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Heart Failure 101out of the lab, into the clinic
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Objectives today Provide an overview of clinical aspects of heart failure
diagnosis assessment management
clinical pearls from the trenches—front line HF care
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Definition of heart failure
state in which the heart cannot pump a sufficient 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
Rosens ER medicine 6th ed
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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
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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
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“I wish I looked worse, and felt better!!”
George J- HF patient
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What is your risk?
1 in 5 will develop heart failure
Lloyd-Jones et al, Lifetime Risk for Developing Congestive Heart FailureCirculation 2002; 106: 3068 - 3072.
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Heart failure: not going away
Arnold Can J Cardiol 2007
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The cost of heart failure
9%
8% 10%
7%
13%
52%
Hospitalization$15.4
Lost Productivity/Mortality*
$2.8
Home Healthcare$2.4
Drugs/Other Medical Durables
$3.1
Physicians/Other Professionals
$2.0
Nursing Home$3.9
*Lost future earnings of persons who will die in 2006, discounted by 3%
Total Cost$2.96 billion
AHA. 2006 Heart and Stroke Statistical UpdateAHA. 2006 Heart and Stroke Statistical Update
$3 billion
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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 32% 5 year 50% J. Ezekowitz 2008
CMAJ 2009, EJHF 2008
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Modes of death in HF
50% of HF patients “DROP” sudden cardiac death
50% of HF patients “DROWN” progressive congestion
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HF etiology
ISCHEMIC (2/3 HF) CAD-ischemia+/-MI
NON ISCHEMIC (1/3 HF) Dilated Hypertrophic Restrictive Valvular
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HF rarely exists in a Vacuum
Diabetes COPD Renal disease Thyroid disorder Cancer
It is not uncommon for the heart failure
patient to have one or all of the above
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Mechanisms of heart failure
mechanical abnormalities
myocardial injury electrical
disorders
left ventricular dysfunction
loss of pump
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Compensatory mechanismsloss of pump (CO)
neurohormonal activation
SNS
AT I - IIaldosterone
vasopressin
BNP
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Chemical mediators of HFAngiotensin I / II Aldosterone ADH-antidiuretic hormone Epinephrine / Norepinephrine Vasopressin EndothelinsNatiuretic peptides
Atrial NPB-type NPC-type NP
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A toxic brew…
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myocardial injury
neurohormonal activation
vasoconstrictionhypertrophy-dilation
“remodeling”
Na+ + H2O retention bythe kidney
heart failure
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Compensatory mechanisms
the heart will attempt to maintain perfusion in response to any increased burden of output loss of functioning myocytes
by a variety of mechanisms…
these mechanisms all worsen HF—by provoking further pump failure over time
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MVO2
MVO2-myocardial oxygen demand a measure of cardiac workload: MVO2
increases with heart size, HR, contraction, and resistance to contraction
in the healthy heart, MVO2 can be easily met with most workload demands
in HF—MVO2 increases as the hearts ability to supply itself decreases
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Compensated heart failure
the patient appears normal but: the exercise capacity is decreased there is an increase in CO and BP there is an increase in the work of the heart further decrease in cardiac function …causing decrease in the force of the
contraction and CO over time
Rosa Guterriez 2006
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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
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Diagnosing HFMore difficult than you’d think
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Diagnosis of HF-CCS 2006
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Diagnostic accuracy of traditional HF work-up
Dao Q et al J Am Coll Cardiol 2001;37:379-85
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Modes of heart failure
Systolic pumping dysfunction
Diastolic filling dysfunction
Right sided HF Left sided HF
A HF patient can have one or several of these It gets complicated….
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HF TESTING
ECHO anyone?
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Echocardiogram
WHY in HF: useful for assessing chamber size volume of cavity thickness of walls assessing pumping function (systolic) assessing filling function (diastolic) determining LVEFx within 10%
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Echo… determines chamber size and function,
thickness of the walls of the heart, and how well each wall moves
evaluates the function of valves and myocardium by looking at blood flow with doppler
can be viewed live, and stored digitally or on tape
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Echo… valve function / movement structure, thickness, movement of valves identify scars / calcifications / infection
vegetations assessing valve repairs / prosthetic valves pericardial fluid congenital defects thrombus
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ECHO
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Echo… WHEN: excellent first line test for determining / confirming
HF as diagnosis ----also for re-assessing patient response to therapy, and improvements or decline of heart function
yearly check of valve disease, prosthetic valve function assessment of LA in patients with atrial fibrillation recheck for thrombus resolution post
anticoagulation Tx
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Additional testing in HF ECG BNP MUGA MIBI Thallium (viability scan) Coronary Angiogram 24 hour Holter monitor VO2 Max
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BNP -CCS 2007BNP -CCS 2007
BNP / NT-proBNPBNP / NT-proBNP … should be measured to … should be measured to confirm or rule out a diagnosis of heart failureconfirm or rule out a diagnosis of heart failure in in the acute or ambulatory care setting in patients the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt in whom the clinical diagnosis is in doubt
(class I, level A)(class I, level A)
currently the most practical use of this testcurrently the most practical use of this test under cut-off point—HF unlikelyunder cut-off point—HF unlikely above cut-off point—HF very likelyabove cut-off point—HF very likely
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BNP (CCS 2007)BNP (CCS 2007)Age Age
(years)(years)Heart Heart
failure is failure is unlikelyunlikely
Heart failure Heart failure possible but other possible but other
diagnosesdiagnoses must be must be consideredconsidered
HeartHeart failure failure is very likelyis very likely
BNPBNP AllAll < 100 < 100 pg/mlpg/ml
100-500 pg/ml100-500 pg/ml > 500 pg/ml> 500 pg/ml
NT-proBNPNT-proBNP < 50< 50 < 300 < 300 pg/mlpg/ml
300-450 pg/ml300-450 pg/ml > 450 pg/ml> 450 pg/ml
50 - 7550 - 75 < 300 < 300 pg/mlpg/ml
450-900 pg/ml450-900 pg/ml > 900 pg/ml> 900 pg/ml
> 75> 75 < 300 < 300 pg/mlpg/ml
900 - 1800 900 - 1800 pg/mlpg/ml
> 1800 pg/ml> 1800 pg/ml
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MUGA
WHY in HF: this test is the current “gold standard” for determining EFx to within 1-2% accuracy, and highly reproducible (little variation with serial testing)
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MUGA WHEN: can be used following any
ECHO to narrow the range of EFx (particularly if EFx is in question), should be considered when assessing / re-assessing patients for
device therapy often used during chemotherapy to monitor
cardiotoxic effects
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HF Signs & Symptoms
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Forward flow HF symptoms
“Out of gas”—related to O2 delivery
fatigue weakness lack of energy cognitive dysfunction decreased exercise tolerance
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Backword flow HF symptoms
“Plumbing”—related to congestion shortness of breath orthopnea paroxysmal nocturnal dyspnea (PND) edema fluid retention / weight gain decreased exercise tolerance
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Uncommon HF presentation
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Cognitive impairment* Altered mentation Delerium* Nausea Abdominal discomfort Oliguria Anorexia Cyanosis*May be more common presentation in elderly
ccs-2006
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HF Management
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HF treatment goals
Slow progression of syndrome
Control symptoms
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Cardiac output– 4 components
PRELOAD force stretching the ventricle before contraction
AFTERLOAD tension against which the ventricle must pump to
eject this volume
HEART RATE CONTRACTILITY
ability of the myocardial cells to produce force-INOTROPY
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How do we do this?“Get with the Guidelines”-CCS 2006
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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!
www.hfcc.ccs.ca
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CCS on HFPSF Guideline based medications should be
considered in HF with preserved EF** (diastolic HF) for:
relief of HF symptoms Pulmonary congestion Peripheral edema
treatment of HF risk factors HR, atrial fibrillation BP (as per HTN guidelines)
**overall lower level of evidence associated with HFPSF
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HF treatment is guided by…
EFx-ejection fractionventricular systolic function
NYHA functional classsymptom status
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Ejection Fraction
EFx—its all about the LV how much blood is ejected per ventricular
contraction is measured by percentage and is indicative of pump efficiency
the normal heart will pump out 60-70% of the blood that enters the left ventricular chamber ---never 100%
the LV’s normal shape is the perfect pump
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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
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“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)
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Medications for HFmorbidity / mortality reduction
ACE inhibitors Beta Blockers Aldosterone antagonists
Goal: to target or maximally tolerated doses
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Medications for HFsymptom control
Diuretics
Nitrates
Digoxin
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Medications for HFrisk factor reduction
ASA
Statins
Warfarin
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Medications to avoid in HF NSAIDS (ibuprofen, indocid, high dose ASA) COX 2 inhibitors (Celebrex®) Thiazolidendiones (Avandia®, “glitizones”) Corticosteroids Tricyclic anti-depressants Antiarrhythmics* Calcium channel blockers** Herbals*exception: amiodarone (Cordarone)
**exception: amlodipine (Norvasc)
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ICD-internal cardiac defibrillator many HF patients at risk
for sudden cardiac death primary / secondary
prevention quantity of life selection criteria:
EFx NYHA functional class prognosis medications maximized
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CRT-cardiac resynchronization mechanical dys-synchrony
impacts pump function third lead attempts to
improve synchrony quality of life selection criteria:
EFx QRS width on ECG NYHA functional class medications maximized
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HF patients in trouble
…and into the hospital
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A fine balance…
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1
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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
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Nutrition management of HF
Limit Sodium Intake
Avoid Excessive Fluids
Daily Morning Weights
Liz Woo MHI HFC 2009
62
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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
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Sodium sources
Liz Woo MHI HFC 2009
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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
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Daily weightsweigh immediately after
voiding upon rising in the morning
no clothes on same scale every day keep a record bring the diary to the
clinic appointments
Rosa Gutierrez 2006
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Medications YES & NO ACE inhibitors Beta blockers Aldosterone
antagonists Diuretics Digoxin Nitroglycerin
NSAIDS Thiazolidendiones Corticosteroids Tricyclic antidepressants Antiarrythmics* Calcium channel
blockers** herbals
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Remember… HF medications require
close monitoring: electrolytes (K+) creatinine
at initiation pre up-titration ongoing
Coumadin INR 2.0-3.0 2.5-3.5
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Infection
URTI flupneumoniaUTIcellulitis
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HF co-morbidity
Diabetes COPD Renal disease HTN Thyroid disorder Cancer
HF rarely exists in a vacuum
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Ischemia
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Arrhythmia
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Disease progression
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Self care in HF “YOU have the most power over your condition”
“AVOID behaviors that make heart failure worse”
“PAY ATTENTION, act EARLY”
“you can ignore your heart failure…”
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HF ASSESSMENT
Details, details, details
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HF assessment Thorough patient history & physical exam
Establish baseline data and monitor trends
Appropriate surveillance ongoing
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HF treatment is guided by…
EFx-ejection fractionventricular systolic function
NYHA functional classsymptom status
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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?”
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history cont…
New or changed: Palpitations Dizziness Lightheadedness Syncope Angina Depression GI / appetite
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history cont…
Review of: Medications Lifestyle / risk factors Co-morbidity Recent admits to Hospital, ER Testing—current EFx? Bloodwork
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Physical exam Weight Edema JVP Heart rate / rhythm Blood pressure HS auscultation Lung auscultation
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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
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Weight“is that water, or is it you?”
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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
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Weight assess if up or down? how much? over what period of time? what is long term trend for wt?
compare current clinic weight to patient baseline, last clinic
to assess fluid balance
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when the “tank’s too full”…
The longer the fluid took to come on, the longer it takes to come off
The more fluid the patient has gained, the longer it takes to come off
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Edema“where do you keep your water?”
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Edema swelling in legs, feet, ankles? bloating in abdomen—ascites? swelling anywhere else?
pitting / non-pitting?
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Edema cont… assess feet, ankles, legs for edema
equal both sides how much pitting
assess above knee, track to sacral area if edema severe
compare edema to patient baseline, last clinic, plus weight
to assess fluid balance
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JVP“up, down, up, down….”
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Jugular Venous Pressure JVP reflects pressure and volume changes
in the right atrium most proximal location to view 10 cm column of blood supported to
clavicle from right atrium when upright observe at 90 degrees, 30-45 degrees measured in cm ASA
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Jugular Venous Pressure elevated JVP indicates high right atrial
pressure, fluid overload, TR should not be > 4cm ASA or > 1cm above
R clavicle when patient upright jugular venous distension at 90 degrees
suggests substantial congestion baseline values key
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Tips for patient placement
90 degrees look at eye level point on opposite wall relax ! wiggle chin
30-45 degrees remove pillow turn head slightly to the left (2 inches)
tell patient why you are looking
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Jugular Venous Pressure cont… observe on right side of neck--- if not
apparent, check left note external jugular position supine to upright position may “pop” JVP
tricuspid regurgitation— “V” wave may not obliterate venous wave venous wave may be pulsatile baseline JVP to chin when euvolemic
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VENOUS vs CAROTID venous is a biphasic, undulating wave, carotid is a
monophasic wave assess in several positions from supine to upright
(venous pulse will change with position) venous wave can usually be obliterated with firm
finger pressure at base of neck venous wave can not usually be palpated as carotid
can occasionally, venous will overlay carotid venous wave may descend with inspiration
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Look up…. way up!
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**Hepatojugular reflex: gentle abdominal pressure causing further distension of jugular veins suggests central congestion/volume overload
**Kussmauls: paradoxical rise in JVP with inspiration
compare JVP to patient baseline, last clinic, plus weight, edema
to assess fluid balance
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What can mislead you…
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Lung auscultation crackles throughout expiratory wheezes decreased AE bases quiet breath sounds
who is wet? who is euvolemic?
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Blood Pressure 79/40 mm/Hg 185/98 mm/Hg 121/83 mm/Hg
who has heart failure? who is wet / dry?
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Creatinine 385 umol/L 110 umol/L 150 umol/L
who is wet? who is dry?
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S3 heart sound normal HS
S3
S4
summation gallup
(Y.E Kocabasolglu, R.H. Henning)
(.wav)
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Cachexia muscle mass
water weight
daily weights?
unchanged
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How much water? 15 kg 5 kg 10 kg 20 kg
or none?
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Take home…wet or dry?
Weight, edema, JVP = MVP compare to additional clinic findings account for specific patient factors
We don’t know where the patient is, if we don’t know where he came from BASELINE-BASELINE-BASELINEBASELINE-BASELINE-BASELINE
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Patient assessment in HF simple things methodically done multiple findings
Baseline data = Monitor trends=
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What’s the plan? Self care teaching / reinforcement
What has or could de-stabilize this patient’s HF? Guideline based treatment options
Medications ICD / CRT Interventions ie. Angiogram, Sx
Follow up What surveillance level does this patient require?
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HF treatment goals
Slow progression of syndrome
Control symptoms
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Why do we need specialty clinics in
HF?
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HF patients take time Readmission rates are high Patients are complicated
9 visits to GP/year 8 visits to a specialist Multiple co-morbid conditions (average 5)
Need time beyond 8-10 minutes of visit Titrate medications Further diagnosis
Potential for huge benefits! JAE 2008
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Heart failure: do specialists matter?
McAlister et al JACC 2004
Ezekowitz et al CMAJ 2005
Collaborative care
GP alone
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Heart Function Clinic est. 1989 Missions:
1. Clinical Care
2. Research
3. Education
Multidisciplinary 6 MDs 4 Nurses with expertise in heart failure Dietician Pharmacist
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MHI Heart Function Clinic Clinic #s:
700 active patients 25 new referrals/month 120 patient visits/month 83000 minutes on the telephone 66000 minutes in clinic 45000 minutes reviewing test results
support for this clinic is backed by extensive local data collection, clinical trials and ongoing quality improvement
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Future of HF care HF patients are complex in every aspect HF has a huge impact on quality and quantity of
life, morbidity and mortality—particularly when not treated
successful treatment requires: timely diagnosis close assessment & surveillance guideline based treatment regimes lifestyle support
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Thank you!
