Congestive Heart Failure:(Not for the) Weak of Heart: Access

Glen Drobot, MD, FRCPC

Assistant Professor, Department of Internal Medicine, University of Manitoba & St. Boniface General Hospital

Co-director & consultant WRHA Heart Failure Clinic

Annual Scientific Assembly 2006,

Manitoba College of Family Physicians

Objectives

• Outline the make-up of the Heart Failure clinic, sited at St. Boniface General Hospital

• Review current access issues– Testing– HF services

• How you can help your patients

HF Clinic

• Inter-disciplinary clinic based in ACF Medicine• Physicians

– Dr. James Tam– Dr. Glen Drobot– Dr. Patrick Griffin– Soon to be… August 2006 Dr. Shelley Zeiroth

• Nurse clinician: Estrellita Estrella-Holder• Pharmacist ● Dietician• Physical and occupational therapists• Social worker

HF Clinic

• Currently 2 half-day clinics/week

• Increasing to 3 half-day clinics upon arrival of Dr. Zeiroth

• Waiting list: should be within 4 weeks

• Some ability to prioritize on basis of severity of illness goal is to improve accessibility with increased staffing

HF Clinic

• Referrals directed to ACF Medicine

• FAX # (204) 233-2157

• Urgent calls: cardiologist on-call

• Inquiries about existing HF clinic patients during the weekdays: (204) 237-2744

Case: Mr. Y.

• 63-year-old male with DM 2, myocardial infarction 4 years ago– 1 month history of fatigue, increasing

shortness of breath on exertion and some peripheral edema

• Medications– ASA 325 mg OD– Atenolol 25 mg OD– Metformin 750 mg tid

Case: Mr. Y.

• O/E BP 130/80, HR 90, SaO2 93%

chest: bibasilar crackles

Heart sounds decreased, no (M)

JVP 6 cm, edema to mid-shins

abdomen: unremarkable

Case: Mr. Y.

• Initial investigations:– CBC– Na, K, Cl, TCO2, urea, creatinine

all normal– glucose 10

– ECG– Chest x-ray

Case: Mr. Y.

• Large group

• Old inferior MI, LAD, LVH

Case: Mr. Y.

• Interstitial pulmonary edema, cardiomegaly

Mr. Y. – what should be done?

• Assess for precipitants of HF– Salt and fluid intake– Non-compliance with medications– Active ischemia– Intercurrent infection

• Determine the type of HF– Systolic vs. diastolic dysfunction– (L) and/or (R) heart failure

Other Investigations

• Assessment of LV function– Nuclear medicine (MUGA) = weeks– Echocardiography = 6 months

• If no significant valvular pathology suspected, MUGA is a reasonable first test

• Either test will distinguish between preserved LV function (diastolic) vs. systolic dysfunction

Mr. Y. – what should be done?

• While waiting for investigations…– Treat congestion with loop diuretics to aim for

euvolemia (accept creatinine elevations of 50% above normal baseline, or 30% above mild-moderate creatinine elevation)

– Can start ACE-I, even if ends up having diastolic dysfunction (likely has HTN)

• Is there isolated (R) HF? If so, do pulmonary investigations as well.

Facilitating Consultations

• Detailed history and last physical exam

• Current list of medications

• ECG, CXR

• Echo or MUGA result, or date for test

• Basic BW

• Main reason for consult: stabilization, further work-up of cardiac problems, consideration for biventricular pacing

Questions about Device Therapy

• Implantable cardioverter-defibrillators– Still go through arrhythmia service

• Biventricular pacemakers for cardiac resynchronization– Wide QRS, >140 msec– EF < 35%– Persistent class III-IV symptoms– Screened by HF clinic, we do special echo

looking for inter-/intra-ventricular asynchrony

Questions

“Big Buddha”, Koh Samui, Thailand