CHFN Review Part 3-1 - Oregon ACC 1 Heart Failure Certification Review Course Part 3 Ashley Moore-Gibbs, MSN, AGPCNP-BC, CHFN Objectives Review the hemodynamic patient profiles of

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Heart Failure Certification

Review CoursePart 3

Ashley Moore-Gibbs, MSN, AGPCNP-BC, CHFN

Objectives

♥ Review the hemodynamic patient profiles of acute decompensated

heart failure (ADHF)

♥ Discuss the current ACCF/AHA Heart Failure Guidelines for management of ADHF

♥ Define advanced HF and outline treatment recommendations

Case Study 1• WD is a 48 year old African American male being evaluated in the ED for

complaints of DOE, worsening lower extremity edema, abdominal distention

• PMH: NICM (Dx 2004) , S/P ICD (2005), NSVT, DM Type 2, Obesity, Gout,

Obstructive Sleep Apnea (OSA). Last admission for HF 3 months ago; 3

admits total in last 9 months

• PSH: none

• Dx Tests:

• Echocardiogram 6 months ago showing LVEF < 20%

• No recent labs

• ICD no interrogations in 9 months

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Case Study 1: WD• Social hx:

– Lives with father

– 3 children with youngest living with him

– Disabled since diagnosis of CMP (2004)

– Assists with coaching basketball at a local Boys & Girls Club

– No prior/current history of tobacco, ETOH, or illicit drug use

• Review of Systems

– Significant for 3 pillow orthopnea, decrease in exercise tolerance,

decrease in appetite, nonproductive cough, lower extremity &

abdominal edema

Case Study 1: WD• Medications

– Aspirin 325 mg PO daily

– Amiodarone 200 mg PO daily

– Lasix 80 mg PO daily

– Aldactone 25mg PO daily

– Colchicine 0.6mg BID prn

– Coreg 12.5mg PO BID

– Glyburide 10mg PO daily

• Allergies:

– PCN: hives

Case Study 1: WD• Physical Exam

– VS: BP 92/54 mm/Hg, HR 110, RR 24, Temp 98.4 degrees, pulse ox 95%

on O2 2LNC, Ht: 5’ 10”, Wt: 295 lbs, BMI 42.3

– HEENT: unremarkable

– Neck: significant JVD (> 10 cm H2O)

– Lungs: clear bilaterally, respirations even; mildly labored during

conversation

– CV: RRR, + S3, - S4, systolic murmur II/VI. PMI displaced laterally; 6th ICS

– Abd: morbidly obese, soft, distended, mild tenderness RUQ. Bowel

sounds x 4 quad

– Ext: 3 + pitting edema mid-thigh down bilaterally.

• Pulses 2 + throughout, capillary refill < 2 sec

– Skin: Intact, cool warm upper/lower extremities bilaterally.

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Cardiac Remodeling

• Damage/insult occurs to the muscle followed by inflammation

• Neurohormonal (NH) activation occurs increasing ventricular pressure, volume, and peripheral vasoconstriction

• Heart changes in structure (dimensions, mass, shape) and function

• NH activity continues causing further structural & functional changes

Case Study 1 : WD

• BMP: Na 130, K 4.0, BUN 20, Cr 1.6

• CBC: WBC 5.0, Hgb 11.5, Hct 32.3, plt 232

• Cardiac BNP: 1160

• Cardiac biomarkers (CK-MB, trop): normal

• 12 lead ECG: Sinus tachycardia, vent rate: 110 bpm, normal axis

• CXR: cardiomegaly

Why did we draw a BNP on WD?

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Treatment Goals for ADHF

Primary Treatment Goals

• Improve/decrease symptoms

• Identify precipitating factors

• Optimize volume status

Other Goals during Hospitalization

• Optimize chronic oral therapy

• Increase exercise tolerance

• Improve heart function

• Identify patients who may benefit

from revascularization

• Educate patients on Self-Care

activities

Heart Failure Updated Guidelines

Chronic versus Acute Decompensated HF

• Chronic HF:

– more stable condition

– organ function remains

adequate

• ADHF:

– unstable condition

– immediate treatment is warranted to prevent injury

to systemic organs

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Treatment Options for ADHF

• Fluid & sodium restriction

• Diuretics (loop and thiazide)

• Intravenous vasodilators (nitropusside, nitroglycerin, nesiritide)

• Inotropes (milrinone, dobutamine)

• Ultrafiltration (in selected patients)

• Mechanical Circulatory Support

• Orthotopic Heart Transplant

Basic Hemodynamic Parameters

1. Presence or absence of elevated filling pressures

– Wet or Dry

2. Perfusion status: Sufficient or Diminished

– Warm or Cold

Evidence of Congestion

• Orthopnea

• Paroxysmal nocturnal

dyspnea

• Jugular venous distention

• Adventitious breath sounds

• Third heart sound (S3)

• Ascites

• Peripheral edema

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Signs of Poor Perfusion

• Mental status changes

• Narrow pulse pressure

• Sinus tachycardia

• Poor urine output

• Hypotension

• Cool extremities above

hands/feet

Monitoring Patients Hospitalized with ADHF

Parameter Frequency Specifics to consider

Weight At least daily � Obtain after patient voids

� Obtain prior to breakfast

Fluid intake & output At least daily

Vital signs More than daily � Include orthostatic blood

pressure

Physical exam At least daily � Edema

� Ascites/hepatojugular reflux

� Hepatomegaly/ Liver tenderness

� Pulmonary rales

�Increased JVP

Symptoms At least daily � Orthopnea/PND

� Nocturnal cough/dyspnea

� Fatigue

Laboratory data At least daily � Serum potassium, sodium,

creatinine, & BUN

HFSA 2010 Comprehensive Heart Failure Practice Guideline

Hemodynamic Profile AssessmentCongestion at Rest

Low

Perfusion

at Rest

No

No Yes

Yes

Warm & Dry Warm & Wet

Cold & WetCold & Dry

Signs/symptoms of congestion:

• Orthopnea/PND

• JVD

• Ascites

• Edema

• Rales (rare in HF)

Possible evidence of low perfusion• Narrow pulse pressure• Sleepy/obtunded• Low serum sodium

• Cool extremities• Hypotension • Renal dysfunction

Stevenson LW. Eur J Heart Fail. 1999;1:251

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Low

Perfusion

at Rest

No

No Yes

Yes

Warm & Dry


• Orthopnea/PND

• JVD

• Ascites

• Edema





Treatment for the Warm-Dry Patient

• Adequate perfusion, no congestion

• Treatment Goals: Continuation of oral heart failure

medications and evaluate to determine if symptoms are

related to causes other than heart failure

• Treatment recommendations: (See Appendix)

1. Angiotensin-converting enzyme inhibitor

2. Beta-blocker

3. Aldosterone antagonist

4. Diuretic

5. Hydralazine/ISDN


Low

Perfusion

at Rest

No

No Yes

Yes

Warm & Wet


• Orthopnea/PND

• JVD

• Ascites

• Edema





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Treatment for the Warm-Wet Patient

• Most common type of ADHF

• Treatment Goals: Reduce ventricular filling pressures &

relieve symptoms

• Limitations in medical therapies in ADHF

• Treatment recommendations:

- Ideally treated with intravenous diuretics

- Vasodilator therapy in combination with IV diuretics in patients with diuretic

resistance or Chronic Kidney Disease

Medical Therapy During Hospitalization

• Patients with HFrEF (HF with reduced Ejection Fraction)

experiencing HF exacerbation should have guideline-driven

medical therapy continued in the absence of hemodynamic

instability contraindications

– Oral therapy should be continued, or even uptitrated, during hospitalization

• Initiation of beta blocker (BB) therapy is recommended after

optimization of volume status and successful discontinuation of

IV diuretics, vasodilators, and inotropic agents

– BB should be initiated at low dose only in stable patients

– Caution should be used in patients when initiating BB that have required

inotropes during their hospital course

2013 ACCF/AHA Guideline for the Management of Heart Failure

Recommendation for Diuretics

• Dose should produce a rate of

diuresis sufficient to achieve

optimal volume status with

relief in symptoms of

congestion without inducing

excessive, rapid reduction in:

– Intravascular volume

– Serum electrolytes

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Diuretics in HF

• Indicated in HF patients with fluid retention.

• Types of Diuretics:

Thiazides (chlorothiazide)

Loop diuretics (furosemide, torsemide, bumetanide)

• Thiazides are useful in hypertensive HF patients with mild

fluid retention.

• Loop diuretics are effective in the presence of renal

impairment.

• HFSA Guidelines 12.10

– Patients with mod to severe renal dysfunction & evidence of fluid

retention should continue to be treated with diuretics

Case Study 1 from Part 1Defining HF, HF symptoms, History & Physical Exam,

Class/Stage of HF, ECHO, HF Medical Therapy

DF is a 72 year old male with a long-standing history of an ischemic

cardiomyopathy. Prior echocardiogram performed in Jan 2012 showed LVEF

40%. He has been added on to the office schedule for cardiac evaluation for

complaints of (C/O) SOB.

Echocardiogram performed the day of the office visit shows a decrease in LVEF

from 40% to 20%.

Current meds:

Lasix 40 mg PO daily

Lisinopril 10mg PO daily

Carvedilol 12.5mg PO BID

Aspirin 81mg PO daily

Atorvastatin 80mg PO QHS

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Diuretic Therapy

• Increase urine excretion & decrease fluid retention

• Two studies (SOLVD & PRAISE) suggested that there is a risk of ↑ in morbidity & mortality when non-potassium- sparing diuretics are used

• No studies have examined the effects of long-term outcomes

• Potential adverse effects:

- electrolyte imbalance

- hypotension

- decline in renal function

- diuretic resistance

- hearing impairment or tinnitus

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Diuretics and HF

Patients may become unresponsive to high doses of diuretic drugs if they:

● Consume large amounts of dietary sodium2

● Take agents that can block effects of diuretics

(eg, NSAIDs, COX-2 inhibitors)1

● Have significant impairment of renal function or

perfusion1

Diuretic resistance can generally be overcome by

● IV administration of diuretics2

● Using 2 or more diuretics in combination2

1Ravnan SL et al. Congest Heart Fail. 2002;8:802Brater DC. Drugs. 1985;30:427

Diuretic Resistance: Considerations for Ultrafiltration

• Known diuretic resistance

• > 10 – 15 pounds of excess fluid

• Volume loaded during surgery and fluctuating blood pressure (once BP stable)

• RV failure/Pul HTN


Low

Perfusion

at Rest

No

No Yes

Yes Cold & Wet


• Orthopnea/PND

• JVD

• Ascites

• Edema





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Treatment for the Cold-Wet Patient

• More intense therapy may be needed in this patient

population. Therapy adjusted based on systemic vascular

resistance (SVR).

• Treatment Goals: Achieve adequate diuresis and maintain

adequate perfusion; can be adjusted based on levels of SVR


- Intravenous loop diuretics + vasodilators or nesiritide in pts with � SVR & �cardiac output

- Short term inotropic treatment may be useful in patients with normal or � SVR

Intravenous Vasodilators

Mechanism of action:

• Directly reduce SVR & filling

pressures which allows for rapid

reversal of decompensation

• Not associated with exacerbations of

ischemia or ventricular dysrhythmias

• Can be utilized with long-term oral

therapy including ACE inhibitors and

diuretics

IV Vasodilators:

• Nitroglycerin- commonly used in ADHF. Primarily through effects on venodilation.

• Nitroprusside- despite favorable impact on hemodynamics not as widely used for ADHF due to it’s pharmacologic effects. (Need PA Cath)

• Nesiritide- VMAC trial established clinical benefit of this agent in ADHF. Meta-analyses have suggested an ↑ in worsening renal function & mortality. Indicated in patients with dyspnea and volume overload


Low

Perfusion

at Rest

No

No Yes

Yes Cold & Dry


• Orthopnea/PND

• JVD

• Ascites

• Edema





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Treatment for the Cold-Dry Patient

• Most challenging to manage

– Low BP + low CO

– Volume management

• Treatment Goals: Improve cardiac output and blood pressure


- Consider inotropic therapy in combination with vasopressors

- Meticulous fluid management required

- Consider decreasing or withdrawing beta-blockers

- Consider intra-aortic balloon pump or ventricular assist device

Inotropes

Mechanism of action:

• Improve cardiac output and cardiac index

• Reserved for patients with a dry-cold or wet-cold profile

• Risk-benefit profile not favorable

Inotropic agents:

Milrinone (Primacor)

Dobutamine (Dobutrex)

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Inotropic Therapy

• Continuous IV infusions of Dobutamine, Dopamine

or Milrinone used as

�Bridge to transplantation

�Bridge to device therapy

�Symptom palliation

• ICDs should be implanted if the patient is going to be discharged on a continuous infusion unless inotrope is used for palliation

• Intermittent infusions NOT recommended

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Patient Treatment Profile

Congestion at Rest

YesNo

Warm & DryPCWP normal

CI normal

(compensated)

Cold & WetPCWP elevated

CI decreased

Cold & DryPCWP low/normal

CI decreased

Vasodilators

Nitroprusside

Nitroglycerin

Inotropic Drugs

Dobutamine

Milrinone

NormalSVR

High SVR

Low

Perfusion

at Rest

No

Yes

Warm & WetPCWP elevated

CI normal

Natriuretic

Peptide

Nesiritide

or


What profile does WD fall in?

Recommendations for Invasive Monitoring

2013 ACCF/AHA Heart Failure Guidelines

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Right Heart Catheterization

Normal Cardiac Pressures• Central venous pressure (CVP) -1-6 mm Hg

– Pressure of blood in the vena cava, near the right atrium

– Reflects the amount of blood returning to the heart

– Good approximation of right atrial pressure

• Right ventricular pressure

– Systolic – 15-30 mm Hg

– Diastolic – 0-5 mm Hg

• Pulmonary artery pressure

– Systolic – 15-30 mm Hg

– Diastolic – 4-12 mm Hg

• Pulmonary capillary wedge pressure (PCWP) 6-15 mm Hg

– Indirect pressure of left atrial pressure

– Pulmonary edema reflective of PCWP >25 mm Hg

• Left ventricular systemic pressure (systolic) 100-140 mm Hg

• Pulmonary vascular resistence (PVR)

– (PAP-PCWP)* 80 } / (CO) =150-250 dynes*sec/cm^5

– PAP- PCWP/ CO= PVR in wood units, normal 0.25-1.6

– An increase in PVR can result in RV failure

– Abnormally high PVR can be a contraindication to cardiac transplantation as it could cause RV dysfunction in the transplanted heart

• Systemic vascular resistance (SVR)– 80 X (PAP-CVP)/CO = <250 dynes-sec/cm-5

-1-6

15-30

0-5

15-30

4-12

100-140

Normal Results of a RHC

•Cardiac index (CI) is 2.8 to 4.2 liters per minute per square meter (of body surface

area)

• Pulmonary artery systolic pressure (PAS)

15 to 30 millimeters of mercury (mmHg)

• Pulmonary artery mean pressure (PAMP)

6 to 15 mmHg

• Pulmonary diastolic pressure (PAD) is 4

to 12 mmHg

• Pulmonary capillary wedge

pressure(PCWP) is 6 to 15 mmHg

• Right atrial pressure (RA) is -1 to 6 mmHg

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Definition of Advanced HF


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Advanced Heart Failure (HF)

• Defined as persistent symptoms (NYHA Class III or IV) that limit daily life despite routine therapy with agents of known benefit.

• Patients with medication intolerance • Inability to uptitrate conventional medications• Decreasing dosage due to intolerance/side effects • One year mortality may be as high as 30-50% • Goals of therapy

– Symptom relief – Prevent re-hospitalization – Prolong survival – Improve quality of life as end of life approaches

Recommendations for Therapies in the

Hospitalized Patient


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Case Study 1 : WD

• BMP: Na 130, K 4.0, BUN 20, Cr 1.6

• CBC: WBC 5.0, Hgb 11.5, Hct 32.3, plt 232

• Cardiac BNP: 1160

• Cardiac biomarkers (CK-MB, trop): normal

• 12 lead ECG: Sinus tachycardia, vent rate: 110 bpm, normal axis

• CXR: cardiomegaly

Hyponatremia

• Hyponatremia defined as serum sodium concentration <136 mmol/L

• Mild hyponatremia is seen in approximately 25% of patients with acute HF

• Hyponatremia poses significantly greater risk of death after discharge

• Reduction in cardiac output triggers hyponatremia.

• Hyponatremia is one of the strongest predictors for poor outcomes in HF patients

• Hyponatremia may be caused by multiple factors:

– RAAS: Aldosterone causes sodium and water retention.

– Antidiuretic Hormone, Vasopressin, ADH

– Impaired renal function leads to a decreased ability of the kidneys to excrete sodium and water.

• Efforts should be made to limit nephrotoxic medications and therapies such as

– Dye loads

– NSAIDS

– Antibiotics

Hyponatremia as a Prognostic Tool

W. H. Lee and M. Packer, “Prognostic importance of serum sodium concentration and its modification by converting-enzyme inhibition in patients with severe chronic heart failure,” Circulation, 1986.

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Therapy Options for Advanced HF

• Continuous intravenous inotropic medications

• Mechanical Circulatory Support

• Heart Transplantation

Mechanical Circulatory Support

• Temporary Devices

– Impella

– TandemHeart

– Centrimag

– ECMO

– IABP

• Long Term Devices

– VAD

– TAH

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• Indicated for patients who are on adequate medical therapy

but have:

– Hemodynamic concerns, symptomatic

– End organ dysfunction

– End stage cardiomyopathy

– Myocarditis

– Bridge to transplant

– Destination therapy

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• Patient selection

– Appropriateness based on degree of illness

– Ability to successfully undergo surgery

– Ability to be discharged to home with adequate family

support for long term success

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Heart Transplant

• Transplant community relies on United Network for Organ Sharing

(UNOS) for fair organ sharing

• Indications:

– NYHA IV on optimal medical therapy

– MVO2 < 14 % or <50 % predicted

– Reliable psychosocial support

– Insurance/financial resources to support life long immunosuppressive therapy

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Heart Transplant

• Exclusion Criteria:

– Fixed Pulmonary Hypertension

– Active systemic infection

– Recent history of Cancer

– Obese with BMI > 35 – 40 (program specific)

– Documented history of noncompliance

– Life limiting disease other than HF

– End organ disease due to HF/poor perfusion

– Psychiatric illness that prevents compliance

– Active substance abuse

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Discharge Criteria for HF Patients

Recommendations for all patients with heart failure:

• Exacerbating factors addressed

• Optimal or at least near-optimal volume status achieved

• Transition from IV to oral diuretics successfully completed

• Patient & family education completed

• At least near-optimal pharmacologic therapy achieved

• Follow-up clinic visit scheduled, usually within 7 to 10 days

HFSA 2010 Comprehensive Heart Failure Practice Guideline

Discharge Criteria for Advanced HF/Recurrent

Admissions

Recommendations for patients with advanced HF /recurrent admissions for HF:

• Oral medications stable for 24 hours

• No IV vasodilator or inotropic agent needed during previous 24 hours

• Ambulation before discharge to assess functional capacity after therapy

• Referral for disease management

• Post discharge plans coordinated (eg, set of scales in home, visiting nurse or telephone follow-up scheduled for no later that 3 days after discharge)

HFSA 2010 Comprehensive Heart Failure Practice Guidelines

Recommendations for Hospital Discharge


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Patient Education

• Salt Restriction (2 gm), avoid potassium-

salt based substitutes

• Fluid Restriction (2 liters /8 cups)

• Monitor daily weight

• Take medications as prescribed

• Notify healthcare provider with

temperature > 1000

• Alcoholic Restriction

• Exercise Training

• Monitoring use of NSAID’s

• Prevent infections (vaccinations)

Teaching Self-Care Maintenance

• Patient must be engaged in their management

• Knowledge is important in achieving treatment adherence but skill building is another essential component

• Assess potential barriers

• Once daily dosing if possible

• Always provide written instruction

• Follow up calls and visits improve adherence

• Do not assume patients’ take medications all of the time

Plans for WD’s Discharge

• Return to outpatient HF Clinic within 7 days

• Dietary education provided

• Self-care education

• Medication education

– Changed diuretic from furosemide to torsemide

– Added Bidil

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Critical Point: Have the appropriate drugs &

devices available for your patient been

addressed?

Patients receiving appropriately prescribed drug & device therapies can have improvement in systolic function in addition to preventing and/or delaying

disease progression.

Established Benefits of Guideline

Recommended Therapies for Systolic HF

Fonarow GC, et al. Am Heart J 2011;161:1024-1030.

Guideline

Recommended

Therapy

Relative Risk

Reduction in

Mortality

Number Needed to

Treat for Mortality

NNT for Mortality

(standardized to 36

months)

Relative Risk Reduction

in HF Hospitalizations

ACEI/ARB 17% 22 over 42 months 26 31%

Beta-blocker 34% 28 over 12 months 9 41%

Aldosterone

Antagonist30% 9 over 24 months 6 35%

Hydralazine/Nitra

te43% 25 over 10 months 7 33%

CRT 36% 12 over 24 months 8 52%

ICD 23% 14 over 60 months 23 NA

Critical Point: Know if your patient has had

their comorbidities addressed.

Comorbidities contribute to negative outcomes, risk of hospitalization readmission, and/or death.

Studies have shown that > 40% of HF patients age 65 years and older have ≥ 5 comorbid conditions.

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Anemia

• Estimated prevalence in 10-55% of HF patients; similar in

systolic and diastolic HF

• World Health Organization (WHO) definition is hemoglobin in

men<13gm/dL; women<12gm/dL

• Risk factors:

– Increased age

– Female

– Decreased body mass index (BMI)/ cachexia

– Use of rennin-aldosterone system blockers (ACE-I or ARB), beta

blockers

– Patients with more severe heart failure

– Chronic Kidney Disease

Managing Comorbid Conditions

• Anemia

– Severity may ↑the severity of HF

– Associated with:

• worsening symptoms of HF

• greater impairment in functional capacity

• ↓ survival

Nieminen et al, Eur Heart J. 2005; 26:384-416.

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COPD

• Occurs in 11-52% in patients with HF

• Likely under-estimated since FEV1 is not routinely

performed to assess respiratory status

• HF and COPD presents diagnostic challenge and is

associated with worse outcomes

• Stable COPD is not a contraindication for beta-

blocker therapy

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Management of Diabetes Mellitus

Goal: HbA1c <7% (ACC/AHA Class IIb, Level of evidence A)

•Sulfonylurea associated with higher risk for HF than metformin

•Metformin- only diabetes drug with morbidity and mortality

benefit

�Concern for lactic acidosis in severe HF

�Contraindicated if creatinine >1.5 men;>1,4 in women

•Thiazolidinediones are associated with fluid retention

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Neuropathic Pain and HF

• Pregabalin – analog of a neurotransmitter

– Exhibits analgesic, anticonvulsant and anxiolytic properties

– Potential side effects

• Dizziness and somnolence

• Peripheral edema 5-20%

• Weight gain 4-12%

– Food and Drug Administration (FDA) warning about possible

hypotension and edema especially if used with a TZD

– FDA cautions against use in NYHA class III or IV

Managing Comorbid Conditions

Cognitive impairment

– Seen as forgetfulness, attention & memory problems, and decreased

concentration

– Twice as likely in HF patients > 65 years of age

– In a study of elderly patients with HF:

• Only 50% could name their medications after receiving verbal and

written information

• 75% had forgotten to take their medications on some occasion

Cline et al. Eur J Heart Fail. 1999; 1: 145-149.

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70

Arthritis

One of the top 10 co-morbidities in HF– Most common is osteoarthritis

Management

1. Physical therapy

2. Capsaicin topical (chronic pain only)

3. Lidocaine 5% patch – neuropathic pain

4. Glucosamine/chondroitin – 40%

patients have a clinical response

5. Intra-articular therapies

6. Narcotics

Staging Heart Failure:

Focus on Disease Progression

� Marked symptoms at rest despite maximal medical therapy (eg, those who

are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions)

Refractory

end-stage HFD

� Known structural heart disease� Shortness of breath and fatigue

� Reduced exercise tolerance

Symptomatic HFC

� Previous MI� LV systolic dysfunction

� Asymptomatic valvular disease

Asymptomatic HFB

� Hypertension� CAD

� Diabetes mellitus� Family history of cardiomyopathy

High risk for developing

heart failure (HF)A

Patient DescriptionStage

Treatment Recommendations for Stage A HF


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Treatment Recommendations for Stage B HF


Treatment Recommendations for Stage C HF


Recommendations for Treatment of HFpEF


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Treatment Recommendations for Stage D HF


Appendix

Guideline-Driven Medical Therapy for Systolic HF

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Prevention: ACE-I • Blocks the conversion of angiotensin I to angiotensin II; prevents functional

deterioration

• Recommended for all heart failure patients

• Relieves symptoms and improves exercise tolerance

• Reduces risk of death and decreases disease progression

• Benefits may not be apparent for 1-2 months after initiation

ACE inhibitors are recommended for prevention of HF in patients at high risk for

this syndrome, including those with:

– Coronary artery disease

– Peripheral vascular disease

– Stroke

– Diabetes and other major risk factor Strength of Evidence = A

ACE inhibitors and beta blockers are recommended for all pts with prior MI.Strength of Evidence = A

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ACE Inhibitors Used in Clinical Trials

Generic Name Trade Name Initial Daily

Dose

Target Dose Mean Dose in

Clinical Trials

Captopril Capoten 6.25 mg tid 50 mg tid 122.7 mg/day

Enalapril Vasotec 2.5 mg bid 10 mg bid 16.6 mg/day

Fosinopril Monopril 5-10 mg qd 80 mg qd N/A

Lisinopril Zestril, Prinivil 2.5-5 mg qd 20 mg qd 4.5 mg/day, 33.2

mg/day*

Quinapril Accupril 5 mg bid 80 mg qd N/A

Ramipril Altace 1.25-2.5 mg qd 10 mg qd N/A

Trandolapril Mavik 1 mg qd 4 mg qd N/A

*No mortality difference between high and low dose groups, but 12% lower risk of death or

hospitalization in high dose group vs. low dose group. HFSA 2010 Practice Guideline

ACE-I Substitutions

It is recommended that other therapy be substituted for ACE inhibitors in the following circumstances:

– In patients who cannot tolerate ACE inhibitors due to cough, ARBs are recommended. Strength of Evidence = A

– The combination of hydralazine and an oral nitrate may be considered in such patients not tolerating ARBs.

Strength of Evidence = C

– Patients intolerant to ACE inhibitors from hyperkalemia or renal insufficiency are likely to experience the same side effects with ARBs. In these cases, the combination of hydralazine and an oral nitrate should be considered.


HFSA 2010 Practice Guideline

Angiotensin Receptor Blockers (ARB)

• Block AT1 receptors, which bind circulating angiotensin II

• ACEi remains the first choice for inhibition of the renin-

angiotensin-aldosterone system in systolic HF but ARBs are a

reasonable alternative

• ARBs should be used to treat patients who are ACEi intolerant

due to intractable cough or who develop angioedema

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ARBs Used in Clinical Trials

Generic Name Trade Name Initial Daily Dose Target Dose Mean Dose in

Clinical Trials

Candesartan Atacand 4-8 mg qd 32 mg qd 24 mg/day

Losartan Cozaar 12.5-25 mg qd 150 mg qd 129 mg/day

Valsartan Diovan 40 mg bid 160 mg bid 254 mg/day


Beta Blockers

• Cardioprotective effects due to blockade of excessive SNS stimulation

• In the short-term, beta blocker decreases myocardial contractility;

increase in EF after 1-3 months of use

• Long-term, placebo-controlled trials have shown symptomatic

improvement in patients treated with certain beta-blockers1

• When combined with conventional HF therapy, beta-blockers reduce

the combined risk of morbidity and mortality, or disease progression1

• Improve left ventricular function

• ↓ Symptoms of HF

• Improve exercise tolerance

• ↓ Mortality

• ↓ HospitalizationHFSA 2010 Practice GuidelineACCF/AHA 2009 HF Update

Beta Blockers

When to initiate:

• Stable or maximally compensated patients

• Avoid initiating in decompensated patients

• May be started before discharge in patients hospitalized for HF, provided they do not require inotropic therapy for HF 2013 ACCF/AHA Heart Failure Guidelines

Symptomatic ExacerbationContinuation of beta blocker therapy is recommended in most patients experiencing a symptomatic exacerbation of HF during chronic maintenance treatment, unless they develop cardiogenic shock, refractory volume overload, or symptomatic bradycardia.


– Temporary dose reduction may be considered– Avoid abrupt discontinuation– Reinstate or gradually increase prior to discharge– Titrate dose to previously tolerated dose as soon as possible


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Beta Blockers

Concomitant Disease

Beta blocker therapy is recommended in the great majority of patients with HF and reduced LVEF—even if there is concomitant diabetes, chronic obstructive lung disease or peripheral vascular disease.

– Use with caution in patients with:

� Diabetes with recurrent hypoglycemia

� Asthma or resting limb ischemia.

– Use with considerable caution in patients with marked bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).

– Not recommended in patients with asthma with active bronchospasm. Strength of Evidence = C


Beta Blockers

Preserved LVEF

Beta blocker treatment is recommended in patients with HF and preserved LVEF who have:

– Prior MI Strength of Evidence = A

– Hypertension Strength of Evidence = B

– Atrial fib. requiring control of ventricular rate Strength of Evidence = B

The elderly

Beta-blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction.

Strength of Evidence = B

In the absence of contraindications, these therapies are also recommended in the very elderly (age > 80 years).



Beta Blocker Overview

General considerations Initiate at low doses

Up-titrate gradually, generally no sooner than at 2 week intervals

Use target doses shown to be effective in clinical trials

Aim to achieve target dose in 8-12 weeks

Maintain at maximum tolerated dose

If symptoms worsen or

other side effects appear

Adjust dose of diuretic or concomitant vasoactive med.

Continue titration to target after symptoms return to baseline

If up-titration continues to

be difficult

Prolong titration interval

Reduce target dose

Consider referral to a HF specialist


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Beta Blockers Used in Clinical Trials

Generic Name Trade Name Initial Daily

Dose

Target Dose Mean Dose in

Clinical Trials

Bisoprolol Zebeta 1.25 mg qd 10 mg qd 8.6 mg/day

Carvedilol Coreg 3.125 mg bid 25 mg bid 37 mg/day

Carvedilol Coreg CR 10 mg qd 80 mg qd

Metoprolol

succinate CR/XL

Toprol XL 12.5-25 mg qd 200 mg qd 159 mg/day


Aldosterone Antagonists

Spironolactone and Eplerenone

• ↓ Mortality, ↓ hospitalization for HF

• Recommended for patients with NYHA class II – IV who have LVEF < 35%, unless

contraindicated (NYHA class II should have a hx of prior CV hospitalization or elevated

BNP levels)

• Combine with ACE-I and beta-blockers

• Initiation and maintenance dosing determined by GFR

• Avoid if K > 5.0 mEq/L or Cr > 2.5 mg/dL in men or Cr > 2.0 mg/dL in women


Aldosterone Antagonists

Spironolactone and Eplerenone

• Check renal function and K+ level within 2-3 days and again at 7 days after initiation

• Subsequent monitoring dictated by general clinical stability of renal function and

fluid status but should occur at least monthly for the first 3 months and every 3

months thereafter.

• If ACEi or ARB dosages increase a new cycling of monitoring should occur

• After initiation of an aldosterone antagonist potassium supplement should be

discontinued (or reduced)

• Avoid foods high in potassium and NSAIDs

Recommended in patients post-MI with LVEF < 40% who develop symptoms of

HF or who have a history of diabetes mellitus, unless contraindicated.


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Hydralazine and Oral Nitrates

• ↓ mortality, improved functional class as compared with use of digoxin and

diuretics (A-HeFT)

• ↓ mortality, morbidity and symptoms in African American patients.

Consider if:

• There is evidence of progression of HF despite optimal regimens that

include beta-blockers, ACE inhibitors (or angiotensin-receptor blockers), and

aldosterone blockers, plus diuretics and possibly digoxin.

• ACE-I and ARB contraindicated (hyperkalemia, angioedema, or CrCl <

30mL/min), OR

• Additional BP lowering needed after ACE-I and/or ARB dose maximized


Loop Diuretics

Agent Initial Daily

Dose

Max Total Daily

Dose

Elimination:

Renal – Met.

Duration of

Action

Furosemide 20-40mg qd or

bid

600 mg 65%R-35%M 4-6 hrs

Bumetanide 0.5-1.0 mg qd

or bid

10 mg 62%R/38%M 6-8 hrs

Torsemide 10-20 mg qd 200 mg 20%R-80%M 12-16 hrs

Ethacrynic acid 25-50 mg qd or

bid

200 mg 67%R-33%M 6 hrs

Diuretics

• Used to relieve fluid retention

• Improve exercise tolerance

• Facilitate the use of other drugs indicated for heart failure

• Electrolyte depletion a frequent complication

• Should not be used alone to treat heart failure

• Higher doses of diuretics are associated with increased mortality

• Some patients can be taught to adjust their diuretic dose based on their goal weight

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Intravenous Diuretics for Treatment of ADHF

Initial Dose (mg) Max Single Dose (mg)

Loop diuretics:Bumetanide 1.0 mg 4-8 mg

Furosemide 40 mg 160-200 mg

Torsemide 10 mg 100-200 mg

Thiazide diuretics:Chlorothiazide 500 mg 1000 mg

Sequential nephron blockade:Chlorothiazide 500 mg – 1000 mg IV daily or BID in addition to

daily loop diuretic

Metolazone (Zaroxolyn) 2.5 mg – 5 mg PO daily of BID with loop diuretic

Intravenous Diuretics for Treatment of ADHF

IV infusions:

Bumetanide Loading dose of 1 mg followed by infusion of 0.1-0.5 mg/h

Furosemide Loading dose of 40 mg followed by infusion of 5-40 mg/h

Torsemide Loading dose of 20 mg followed by infusion of 5-20 mg/h

Digoxin

• Enhances inotropy of cardiac muscle

• Reduces activation of neurohormonal activity (SNS and RAAS)

• Controlled trials have shown long-term digoxin therapy:

- Reduces symptoms

- Increases exercise tolerance

- Decreases risk of HF progression

- Reduces hospitalization rates for decompensated HF

- Does not improve survival

RADIANCE Study. New Engl J Med 1993;329:1-7.The Digitalis Investigation Group. New Engl J Med 1997;336:525-33.

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Other Meds Frequently Prescribed

• Electrolyte supplements: Potassium and magnesium

supplementation as needed with monitoring of serum

electrolytes to assess response to therapy.

• Statins: Patients with HF often have co-morbid conditions that

necessitate the use of statin therapy (diabetes, coronary artery

disease, cerebrovascular disease, peripheral vascular disease).

Statin therapy should be prescribed based on current guidelines

for these conditions.

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Accreditation Agencies for HF Certification

• The Joint Commission Disease-specific Certificationoffers basic and advanced certification:

– For advanced certification, a center must already have achieved Get With The Guidelines Bronze Level and work towards meeting standards

• The Society of Chest Pain Centers:

– Accreditation that includes a collaborative approach providing resources, education, feedback towards improving gaps in processes of care.

• The Healthcare Accreditation Colloquium

– The Colloquium centers its approach around accreditation as an opportunity for improvement of relationships, processes, systems, and outcomes for HF patients.

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Quality Improvement

• Quality improvement is a process of purposeful change toward meeting accepted quality standards for a health care population.

• Quality improvement teams

– Employ quality of care performance indicators that are described in clinical practice guidelines

– Use data for measuring progress

– Ensure ways to evaluate and address gaps in the quality of care

– Repeat evaluations or audits over time to ensure the care level is maintained and continually evaluated for further improvement

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The Nurse’s Role Quality Improvement

• Know the indicators being used to measure quality in one’s work environment

• Be familiar with mechanisms to capture data and report on the quality indicators for HF (Core Measures)

• Participate in quality improvement meetings and projects• Identify disparities or gaps in clinical management of HF

patients.• Incorporate evidence-based practices and professional

guideline recommendations when managing patients with HF.

• Use a collaborative (interdisciplinary) framework when planning actions for quality improvement.

• Assist with achieving accreditation or certification for specialty HF services to gain recognition for quality improvement processes and improved outcomes.

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Measuring Outcomes• Structural indicators are those indicators that relate to the

organization and delivery of care

• Examples of structural indicators that may improve quality of HF care include:

– Telephone support and telemonitoring

– Electronic health records as a means of communication and data collection

– Access to providers- family practice, cardiologists, HF specialist

– Access to healthcare for minority/marginal or high risk groups (older patients, multiple co-morbid conditions, ethnic groups and women

– Mechanisms to support and evaluate patient adherence and health literacy

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Inpatient Process of Care Indicators

• Core Measures for HF as adopted by The Joint Commission and Centers for Medicare and Medicaid in the United States have been established as indicators for inpatient processes of care since May 2001.

– Documentation on the medical record that left ventricular systolic function (LVEF) was evaluated before arrival, during hospitalization, or is planned after discharge.

– HF patients with LVEF < 40% are prescribed an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) unless a contraindication is documented.

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Core Measures for HF

Discharge instructions are to be provided in writing to patients/caregivers at time of discharge from hospital addressing all of the following:

• Activity level

• Diet

• Discharge medications

• Follow-up appointment

• Weight monitoring

• What to do if symptoms worsen

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Get with the Guidelines-HF

• Developed by the American Heart Association

– offers educational opportunities, national and local recognition, and support with a data management tool for tracking clinical details for internal and external comparison.

– Hospitals can purchase the data management tool and manual.

– Clinical teams are supported to educate staff and implement care based on the latest HF guidelines.

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Hospital to Home (H2H)

• National quality improvement to reduce unnecessary readmissions for cardiovascular patients through national networking and learning initiatives

• H2H’s goal is to reduce all-cause readmission rates by 20% among patients discharged with HF or acute MI by December 2012

• Core concepts: medication management post-discharge, early follow-up, symptom management

• Although care that prevents readmission occurs largely outside hospitals, it starts in hospitals

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Institute for Healthcare Improvement (IHI)

• Offers education and tools for implementation of core processes for improving the treatment of HF.

• Tools and recommended steps for the “ideal transition home” focus on these four components:

– Enhanced admission assessment for post-discharge needs (e.g. caregivers, medication reconciliation).

– Enhanced teaching and learning – how to tailor patient/family education

– Patient and family-centered handoff communication (e.g. medication reconciliation, critical elements to communicate to families, physicians, and other involved agencies.

– Post-acute care follow-up – inclusion of home care or telephone follow-up for high or moderately high risk patients.

Documents

CHFN Review Part 3-1 - Oregon ACC 1 Heart Failure Certification Review Course Part 3 Ashley Moore-Gibbs, MSN, AGPCNP-BC, CHFN Objectives Review the hemodynamic patient profiles of