Staging

Classifying Heart Failure: Terminology and Staging

A Key Indicator for Diagnosing Heart Failure Ejection Fraction (EF) • Ejection Fraction (EF)

A Key Indicator for Diagnosing Heart Failure Ejection Fraction (EF) • Ejection Fraction (EF) is the percentage of blood that is pumped out of your heart during each beat

Definition of Heart Failure Classification I. Heart Failure with Reduced Ejection Fraction (HFr. EF)

Definition of Heart Failure Classification I. Heart Failure with Reduced Ejection Fraction (HFr. EF) Ejection Fraction ≤ 40% II. Heart Failure with ≥ 50% Preserved Ejection Fraction (HFp. EF) a. HFp. EF, Borderline 41% to 49% b. HFp. EF, Improved >40% Description Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFr. EF and it is only in these patients that efficacious therapies have been demonstrated to date. Also referred to as diastolic HF. Several different criteria have been used to further define HFp. EF. The diagnosis of HFp. EF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified. These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFp. EF. It has been recognized that a subset of patients with HFp. EF previously had HFr. EF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients.

Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class ACC/AHA HF

Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class ACC/AHA HF Stage 1 NYHA Functional Class 2 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) B Structural heart disease but without symptoms of heart failure C D 1 Hunt SA et al. J I None Asymptomatic II Symptomatic with moderate exertion Structural heart disease with prior or current symptoms of heart failure III Symptomatic with minimal exertion Refractory heart failure requiring specialized interventions IV Symptomatic at rest Am Coll Cardiol. 2001; 38: 2101– 2113. 2 New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002; 287: 890– 897.

How Heart Failure Is Diagnosed • Medical history is taken to reveal symptoms •

How Heart Failure Is Diagnosed • Medical history is taken to reveal symptoms • Physical exam is done • Tests Chest X-ray • Blood tests • • Electrical tracing of heart (Electrocardiogram or “ECG”) Ultrasound of heart (Echocardiogram or “Echo”) • X-ray of the inside of blood vessels (Angiogram) •

History and Physical Examination I IIa IIb III A thorough history and physical examination

History and Physical Examination I IIa IIb III A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. In patients with idiopathic DCM, a 3 -generational family history should be obtained to aid in establishing the diagnosis of familial DCM. I IIa IIb III Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea.

Risk Scores to Predict Outcomes in HF Risk Score Reference (from full-text guideline)/Link Chronic

Risk Scores to Predict Outcomes in HF Risk Score Reference (from full-text guideline)/Link Chronic HF All patients with chronic HF Seattle Heart Failure Model Heart Failure Survival Score (204) / http: //Seattle. Heart. Failure. Model. org CHARM Risk Score (200) / http: //handheld. softpedia. com/get/Health/Calculator/HFSS-Calc 37354. shtml (207) CORONA Risk Score (208) Specific to chronic HFp. EF I-PRESERVE Score (202) Acutely Decompensated HF ADHERE Classification and Regression Tree (CART) Model (201) American Heart Association Get With the Guidelines Score EFFECT Risk Score (206) / http: //www. heart. org/HEARTORG/Healthcare. Professional/Get. With. The. Guide lines. HFStroke/Get. With. The. Guidelines. Heart. Failure. Home. Page/Get-With-The. Guidelines-Heart-Failure-Home- %20 Page_UCM_306087_Sub. Home. Page. jsp (203) / http: //www. ccort. ca/Research/CHFRisk. Model. aspx ESCAPE Risk Model and Discharge Score (215) OPTIMIZE HF Risk-Prediction Nomogram (216)

Diagnostic Tests I IIa IIb III Initial laboratory evaluation of patients presenting with HF

Diagnostic Tests I IIa IIb III Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, and thyroid-stimulating hormone. Serial monitoring, when indicated, should include serum electrolytes and renal function.

Diagnostic Tests (cont. ) I IIa IIb III A 12 -lead ECG should be

Diagnostic Tests (cont. ) I IIa IIb III A 12 -lead ECG should be performed initially on all patients presenting with HF. I IIa IIb III Screening for hemochromatosis or HIV is reasonable in selected patients who present with HF. I IIa IIb III Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases.

Ambulatory/Outpatient I IIa IIb III In ambulatory patients with dyspnea, measurement of BNP or

Ambulatory/Outpatient I IIa IIb III In ambulatory patients with dyspnea, measurement of BNP or N-terminal pro-B-type natriuretic peptide (NT-pro. BNP) is useful to support clinical decision making regarding the diagnosis of HF, especially in the setting of clinical uncertainty. Measurement of BNP or NT-pro. BNP is useful for establishing prognosis or disease severity in chronic HF.

Ambulatory/Outpatient (cont. ) I IIa IIb III BNP- or NT-pro. BNP guided HF therapy

Ambulatory/Outpatient (cont. ) I IIa IIb III BNP- or NT-pro. BNP guided HF therapy can be useful to achieve optimal dosing of GDMT in select clinically euvolemic patients followed in a well-structured HF disease management program. I IIa IIb III The usefulness of serial measurement of BNP or NT-pro. BNP to reduce hospitalization or mortality in patients with HF is not well established. I IIa IIb III Measurement of other clinically available tests such as biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with chronic HF.

Recommendations for Noninvasive Imaging Recommendation Patients with suspected, acute, or new-onset HF should undergo

Recommendations for Noninvasive Imaging Recommendation Patients with suspected, acute, or new-onset HF should undergo a chest xray A 2 -dimensional echocardiogram with Doppler should be performed for initial evaluation of HF Repeat measurement of EF is useful in patients with HF who have had a significant change in clinical status or received treatment that might affect cardiac function, or for consideration of device therapy Noninvasive imaging to detect myocardial ischemia and viability is reasonable in HF and CAD Viability assessment is reasonable before revascularization in HF patients with CAD Radionuclide ventriculography or MRI can be useful to assess LVEF and volume MRI is reasonable when assessing myocardial infiltration or scar Routine repeat measurement of LV function assessment should not be performed COR LOE I C I C IIa B IIa C IIa B III: No Benefit B

Recommendations for Invasive Evaluation Recommendation COR LOE Monitoring with a pulmonary artery catheter should

Recommendations for Invasive Evaluation Recommendation COR LOE Monitoring with a pulmonary artery catheter should be performed in patients with respiratory distress or impaired systemic perfusion when clinical assessment is inadequate I C IIa C Routine use of invasive hemodynamic monitoring is not recommended in normotensive patients with acute HF III: No Benefit B Endomyocardial biopsy should not be performed in the routine evaluation of HF III: Harm C Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF with persistent symptoms and/or when hemodynamics are uncertain When coronary ischemia may be contributing to HF, coronary arteriography is reasonable Endomyocardial biopsy can be useful in patients with HF when a specific diagnosis is suspected that would influence therapy

Pathophysiology

Pathophysiology

Pathologic Progression of CV Disease Sudden Death Coronary artery disease Hypertension Diabetes Myocardial injury

Pathologic Progression of CV Disease Sudden Death Coronary artery disease Hypertension Diabetes Myocardial injury Pathologic remodeling Low ejection fraction Cardiomyopathy Death Pump failure Valvular disease • Neurohormonal stimulation • Myocardial toxicity Adapted from Cohn JN. N Engl J Med. 1996; 335: 490– 498. Symptoms: Dyspnea Fatigue Edema Chronic heart failure

Compensatory Mechanisms: Renin-Angiotensin-Aldosterone System Beta Stimulation • CO • Na+ Renin + Angiotensinogen Angiotensin

Compensatory Mechanisms: Renin-Angiotensin-Aldosterone System Beta Stimulation • CO • Na+ Renin + Angiotensinogen Angiotensin I ACE Angiotensin II Kaliuresis Aldosterone Secretion Peripheral Vasoconstriction Fibrosis Salt & Water Retention Plasma Volume Afterload ¯ Cardiac Output Preload Cardiac Workload Heart Failure Edema

Drug Therapy

Drug Therapy

Heart Failure Treatments: Medication Types Type What it does • ACE inhibitor (angiotensin-converting enzyme)

Heart Failure Treatments: Medication Types Type What it does • ACE inhibitor (angiotensin-converting enzyme) • Expands blood vessels which lowers blood pressure, neurohormonal blockade • ARB (angiotensin receptor blockers) • Similar to ACE inhibitor—lowers blood pressure • Beta-blocker • Reduces the action of stress hormones and slows the heart rate • Digoxin • Slows the heart rate and improves the heart’s pumping function (EF) • Diuretic • Filters sodium and excess fluid from the blood to reduce the heart’s workload • Aldosterone blockade • Blocks neurohormal activation and controls volume

Rational for Medications (Why does my doctor have me on so many pills? ?

Rational for Medications (Why does my doctor have me on so many pills? ? ) • Improve Symptoms Diuretics (water pills) • digoxin • • Improve Survival Betablockers • ACE-inhibitors • Aldosterone blockers • Angiotensin receptor blockers (ARB’s) •

Drugs Commonly Used for HFr. EF (Stage C HF) Drug Initial Daily Dose(s) ACE

Drugs Commonly Used for HFr. EF (Stage C HF) Drug Initial Daily Dose(s) ACE Inhibitors Captopril 6. 25 mg 3 times Enalapril 2. 5 mg twice Fosinopril 5 to 10 mg once Lisinopril 2. 5 to 5 mg once Perindopril 2 mg once Quinapril 5 mg twice Ramipril 1. 25 to 2. 5 mg once Trandolapril 1 mg once ARBs Candesartan 4 to 8 mg once Losartan 25 to 50 mg once Valsartan 20 to 40 mg twice Aldosterone Antagonists Spironolactone 12. 5 to 25 mg once Eplerenone 25 mg once Maximum Doses(s) Mean Doses Achieved in Clinical Trials 50 mg 3 times 10 to 20 mg twice 40 mg once 20 to 40 mg once 8 to 16 mg once 20 mg twice 10 mg once 4 mg once 122. 7 mg/d (421) 16. 6 mg/d (412) ----32. 5 to 35. 0 mg/d (444) ----------------- 32 mg once 50 to 150 mg once 160 mg twice 24 mg/d (419) 129 mg/d (420) 254 mg/d (109) 25 mg once or twice 50 mg once 26 mg/d (424) 42. 6 mg/d (445)

Drugs Commonly Used for HFr. EF (Stage C HF) (cont. ) Drug Initial Daily

Drugs Commonly Used for HFr. EF (Stage C HF) (cont. ) Drug Initial Daily Dose(s) Beta Blockers Bisoprolol 1. 25 mg once Carvedilol 3. 125 mg twice Carvedilol CR 10 mg once Metoprolol succinate extended release 12. 5 to 25 mg once (metoprolol CR/XL) Hydralazine & Isosorbide Dinitrate 37. 5 mg hydralazine/ Fixed dose combination 20 mg isosorbide dinitrate 3 times daily Hydralazine and Hydralazine: 25 to 50 isosorbide dinitrate mg, 3 or 4 times daily and isorsorbide dinitrate: 20 to 30 mg 3 or 4 times daily Maximum Doses(s) Mean Doses Achieved in Clinical Trials 10 mg once 50 mg twice 80 mg once 8. 6 mg/d (118) 37 mg/d (446) ----- 200 mg once 159 mg/d (447) 75 mg hydralazine/ 40 mg isosorbide dinitrate 3 times daily Hydralazine: 300 mg daily in divided doses and isosorbide dinitrate 120 mg daily in divided doses ~175 mg hydralazine/90 mg isosorbide dinitrate daily -----

Treatment of HFp. EF Recommendations Systolic and diastolic blood pressure should be controlled according

Treatment of HFp. EF Recommendations Systolic and diastolic blood pressure should be controlled according to published clinical practice guidelines Diuretics should be used for relief of symptoms due to volume overload Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial ischemia is present despite GDMT Management of AF according to published clinical practice guidelines for HFp. EF to improve symptomatic HF Use of beta-blocking agents, ACE inhibitors, and ARBs for hypertension in HFp. EF ARBs might be considered to decrease hospitalizations in HFp. EF Nutritional supplementation is not recommended in HFp. EF COR LOE I B I C IIa C IIb B III: No Benefit C

Lifestyle Changes What Why • Eat a low-sodium, low-fat diet • Sodium is bad

Lifestyle Changes What Why • Eat a low-sodium, low-fat diet • Sodium is bad for high blood pressure, causes fluid retention • Lose weight • Extra weight can put a strain on the heart • Stay physically active • Exercise can help reduce stress and blood pressure • Reduce or eliminate alcohol and caffeine • Alcohol and caffeine can weaken an already damaged heart • Quit Smoking • Smoking can damage blood vessels and make the heart beat faster

Water Restriction I IIa IIb III Fluid restriction (1. 5 to 2 L/d) is

Water Restriction I IIa IIb III Fluid restriction (1. 5 to 2 L/d) is reasonable in stage D, especially in patients with hyponatremia, to reduce congestive symptoms.

Surgical/Percutaneous/Transcatheter Interventional Treatment of HF Recommendation CABG or percutaneous intervention is indicated for HF

Surgical/Percutaneous/Transcatheter Interventional Treatment of HF Recommendation CABG or percutaneous intervention is indicated for HF patients on GDMT with angina and suitable coronary anatomy especially, significant left main stenosis or left main equivalent disease CABG to improve survival is reasonable in patients with mild to moderate LV systolic dysfunction and significant multivessel CAD or proximal LAD stenosis when viable myocardium is present CABG or medical therapy is reasonable to improve morbidity and mortality for patients with severe LV dysfunction (EF <35%), HF and significant CAD Surgical aortic valve replacement is reasonable for patients with critical aortic stenosis and a predicted surgical mortality of no greater than 10% Transcatheter aortic valve replacement is reasonable for patients with critical aortic stenosis who are deemed inoperable CABG may be considered in patients with ischemic heart disease, severe LV systolic dysfunction and suitable coronary anatomy whether or not viable myocardium is present Transcatheter mitral valve repair or mitral valve surgery for functional mitral insufficiency is of uncertain benefit Surgical reverse remodeling or LV aneurysmectomy may be considered in HFr. EF for specific indications including intractable HF and ventricular arrhythmias COR LOE I C IIa B IIb B

Device Therapy: Biventricular Pacing

Device Therapy: Biventricular Pacing

Biventricular Pacing Ventricular Dysynchrony • Abnormal ventricular conduction resulting in a mechanical delay and

Biventricular Pacing Ventricular Dysynchrony • Abnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction Overview of Device Therapy

Bi. V Pacing

Bi. V Pacing

Cardiac Resynchronization Therapy Key Points • Indications Moderate to severe CHF who have failed

Cardiac Resynchronization Therapy Key Points • Indications Moderate to severe CHF who have failed optimal medical therapy • EF<30% • Evidence of electrical conduction delay • • Timing of Referral Important Patients often not on optimal Medical Rx • Patients referred too late- Not a Bail Out •

Defibrillators (ICD’s)

Defibrillators (ICD’s)

Heart Failure and Sudden Cardiac Death (SCD) • Your heart suddenly goes into a

Heart Failure and Sudden Cardiac Death (SCD) • Your heart suddenly goes into a very fast and chaotic rhythm and stops pumping blood • Caused by an “electrical” problem in your heart • SCD is one of the leading causes of death in the U. S. – approximately 450, 000 deaths a year • Patients with heart failure are 6 -9 times as likely to develop sudden cardiac death as the general population

How does a defibrillator for sudden cardiac death work? Device Shown: Combination Pacemaker &

How does a defibrillator for sudden cardiac death work? Device Shown: Combination Pacemaker & Defibrillator

Implantable Cardiac Defribrillators EBM Therapies Relative Risk Reduction Mortality 2 year ACE-I 23% 27%

Implantable Cardiac Defribrillators EBM Therapies Relative Risk Reduction Mortality 2 year ACE-I 23% 27% Β-Blockers 35% 12% Aldosterone Antagonists 30% 19% ICD 31% 8. 5%

Who should Consider an ICD? • Patients with weakend heart, New York Heart Association

Who should Consider an ICD? • Patients with weakend heart, New York Heart Association (NYHA) Class II and III heart failure, and measured left ventricular ejection fraction (LVEF) < 35% • Patients who meet all current requirements for a cardiac resynchronization therapy (CRT) device and have NYHA Class IV heart failure;

Other Therapies? • Transplant • Artificial hearts • New “gadgets” to help doctors manage

Other Therapies? • Transplant • Artificial hearts • New “gadgets” to help doctors manage heart failure

Heart Transplantation • A good solution to the failing heart– get a new heart

Heart Transplantation • A good solution to the failing heart– get a new heart • Unfortunately we are limited by supply, not demand • Approximately 2200 transplants are performed yearly in the US, and this number has been stable for the past 20 years.

Worldwide Heart Transplants

Worldwide Heart Transplants

Newer Generation Artificial Hearts

Newer Generation Artificial Hearts

Future Tech

Future Tech

Intrathoracic Impedance for Heart Failure

Intrathoracic Impedance for Heart Failure

One of the Best Devices for Monitoring Heart Failure

One of the Best Devices for Monitoring Heart Failure

Nursing care of patients with congestive heart failure • Maintain the patient in high

Nursing care of patients with congestive heart failure • Maintain the patient in high fowler's position • Elevate extremities except when the patient is in acute distress • Frequently monitor vital signs • Change position frequently • Monitor intake and output and daily weight

Nursing care of patients with congestive heart failure • Restrict fluids as ordered •

Nursing care of patients with congestive heart failure • Restrict fluids as ordered • Teach the patient and family and provide emotional support (life style change) • Explain the side effect of diuretic medications for additional actions ( side effects of diuretics include electrolyte imbalance, symptomatic hypotension • Use aseptic procedures when caring for invasive lines

Stages, Phenotypes and Treatment of HF

Stages, Phenotypes and Treatment of HF

What have we learned?

What have we learned?

In Summary…. • Heart failure is common and has high mortality • Drug therapy

In Summary…. • Heart failure is common and has high mortality • Drug therapy improves survival • Betablockers, ACE-I, aldosterone antagonists • Newer device therapies are showing promise for symptom relief and improved survival • Biventricular pacing, ICD’s • Transplants remain rare, but technology for mechanical assist devices continues to improve- stay tuned!