Systolic and Diastolic Heart Failure Barbara Brown, DNP, MSN, RN, ACNP-C, FNP Barbara Brown, DNP, MSN, RN, ACNP-C, FNP FOCUS Conference The Gaylord Opryland

Systolic and Diastolic Systolic and Diastolic Heart FailureHeart Failure

Barbara Brown, DNP, MSN, RN, ACNP-C, Barbara Brown, DNP, MSN, RN, ACNP-C, FNPFNP

FOCUS ConferenceFOCUS Conference

The Gaylord Opryland Hotel - Nashville, TNThe Gaylord Opryland Hotel - Nashville, TN

May 9, 2013May 9, 2013

Objectives of StudyObjectives of Study

Participants will identify current diagnostic and Participants will identify current diagnostic and testing methodologies for systolic and diastolic testing methodologies for systolic and diastolic heart failure applying best-practice strategies.heart failure applying best-practice strategies.

Participants will examine a strategy for Participants will examine a strategy for multidisciplinary management of care for multidisciplinary management of care for patients with systolic or diastolic heart failure and patients with systolic or diastolic heart failure and identify the benefits associated with utilizing this identify the benefits associated with utilizing this strategy in the care of these patients in strategy in the care of these patients in improving outcomes for heart failure patients.improving outcomes for heart failure patients.

Participants will identify the process for a heart Participants will identify the process for a heart failure patient in moving from hospital to home. failure patient in moving from hospital to home.

Heart Failure Heart Failure TerminologyTerminology Heart failureHeart failure is a global term for is a global term for

the physiological state in which the physiological state in which cardiac output is insufficient for the cardiac output is insufficient for the body's needs. Heart Failure is a body's needs. Heart Failure is a condition in which a problem with condition in which a problem with the structure or function of the heart the structure or function of the heart impairs its ability to supply sufficient impairs its ability to supply sufficient blood flow to meet the body's blood flow to meet the body's needs. needs.

Heart Failure Heart Failure PathophysiologyPathophysiologyHeart failure is caused by any condition which reduces the Heart failure is caused by any condition which reduces the efficiency of the myocardium leading to overload on theefficiency of the myocardium leading to overload on themyocardium. Over time the increased workload will myocardium. Over time the increased workload will

produceproducechanges to the heart:changes to the heart:

Reduced contractility, or force of contraction, due to overloading of the Reduced contractility, or force of contraction, due to overloading of the ventricle. ventricle.

A reduced stroke volume, as a result of a failure of systole, diastole or A reduced stroke volume, as a result of a failure of systole, diastole or both.both.

Reduced spare capacity. Reduced spare capacity. Increased heart rate, stimulated by increased sympathetic activity in Increased heart rate, stimulated by increased sympathetic activity in

order to maintain cardiac output. order to maintain cardiac output. Hypertrophy of the myocardium, caused by the terminally Hypertrophy of the myocardium, caused by the terminally

differentiated heart muscle fibers increasing in size in an attempt to differentiated heart muscle fibers increasing in size in an attempt to improve contractility.improve contractility.

Enlargement of the ventricles, contributing to the enlargement and Enlargement of the ventricles, contributing to the enlargement and spherical shape of the failing heart. spherical shape of the failing heart.

Heart Failure StatisticsHeart Failure Statistics

PrevalencePrevalence Heart failure (HF) affects an estimated 5.1 million Americans Heart failure (HF) affects an estimated 5.1 million Americans >> 20 years of age. 20 years of age. By 2013 the prevalence of HF will increase by 25%.By 2013 the prevalence of HF will increase by 25%. 400,000 new cases of heart failure are diagnosed in the United States annually.400,000 new cases of heart failure are diagnosed in the United States annually.

IncidenceIncidence One-percent of adults 50 to 60 years of age.One-percent of adults 50 to 60 years of age. Seventy-five percent of HF cases have antecedent hypertension. Ten-percent of adults 80 years of age or older.Ten-percent of adults 80 years of age or older.

Mortality and MorbidityMortality and Morbidity The lifetime risk for people with BP > 160/90 mmHg is double that of those The lifetime risk for people with BP > 160/90 mmHg is double that of those

persons with BP < 140/90 mmHgpersons with BP < 140/90 mmHg At 40 years of age, the lifetime risk of developing HF for both men and women is At 40 years of age, the lifetime risk of developing HF for both men and women is

1 in 5; a1 in 5; at 80 years of age, the lifetime risk of developing new HF is 20%. Most frequent cause of hospitalizations in the elderly and is responsible for 7 to Most frequent cause of hospitalizations in the elderly and is responsible for 7 to

12 percent of all hospital admissions.12 percent of all hospital admissions. Contributes to approximately 275,000 deaths every year.Contributes to approximately 275,000 deaths every year.

Categorization of Categorization of Heart FailureHeart FailureThere are many different ways to categorize

heart failure, including:

Which side of the heart involved (left heart failure versus right heart failure) Whether the abnormality is due to contraction (systolic dysfunction) or relaxation of the heart (diastolic ) Degree of functional impairment conferred by the abnormality (as in the NYHA

functional classification) Whether the problem is primarily increased venous back pressure (behind) the

heart, or failure to supply adequate arterial perfusion (in front of)

the heart (backward vs. forward failure) Whether the abnormality is due to low cardiac output with high systemic

vascular resistance or high cardiac output with low vascular resistance

(low-output heart failure vs. high-output heart failure)

Anatomy of the HeartAnatomy of the Heart

The heart is made up of four chambers. The left and right atrium collect the blood and the left and right ventricle pump the blood. The right side of the heart receives oxygen-depleted bloodfrom the body and pumps it to the lungs to be

replenished with oxygen. The left side receives oxygen-rich blood from the lungs and pumps it to the rest of the body.

Left-sided Heart Left-sided Heart FailureFailure

Left-sided heart failure or “forward” failureis the most common type of heart failure. Theleft ventricle is the main pumping chamber. When it fails, oxygen-rich blood is not pumped to the rest of the body; instead, it can back up into the left atrium and into the lungs, where it builds up. Left-sided heart failure causes fatigue because the body is not receiving enough blood and shortness of breath with orwithout exertion because of congestion in thelungs. A person may experience orthopnea andparoxysmal nocturnal dyspnea. Compromise in function can result in symptoms of poor systemic circulation such as dizziness, confusion and cool extremities at rest.

Left-sided Heart Left-sided Heart FailureFailure

SignsSigns Tachypnea Tachypnea Increased ''work'' of breathing (non-specific Increased ''work'' of breathing (non-specific

signs of respiratory distress). signs of respiratory distress). Rales or crackles, heard initially in the lung Rales or crackles, heard initially in the lung

bases, and when severe, throughout the lung bases, and when severe, throughout the lung fields suggest the development of pulmonary fields suggest the development of pulmonary edema (fluid in the alveoli). edema (fluid in the alveoli).

Cyanosis which suggests severe hypoxemia, Cyanosis which suggests severe hypoxemia, is a late sign of extremely severe pulmonary is a late sign of extremely severe pulmonary edema. edema.

Right-sided Heart Right-sided Heart FailureFailure

Right-sided heart failure or “backward” failureusually happens as a result of left-sided heart failure. As the failing left ventricle causes fluid tobuild up in the lungs, the right ventricle finds it harder to pump blood to the lungs to pick up oxygen. Right-sided heart failure can occur on its own, for example, when caused by lung disease (COPD) or heart valve disease. Right-sided heart failure can cause blood toback up in the veins, leading to swelling in the ankles, legs or belly, resulting in shortness ofbreath. In progressively severe cases, ascites and hepatomegaly may develop, leading to impaired liver function, jaundice and coagulopathy.Right-sided heart failure can cause fatigue when the LV doesn’t fill with enough blood and can’t supply the body withoxygen-rich blood.

Right-sided Heart Right-sided Heart FailureFailure

SignsSigns Peripheral edema Peripheral edema Ascites Ascites Hepatomegaly. Hepatomegaly. Jugular venous pressure is frequently assessed Jugular venous pressure is frequently assessed

as a marker of fluid status, which can be as a marker of fluid status, which can be accentuated by the hepatojugular reflux. accentuated by the hepatojugular reflux.

If the right ventricular pressure is increased, a If the right ventricular pressure is increased, a parasternal heave may be present, signifying parasternal heave may be present, signifying the compensatory increase in contraction the compensatory increase in contraction strength. strength.

Bi-Ventricular FailureBi-Ventricular Failure

Left sided ''forward'' failure overlaps Left sided ''forward'' failure overlaps with right sided ''backward'' failure. with right sided ''backward'' failure.

Most common cause of right-sided heart Most common cause of right-sided heart failure is left-sided heart failure, failure is left-sided heart failure, therefore, patients present with both therefore, patients present with both sets of signs and symptoms. sets of signs and symptoms.

Dullness of the lung fields to finger Dullness of the lung fields to finger percussion and reduced breath sounds percussion and reduced breath sounds at the bases of the lung may suggest at the bases of the lung may suggest the development of a pleural effusion the development of a pleural effusion and a more common sign of and a more common sign of biventricular failure. biventricular failure.

Types of Heart FailureTypes of Heart Failure

Classification of heart failure is based on which heart function or which side of the heart is most affected by the condition. Systolic heart failure – failure of contraction to – failure of contraction to

pump blood out of the chambers. This is measured by pump blood out of the chambers. This is measured by ejection fraction (EF) or the percentage of blood that ejection fraction (EF) or the percentage of blood that is ejected out of the ventricle. Normal is 50% or is ejected out of the ventricle. Normal is 50% or higher.higher.

Diastolic heart failureDiastolic heart failure – failure of relaxation to fill – failure of relaxation to fill the chambers with bloodthe chambers with blood

Heart failure may affect only the right ventricle Heart failure may affect only the right ventricle ((right-sided heart failureright-sided heart failure) or the left ventricle () or the left ventricle (left-left-

sided heart failuresided heart failure), or both. ), or both.

Systolic and Diastolic Systolic and Diastolic Heart FailureHeart FailureEach beat of the heart consists of contraction ( systole) and relaxation ( diastole). When the heart contracts, chambers of the heart (ventricles) pump out blood into the lungs and the rest of the body.When the heart relaxes and expands, the ventricles fill completely with blood.

Characteristics of Diastolic Heart Characteristics of Diastolic Heart Failure as Compared with Those of Failure as Compared with Those of Systolic Heart FailureSystolic Heart Failure

NYHA Functional NYHA Functional ClassificationClassification

Class Description

I (Mild) No limitation of physical activity - ordinary physical activity doesn't cause tiredness, heart palpitations, or shortness of breath

II (Mild) Slight limitation of physical activity, comfortable at rest, but ordinary physical activity results in tiredness, heart palpitations, or shortness of breath

III (Moderate

)

Marked or noticeable limitations of physical activity, comfortable at rest, but less than ordinary physical activity causes tiredness, heart palpitations, or shortness of breath

IV IV

(Severe)(Severe)

Severe limitation of physical activity, unable to carry out any physical activity without discomfort. Symptoms also present at rest. If any physical activity is undertaken, discomfort increases.

AHA/ACC 2009 - AHA/ACC 2009 - Staging System of Staging System of HeartHeartStageStage DescriptionDescription Examples

AA People at high risk for developing heart failure but without structural heart disease or symptoms of heart failure. Encompasses “pre heart failure” where intervention with management can overt

Progression to symptomsProgression to symptoms

CAD (coronary artery disease), CAD (coronary artery disease), diabetes, hypertension, metabolic diabetes, hypertension, metabolic syndrome, obesity, using syndrome, obesity, using cardiotoxins or alcohol, family cardiotoxins or alcohol, family history of cardiomyopathy, history of cardiomyopathy, cerebrovascular accident (CVA), cerebrovascular accident (CVA), personal history of rheumatic feverpersonal history of rheumatic fever

BB People with structural heart disease but without signs and symptoms of heart failure

NYHA Class INYHA Class I

Left ventricular hypertrophy (LVH) Left ventricular hypertrophy (LVH) or reduced left ventricular ejection or reduced left ventricular ejection fraction (LVEF), asymptomatic fraction (LVEF), asymptomatic valvular heart disease, previous MIvalvular heart disease, previous MI

CC People with structural heart disease with prior or current symptoms of heart failure

NYHA Class II and IIINYHA Class II and III

Known structural heart disease with dyspnea, fatigue, inability to exercise

DD People who have advanced heart failure and severe symptoms difficult to manage with standard treatment

NYHA Class IVNYHA Class IV

Marked symptoms at rest despite Marked symptoms at rest despite maximal medical therapy, with maximal medical therapy, with recurrent hospitalizationsrecurrent hospitalizations

Diagnostic Criteria – Diagnostic Criteria – Boston CriteriaBoston Criteria

Criterion Point value

Category I: history

Rest dyspnea 4

Orthopnea 4

Paroxysmal nocturnal dyspnea 3

Dyspnea while walking on level area 2

Dyspnea while climbing 1

Category II: physical examination

Heart rate abnormality (1 point if 91 to 110 beats per minute; 2 points if more than 110 beats per minute)

1 or 2

Jugular venous elevation (2 points if greater than 6 cm H2O; 3 points if greater than 6 cm H2O plus hepatomegaly or edema)

2 or 3

Lung crackles (1 point if basilar; 2 points if more than basilar) 1 or 2

Wheezing 3

Third heart sound 3

Category III: chest radiography

Alveolar pulmonary edema 4

Interstitial pulmonary edema 3

Bilateral pleural effusion 3

Cardiothoracic ratio greater than 0.50 3

Upper zone flow redistribution 2

The diagnosis of heart failure is classified as "definite" at a score of 8 to 12 points, "possible" at a score of 5 to 7 points, and "unlikely" at a score of 4 points or less.

Systolic Heart FailureSystolic Heart Failure

Etiologies of Systolic Etiologies of Systolic Heart FailureHeart Failure Coronary Artery Disease (65%)Coronary Artery Disease (65%) Idiopathic dilated cardiomyopathyIdiopathic dilated cardiomyopathy Alcohol/toxin-induced cardiomyopathyAlcohol/toxin-induced cardiomyopathy Infectious/inflammatory processInfectious/inflammatory process Familial dilated cardiomyopathyFamilial dilated cardiomyopathy Postpartum cardiomyopathyPostpartum cardiomyopathy Stress induced cardiomyopathyStress induced cardiomyopathy Endocrine/nutritional causesEndocrine/nutritional causes Iron overload cardiomyopathyIron overload cardiomyopathy Tachycardia mediated cardiomyopathyTachycardia mediated cardiomyopathy

Characteristics of Characteristics of Systolic Heart FailureSystolic Heart Failure More readily recognized. More readily recognized. Described as failure of the pump function of the heart. Described as failure of the pump function of the heart. Characterized by a decreased ejection fraction (less Characterized by a decreased ejection fraction (less

than 45%). than 45%). The strength of ventricular contraction is attenuated The strength of ventricular contraction is attenuated

and inadequate for creating an adequate stroke and inadequate for creating an adequate stroke volume volume resulting in inadequate cardiac output. resulting in inadequate cardiac output.

Caused by dysfunction or destruction of cardiac Caused by dysfunction or destruction of cardiac myocytes or their molecular components.myocytes or their molecular components.

Most common mechanism of damage is ischemia Most common mechanism of damage is ischemia causing infarction and scar formation causing infarction and scar formation dead dead myocytes are replaced by scar tissue myocytes are replaced by scar tissue decreased decreased function of myocardium causing wall motion function of myocardium causing wall motion abnormality. abnormality.

Characteristics of Characteristics of Systolic Heart FailureSystolic Heart Failure Since the ventricle is inadequately emptied, Since the ventricle is inadequately emptied,

ventricular end-diastolic pressure and volumes ventricular end-diastolic pressure and volumes increase affecting the atrium. increase affecting the atrium.

On the left side of the heart, the increased On the left side of the heart, the increased pressure is transmitted to the pulmonary pressure is transmitted to the pulmonary vasculature vasculature extravasation of fluid into the lung extravasation of fluid into the lung parenchyma extravasation of fluid into the lung parenchyma extravasation of fluid into the lung parenchyma parenchyma pulmonary edema. pulmonary edema.

On the right side of the heart, the increased On the right side of the heart, the increased pressure is transmitted to the systemic venous pressure is transmitted to the systemic venous circulation and systemic capillary beds circulation and systemic capillary beds extravassation of fluid into the tissues of target extravassation of fluid into the tissues of target organs and extremities organs and extremities dependent peripheral dependent peripheral edema. edema.

Ejection fraction drops below 40%.Ejection fraction drops below 40%.

Characteristics of Characteristics of Diastolic Heart FailureDiastolic Heart Failure Described as failure of the ventricle to Described as failure of the ventricle to

adequately relax and typically denotes a stiffer adequately relax and typically denotes a stiffer ventricular wall. ventricular wall.

Inadequate filling of the ventricle Inadequate filling of the ventricle results in results in an inadequate stroke volume.an inadequate stroke volume.

Failure of ventricular relaxation also results in Failure of ventricular relaxation also results in elevated end-diastolic pressures elevated end-diastolic pressures with with pulmonary edema in left heart failure and pulmonary edema in left heart failure and peripheral edema in right heart failure. peripheral edema in right heart failure.

Caused by processes that affect cardiac Caused by processes that affect cardiac remodeling. remodeling.

May be asymptomatic. May be asymptomatic.

Characteristics of Characteristics of Diastolic Heart FailureDiastolic Heart Failure Sensitive to increases in heart rate Sudden bouts of tachycardia (caused

simply by physiological responses to exertion, fever, or dehydration) can lead to flash edema.

Pathological tachyarrhythmias (e.g., Pathological tachyarrhythmias (e.g., atrial fibrillation with rapid ventricular atrial fibrillation with rapid ventricular response) may result in flash pulmonary response) may result in flash pulmonary edema. edema.

Diastolic function worsens with age even Diastolic function worsens with age even in individuals without ischemic heart in individuals without ischemic heart disease. disease.

Characteristics of Characteristics of Diastolic Heart FailureDiastolic Heart Failure Low stroke volumeLow stroke volume Reduced cardiac output despite a Reduced cardiac output despite a

normal ejection fractionnormal ejection fraction Limited exercise tolerance as a Limited exercise tolerance as a

result of elevated left ventricular result of elevated left ventricular diastolic and pulmonary venous diastolic and pulmonary venous pressure pressure reduction in lung reduction in lung compliance compliance increase in the increase in the work of breathingwork of breathing

Epidemiology of Diastolic Epidemiology of Diastolic Heart FailureHeart Failure

About one third of all patients with About one third of all patients with congestive heart failure have diastolic congestive heart failure have diastolic heart failureheart failure

Prevalence is highest in patients older Prevalence is highest in patients older than 75 years oldthan 75 years old

Mortality rate is about 5-8 % annually Mortality rate is about 5-8 % annually as compared to 10-15% among as compared to 10-15% among patients with systolic heart failurepatients with systolic heart failure

Mortality rate is directly related to age Mortality rate is directly related to age and the presence/absence of coronary and the presence/absence of coronary disease.disease.

Factors that Exacerbate Factors that Exacerbate Diastolic Heart FailureDiastolic Heart Failure

Uncontrolled hypertensionUncontrolled hypertension Atrial Fibrillation (AF)Atrial Fibrillation (AF) Non-compliance with or inappropriate Non-compliance with or inappropriate

discontinuation of medications for heart discontinuation of medications for heart failurefailure

Myocardial ischemiaMyocardial ischemia AnemiaAnemia Renal insufficiencyRenal insufficiency Use of nonsteroidal anti-inflammatory drugsUse of nonsteroidal anti-inflammatory drugs

(NSAIDS) or thiazolidinediones(NSAIDS) or thiazolidinediones Dietary indiscretion with over-indulgence in Dietary indiscretion with over-indulgence in

salty foodssalty foods

Diagnosis of Diastolic Diagnosis of Diastolic Heart FailureHeart Failure A clinical diagnosis based on the A clinical diagnosis based on the

finding of typical symptoms and finding of typical symptoms and signs of heart failure in a patient signs of heart failure in a patient who is shown to have normal left who is shown to have normal left ventricular ejection fraction and no ventricular ejection fraction and no valvular abnormalities on valvular abnormalities on echocardiogram according to the echocardiogram according to the American College of Cardiology American College of Cardiology (ACC) and the American Heart (ACC) and the American Heart Association (AHA).Association (AHA).

Management Principles for Management Principles for Patients with Diastolic Heart Patients with Diastolic Heart FailureFailure

Diuretics –use with caution; aggressive diuresis may result in serious hypotension given Diuretics –use with caution; aggressive diuresis may result in serious hypotension given

the steep curve of the left ventricular diastolic pressure in relation to volumethe steep curve of the left ventricular diastolic pressure in relation to volume

Management Goals of Management Goals of Diastolic Heart FailureDiastolic Heart Failure To reverse the consequences of To reverse the consequences of

diastolic dysfunction, i.e. venous diastolic dysfunction, i.e. venous congestion, exercise intolerance.congestion, exercise intolerance.

To eliminate or reduce the factor To eliminate or reduce the factor responsible for the diastolic responsible for the diastolic dysfunction.dysfunction.

Symptoms of Heart Symptoms of Heart FailureFailure

The Heart Failure Society of America coinedthe FACES mnemonic to help identify the main symptoms of heart failure:

Fatigue - Feeling tired and weak all the timeActivities limited - Difficulty doing usual activities like carrying groceriesChest congestion and persistent coughEdema or ankle swelling - Swollen ankles, feet, leg and belly Shortness of breath – Breathless while walking, sitting or lying down flat

Symptoms of Heart Symptoms of Heart Failure continuedFailure continued

Other symptoms of heart failure Other symptoms of heart failure include:include:

Sudden weight gain more than 2 pounds in 1 Sudden weight gain more than 2 pounds in 1 day or 5 pounds in 1 week day or 5 pounds in 1 week

Bulging of the veins in the neck Bulging of the veins in the neck Chest pain Chest pain A racing heartbeat A racing heartbeat Lack of appetiteLack of appetite Urination at nightUrination at night

The Reason Behind the The Reason Behind the SymptomsSymptoms

SymptoSymptomm

CauseCause

Shortness Shortness ofof

breathbreath

Blood returning to the heart backs up. This causes fluid to leak into the lungs, making it harder for you to breathe.

Persistent Persistent cough orcough or

wheezingwheezing

When fluid leaks into the lungs, it often causes a cough the lungs' When fluid leaks into the lungs, it often causes a cough the lungs' way of trying to remove the fluid. Some people also have wheezing way of trying to remove the fluid. Some people also have wheezing that mimics asthma. that mimics asthma.

EdemaEdema Because the heart isn't pumping effectively, blood and fluid collects Because the heart isn't pumping effectively, blood and fluid collects around the body. Gravity causes much of this fluid to collect in the around the body. Gravity causes much of this fluid to collect in the feet, ankles, and legs. feet, ankles, and legs.

Fatigue, Fatigue,

tirednesstirednessBecause the heart isn't pumping out enough blood to the body, Because the heart isn't pumping out enough blood to the body, blood is rationed out first to the most vital organs; all other organs blood is rationed out first to the most vital organs; all other organs have to work with a shortage of blood. Without enough oxygen-rich have to work with a shortage of blood. Without enough oxygen-rich blood, the body tires easily. blood, the body tires easily.

The Reason Behind the The Reason Behind the SymptomsSymptoms

SymptoSymptomm

CauseCause

Increased Increased

heart rateheart rateThe heart beats faster so that it can compensate for its weaker The heart beats faster so that it can compensate for its weaker pumping ability. pumping ability.

Weight gainWeight gain The buildup of excess fluid can cause sudden increase in weight. The buildup of excess fluid can cause sudden increase in weight.

Lack of Lack of

appetiteappetiteFluid backs up in the liver, causing the liver to enlarge so the Fluid backs up in the liver, causing the liver to enlarge so the stomach can't expand much. This makes you feel full after eating stomach can't expand much. This makes you feel full after eating small amounts of food.small amounts of food.

Nighttime Nighttime

urinationurinationAs the blood is pulled away from your kidneys during the day to As the blood is pulled away from your kidneys during the day to be used by other organs and tissues, less urine is produced. When be used by other organs and tissues, less urine is produced. When you lie down at night, the kidneys get more blood and produce you lie down at night, the kidneys get more blood and produce more urine. Some medications used to treat high more urine. Some medications used to treat high blood pressureblood pressure may also increase your urine output. may also increase your urine output.

Algorithm for Algorithm for Management of Heart Management of Heart FailureFailure

Stage A Therapy – At Risk for Stage A Therapy – At Risk for Development of Heart FailureDevelopment of Heart Failure

GoalsGoals DrugsDrugs Additional OptionsAdditional Options

Treat hypertensionTreat hypertension ACE inhibitors or ARBs in ACE inhibitors or ARBs in appropriate patients for appropriate patients for vascular disease and vascular disease and diabetesdiabetes

Treat lipid disordersTreat lipid disorders

Control metabolic Control metabolic syndromesyndrome

Encourage regular Encourage regular exercise and healthy exercise and healthy eatingeating

Encourage smoking Encourage smoking cessationcessation

Discourage alcohol Discourage alcohol intake and illicit drug useintake and illicit drug use

Stage B Therapy – Stage B Therapy – Structural Heart Structural Heart DiseaseDisease


All measures under Stage All measures under Stage A A

ACE inhibitors or ARBs in ACE inhibitors or ARBs in appropriate patientsappropriate patients

Devices in selective Devices in selective patients: Implantable patients: Implantable cardioverter-cardioverter-defibrillatorsdefibrillators

Beta blockers in Beta blockers in appropriate patientsappropriate patients

Stage C Therapy – Development Stage C Therapy – Development of Symptoms of Heart Failureof Symptoms of Heart Failure


All measures under Stage All measures under Stage A and Stage B A and Stage B

Routine use of ACE Routine use of ACE inhibitorsinhibitors

Devices in selective Devices in selective patients: Biventricular patients: Biventricular pacing, Implantable pacing, Implantable cardioverter-cardioverter-defibrillatorsdefibrillators

Restrict dietary sodium Restrict dietary sodium intakeintake

Routine use of Beta Routine use of Beta blockersblockers

To prevent and treat To prevent and treat myocardial ischemiamyocardial ischemia

Routine use of diuretics Routine use of diuretics for fluid retentionfor fluid retention

Drugs in selected Drugs in selected patients: Aldosterone patients: Aldosterone antagonists, ARBs, antagonists, ARBs, Digitalis, Digitalis, hydrolyzing/nitrateshydrolyzing/nitrates

Stage D Therapy - Refractory Stage D Therapy - Refractory Symptoms of Heart Failure at Symptoms of Heart Failure at RestRest


All measures under Stage All measures under Stage A, B and CA, B and C

Compassionate end of Compassionate end of life life

Decide appropriate level Decide appropriate level of careof care

Extraordinary Extraordinary measures (e.g., measures (e.g., chronic inotropes, chronic inotropes, experimental drugs or experimental drugs or surgery, heart surgery, heart transplant, permanent transplant, permanent mechanical support mechanical support (LVAD)(LVAD)

Diagnostic Algorithm Diagnostic Algorithm for Heart Failurefor Heart Failure

Persons suspected of heart failure

Physical ExamPhysical Exam

Consists of taking a complete set of vital signs.Consists of taking a complete set of vital signs. Assess for sudden weight gain.Assess for sudden weight gain. Check for edema of abdomen, arms, and legs.Check for edema of abdomen, arms, and legs. Check for jugular venous distention (JVD).Check for jugular venous distention (JVD). Using a stethoscope, listen to the heart for abnormal Using a stethoscope, listen to the heart for abnormal

or extra heart sounds, a rapid or irregular heart beat, or extra heart sounds, a rapid or irregular heart beat, displaced point of maximum impulse and for a displaced point of maximum impulse and for a murmur.murmur.

Listen for normal S1 and S2 and for abnormal sounds Listen for normal S1 and S2 and for abnormal sounds such as S3 or S4, murmurs, clicks, or rubs which could such as S3 or S4, murmurs, clicks, or rubs which could indicate heart pathology. indicate heart pathology.

Using a stethoscope listen to the lungs for rales or Using a stethoscope listen to the lungs for rales or crackles.crackles.

Physical Exam - Non Physical Exam - Non Invasive Hemodynamic Invasive Hemodynamic AssessmentAssessment

AssessmentAssessment RationaleRationale

Take vital signs:Take vital signs: Assess pulse for rhythm, Assess pulse for rhythm, strength and rate. Assess blood pressure. strength and rate. Assess blood pressure.

Blood pressureBlood pressure is determined by cardiac is determined by cardiac output, peripheral vascular resistance, output, peripheral vascular resistance, circulating blood volume, blood viscosity, and circulating blood volume, blood viscosity, and vessel elasticity. vessel elasticity.

Precordium:Precordium: Inspect the anterior chest for Inspect the anterior chest for heaves heaves and an increase in visible pulsatility. and an increase in visible pulsatility.

HeavesHeaves indicate ventricular hypertrophy due to indicate ventricular hypertrophy due to an increased workload. an increased workload.

Palpate the PMIPalpate the PMI (point of maximum impulse) (point of maximum impulse) for a normal 2+ pulse. for a normal 2+ pulse.

A A PMIPMI that is displaced down and to the left that is displaced down and to the left indicates ventricular hypertrophy which may be indicates ventricular hypertrophy which may be due to volume overload. An increase in force due to volume overload. An increase in force and duration of the pulse may indicate an and duration of the pulse may indicate an increase in pressure without volume overload. increase in pressure without volume overload.

Inspect the neckInspect the neck for jugular venous distention for jugular venous distention (JVD). (JVD).

Indicates Central Venous Pressure (CVP).Indicates Central Venous Pressure (CVP). Full distention as the patient sits at a 45 degree Full distention as the patient sits at a 45 degree angle indicates an increase in CVP. angle indicates an increase in CVP.

Auscultate and palpate Auscultate and palpate the carotid arteries the carotid arteries to assess arterial blood flow. to assess arterial blood flow.

A decrease in pulse amplitude indicates a A decrease in pulse amplitude indicates a decrease in stroke volume. decrease in stroke volume.

AssessAssess for for hepatojugular reflux.hepatojugular reflux. A positive hepatojugular reflux indicates heart A positive hepatojugular reflux indicates heart failure.failure.

Palpate the peripheral pulsesPalpate the peripheral pulses and check and check nailbed capillary refill which is normally less nailbed capillary refill which is normally less than 3 seconds.than 3 seconds.

Changes in pulses indicate a change in cardiac Changes in pulses indicate a change in cardiac output and tissue perfusion. output and tissue perfusion.

Physical Exam-Jugular Physical Exam-Jugular Venous DistentionVenous Distention

Man with congestive heart failure and marked jugular venous distension

Technique for Technique for Measuring Jugular Measuring Jugular Venous PressureVenous Pressure

Patient reclining with head elevated 45°. Measure elevation of neck veins abovethe sternal angle (Lewis Method). Add 5 cm to measurement since right atrium is 5 cm below the sternal angle. Normal CVP <= 8 cm H2O

ElectrophysiologyElectrophysiology

Electrocardiogram Electrocardiogram (ECG/EKG) is (ECG/EKG) is used to identify arrhythmias, used to identify arrhythmias, ischemic heart disease, right and ischemic heart disease, right and left ventricular hypertrophy, and left ventricular hypertrophy, and presence of conduction delay or presence of conduction delay or abnormalities (e.g. left bundle abnormalities (e.g. left bundle branch block).branch block).

An ECG may also diagnose acute An ECG may also diagnose acute myocardial ischemia or infarction (if myocardial ischemia or infarction (if ST depression or elevation are ST depression or elevation are present).present).

Blood testsBlood tests Electrolytes, measures of renal Electrolytes, measures of renal

function, liver function tests, thyroid function, liver function tests, thyroid function tests, a complete blood count, function tests, a complete blood count, and often C-reactive protein if infection and often C-reactive protein if infection is suspected. is suspected.

B-type natriuretic peptide (BNP).B-type natriuretic peptide (BNP). Cardiac markers (e.g., CKMB, troponin Cardiac markers (e.g., CKMB, troponin

I) if myocardial infarction suspected.I) if myocardial infarction suspected. N-terminal pro-BNP (NTproBNP).N-terminal pro-BNP (NTproBNP).

B-type Natriuretic B-type Natriuretic PeptidePeptide B-type Natriuretic PeptideB-type Natriuretic Peptide (BNP) is a (BNP) is a

substance secreted from the ventricles of the substance secreted from the ventricles of the heart in response to changes in pressure that heart in response to changes in pressure that occur when heart failure develops and occur when heart failure develops and worsens. worsens.

BNP in the blood increases when heart failure BNP in the blood increases when heart failure symptoms worsen, and decreases when the symptoms worsen, and decreases when the heart failure condition is stable. heart failure condition is stable.

In a recent study reported, BNP accurately In a recent study reported, BNP accurately detected heart failure 83% of the time and detected heart failure 83% of the time and reduced clinical indecision from 43% to 11%. reduced clinical indecision from 43% to 11%.

BNP are important in diagnosis and BNP are important in diagnosis and assessment of prognosis, in patients with HF.assessment of prognosis, in patients with HF.

B-type Natriuretic PeptideB-type Natriuretic PeptideResultsResults

BNP levels below 100 pg/mL indicate BNP levels below 100 pg/mL indicate no heart failure no heart failure

BNP levels of 100-300 suggest heart BNP levels of 100-300 suggest heart failure is present failure is present

BNP levels above 300 pg/mL indicate BNP levels above 300 pg/mL indicate mild heart failure mild heart failure

BNP levels above 600 pg/mL indicate BNP levels above 600 pg/mL indicate moderate heart failure. moderate heart failure.

BNP levels above 900 pg/mL indicate BNP levels above 900 pg/mL indicate severe heart failure. severe heart failure.

Note: The BNP level in a person with heart failure, even someone whose condition is stable, is higher than in a person with normal heart function.

Imaging Modalities-Imaging Modalities-EchocardiographyEchocardiography Echocardiography is commonly used to support a Echocardiography is commonly used to support a

clinical diagnosis of heart failure.clinical diagnosis of heart failure. Uses ultrasound to determine the stroke volume (SV Uses ultrasound to determine the stroke volume (SV

or the amount of blood in the heart that exits the or the amount of blood in the heart that exits the ventricles with each beat), the end-diastolic volume ventricles with each beat), the end-diastolic volume (EDV or the total amount of blood at the end of (EDV or the total amount of blood at the end of diastole).diastole).

Determines the SV in proportion to the EDV, a value Determines the SV in proportion to the EDV, a value known as the ''ejection fraction'' (EF). known as the ''ejection fraction'' (EF).

Identify valvular heart disease.Identify valvular heart disease. Assess the pericardium.Assess the pericardium. Can aid in deciding what treatments will help the Can aid in deciding what treatments will help the

patient.patient. Detect wall motion abnormality seen with myocardial Detect wall motion abnormality seen with myocardial

ischemia. ischemia.

EchocardiographyEchocardiography

Left: an echocardiogram of a normal heart. Right: an echocardiogram with a thickened left ventricle wall (Left ventricular hypertrophy or LVH), a sign of heart failure.

Abbreviations: LV=left ventricle; RV: right ventricle; LA=left atrium.

Left Ventricular Pressure -Left Ventricular Pressure -Volume Loops in Systolic and Volume Loops in Systolic and Diastolic DysfunctionDiastolic Dysfunction

Echocardiography – Echocardiography – Systolic DysfunctionSystolic Dysfunction

Two-dimensional echocardiogram showing a four-chambers view of theheart in a patient with systolic dysfunction. Left ventricle is dilated.

Abbreviations: LV = left ventricle; RV = right ventricle; RA = right atrium; LA = left atrium)

EchocardiographyEchocardiographyDiastolic DysfunctionDiastolic Dysfunction

Two-dimensional echocardiogram showing a four-chambers view of theheart in a patient with diastolic dysfunction. Left ventricle is hypertrophied.

Abbreviations: LV = left ventricle; RV = right ventricle; RA = right atrium; LA = left atrium)

EchocardiographyEchocardiographyDiastolic DysfunctionDiastolic Dysfunction Doppler echocardiography: measures the Doppler echocardiography: measures the

velocity of intracardiac blood flow.velocity of intracardiac blood flow. Diastolic flow from the left atrium and left Diastolic flow from the left atrium and left

ventricle across the mitral valve has two ventricle across the mitral valve has two components: the E wave, early diastolic filling components: the E wave, early diastolic filling and A wave, atrial contraction in late diastole.and A wave, atrial contraction in late diastole.

E wave velocity is influenced by both the rate E wave velocity is influenced by both the rate of early diastolic relaxation and the left atrial of early diastolic relaxation and the left atrial pressure.pressure.

Alterations in the pattern of E wave velocity Alterations in the pattern of E wave velocity reflects the degree of left ventricular diastolic reflects the degree of left ventricular diastolic dysfunction and prognosis.dysfunction and prognosis.

Patterns of Left Ventricular Patterns of Left Ventricular Diastolic Filling as Shown by Diastolic Filling as Shown by Standard Doppler EchocardiographyStandard Doppler Echocardiography

Imaging Modalities-Imaging Modalities-RadiographicRadiographic Chest X-raysChest X-rays in the compensated in the compensated

patient may show cardiomegaly.patient may show cardiomegaly. Chest X-rays in left ventricular Chest X-rays in left ventricular

failure may reveal evidence of failure may reveal evidence of vascular redistribution. vascular redistribution.

Pulmonary EdemaPulmonary Edema

Unilateral pulmonary edema in diastolic heart failure

Pulmonary CongestionPulmonary Congestion

Pulmonary congestion in cardiac failure

Imaging Modalities-Imaging Modalities- Stress TestingStress Testing Stress tests measure how your heart and blood Stress tests measure how your heart and blood

vessels respond to exertion.vessels respond to exertion. Exercise treadmill testing. Exercise treadmill testing. For those who are unable to walk a pharmacologic For those who are unable to walk a pharmacologic

agent may be given intravenously that stimulates your agent may be given intravenously that stimulates your heart similar to exercise.heart similar to exercise.

Nuclear stress test utilizes injected dye and a Nuclear stress test utilizes injected dye and a pharmacologic agent to stress the heart for pharmacologic agent to stress the heart for visualization of the heart.visualization of the heart.

Stress tests help to determine coronary artery Stress tests help to determine coronary artery disease. Stress tests also determine how well your disease. Stress tests also determine how well your body is responding to your heart's decreased pumping body is responding to your heart's decreased pumping effectiveness and can help guide long-term treatment effectiveness and can help guide long-term treatment decisions. decisions.

Cardiac Computerized Cardiac Computerized Tomography (CT) or Magnetic Tomography (CT) or Magnetic

Resonance Imaging (MRI).Resonance Imaging (MRI). Cardiac Computerized Cardiac Computerized

Tomography Tomography (CT)(CT) or or Magnetic Resonance Magnetic Resonance Imaging Imaging (MRI)(MRI) are used are used to to diagnose causes of heart diagnose causes of heart failure. The give a more failure. The give a more detailed look at the detailed look at the structure of the heart.structure of the heart.

AngiographyAngiography

Used to identify possibilities for Used to identify possibilities for revascularization through revascularization through percutaneous coronary percutaneous coronary intervention or bypass surgery. intervention or bypass surgery.

MonitoringMonitoring

Various measures are often used Various measures are often used to assess the progress of patients to assess the progress of patients being treated for heart failure. being treated for heart failure. These include fluid balance These include fluid balance (calculation of fluid intake and (calculation of fluid intake and excretion), monitoring body excretion), monitoring body weight which reflects fluid shifts. weight which reflects fluid shifts.

Clues for Differentiating Between Clues for Differentiating Between Systolic and Diastolic Dysfunction in Systolic and Diastolic Dysfunction in Patients with Heart FailurePatients with Heart Failure

Clues from the EvaluationClues from the Evaluation Systolic DysfunctionSystolic Dysfunction Diastolic DysfunctionDiastolic Dysfunction

HistoryHistory

HypertensionHypertension XXXX XXXXXX

Coronary Artery Disease*Coronary Artery Disease* XXXXXX XXXX

Diabetes mellitusDiabetes mellitus XXXXXX XXXX

Valvular heart disease*Valvular heart disease* XXXXXX ____

Physical ExaminationPhysical Examination

Third heard sound (S3) Third heard sound (S3) gallop* gallop*

XXXXXX XX

Fourth heart sound (S4) Fourth heart sound (S4) gallopgallop

XXXX XXXXXX

RalesRales XXXX XXXX

Jugular venous distentionJugular venous distention XXXX XX

EdemaEdema XXXX XX

Diplaced point of maximal Diplaced point of maximal impulse*impulse*

XXXX ____

Mitral regurgitation*Mitral regurgitation* XXXXXX XX

Clues for Differentiating Between Clues for Differentiating Between Systolic and Diastolic Dysfunction in Systolic and Diastolic Dysfunction in Patients with Heart Failure Patients with Heart Failure continuedcontinued

Clues from the Clues from the evaluationevaluation

Systolic DysfunctionSystolic Dysfunction Diastolic DysfunctionDiastolic Dysfunction

Chest RadiographChest Radiograph

Cardiomegaly*Cardiomegaly* XXXXXX XX

Pulmonary congestionPulmonary congestion XXXXXX XXXXXX

ElectrocardiogramElectrocardiogram

Q waveQ wave XXXX XX

Left ventricular Left ventricular hypertrophy*hypertrophy*

XX XXXXXX

EchocardiogramEchocardiogram

Decreased ejection Decreased ejection fraction*fraction*

XXXXXX ____

Dilated left ventricle*Dilated left ventricle* XXXX ____

Left ventricle hypertrophy*Left ventricle hypertrophy* XX XXXXXX

X = suggestive, the number of Xs reflects the relative weight; — = not suggestive.* and — Particularly helpful in distinguishing systolic from diastolic dysfunction in heart failure.

Algorithm - Pharmacological Algorithm - Pharmacological Management of Heart Management of Heart FailureFailure

Drugs to avoid in heart failure: NSAIDS, most calcium channel blockers (felodipine and amlodipine are likely safe), thiazolidinediones, most antiarrhythmics.

Initiation and Management of Initiation and Management of Angiotension-Converting Enzyme Angiotension-Converting Enzyme InhibitorInhibitor Assess patient’s volume status, serum Assess patient’s volume status, serum

electrolytes, and renal function before electrolytes, and renal function before initiation of therapy.initiation of therapy.

Do not start in patients with Do not start in patients with symptomatic hypotension, symptomatic hypotension, hyperkalemia, or severe renal disease.hyperkalemia, or severe renal disease.

Initiate at a low dose and titrate Initiate at a low dose and titrate upward every 2-4 weeks.upward every 2-4 weeks.

Repeat serum electrolytes and renal Repeat serum electrolytes and renal status in 1-2 weeks after initiation or status in 1-2 weeks after initiation or with dosage change.with dosage change.

Angiotension-Converting Angiotension-Converting Enzyme Inhibitor (ACEI)Enzyme Inhibitor (ACEI)

Contraindications include cardiogenic Contraindications include cardiogenic shock, angioneurotic edema, and shock, angioneurotic edema, and hyperkalemia.hyperkalemia.

Renal insufficiency is not a Renal insufficiency is not a contraindication; start low and monitor contraindication; start low and monitor renal function closely.renal function closely.

Heart Failure patients with severe renal Heart Failure patients with severe renal insufficiency and on dialysis should be insufficiency and on dialysis should be treated.treated.

To promote regression of left ventricular To promote regression of left ventricular hypertrophy.hypertrophy.

To treat hypertension.To treat hypertension.

Recommended Beta Recommended Beta Blockers and DosageBlockers and Dosage

DrugDrug Initial DoseInitial Dose Target DoseTarget Dose

Bisoprolol Bisoprolol 1.25 mg PO qd1.25 mg PO qd 10 mg PO qd10 mg PO qd

CarveidololCarveidolol 3.125 mg PO bid3.125 mg PO bid 25 mg PO bid25 mg PO bid

Metoprolol SuccinateMetoprolol Succinate 25 mg PO qd25 mg PO qd 200 mg PO qd200 mg PO qd

Bisoprolol is not approved for heart failure in the United States by The FDA.A maximum dose of Carveidolol 50 mg bid has been administered to patients with mild to moderate heart failure who weigh over 85 kg (187 lb).Metoprolol succinate 12.5 mg may be used in severe heart failure(25 mg cut in half) Contraindications to beta blockers: Symptomatic bradycardia, hypotension

( SBP below 80mmHg), signs of peripheral hypoperfusion (e.g., cold, clammy skin, cyanosis, oliguria, impaired mental status), carcinogenic shock, acute pulmonary edema, advanced heart block without pacemaker, reactive airway disease.

DigitalisDigitalis

Symptomatic improvement with Symptomatic improvement with reduced hospitalizations in patients reduced hospitalizations in patients with mild to moderate heart failure.with mild to moderate heart failure.

Less effective in women than in Less effective in women than in men.men.

Optimal target level is 0.6 to 0.9, Optimal target level is 0.6 to 0.9, above which there is an increase in above which there is an increase in mortality.mortality.

Drug interactions with amiodarone.Drug interactions with amiodarone.

Aldosterone Aldosterone AntagonistAntagonist Use cautiously in patients with creatinine Use cautiously in patients with creatinine

above 1.5 or potassium above 5.above 1.5 or potassium above 5. Avoid potassium and salt substitutes.Avoid potassium and salt substitutes. Monitor potassium and creatinine levels.Monitor potassium and creatinine levels. Limited study populations (e.g., NYHA Limited study populations (e.g., NYHA

class III and IV, post MI with reduced EF, class III and IV, post MI with reduced EF, and diabetes mellitus).and diabetes mellitus).

To reduce development of fibrosis.To reduce development of fibrosis.

Nonpharmacologic Nonpharmacologic Management - Sleep ApneaManagement - Sleep Apnea

Obstructive sleep apnea (OSA) Obstructive sleep apnea (OSA) worsens heart failure (HF).worsens heart failure (HF).

All patients with HF should be All patients with HF should be evaluated for sleep apnea.evaluated for sleep apnea.

Persons at risk for OSA should undergo Persons at risk for OSA should undergo polysomnography.polysomnography.

Periods of hypoxia in OSA worsen Periods of hypoxia in OSA worsen hypertension hypertension contributes to systolic contributes to systolic and diastolic dysfunction.and diastolic dysfunction.

Management Goals - Acute Management Goals - Acute Decompensation of Heart FailureDecompensation of Heart Failure

Immediate goal is to re-establish adequate Immediate goal is to re-establish adequate perfusion and oxygen delivery to end organs. perfusion and oxygen delivery to end organs.

Ensure that airway, breathing, and circulation Ensure that airway, breathing, and circulation are adequate.are adequate.

Immediate treatments involve combination of Immediate treatments involve combination of vasodilators such as nitroglycerin and diuretics vasodilators such as nitroglycerin and diuretics (e.g., furosemide), and possibly non invasive (e.g., furosemide), and possibly non invasive positive pressure ventilation (NIPPV). positive pressure ventilation (NIPPV).

Vasodilators (e.g., nitropresside, nitroglycerin, Vasodilators (e.g., nitropresside, nitroglycerin, or nesiritide).or nesiritide).

Inotropes (e.g., milrinone, dobutamine).Inotropes (e.g., milrinone, dobutamine).

Recommendations of Management Recommendations of Management of Concomitant Diseases in Patients of Concomitant Diseases in Patients with Heart Failurewith Heart Failure

Nitrates and beta-blockers in conjunction with Nitrates and beta-blockers in conjunction with diuretics for the treatment of angina in patients diuretics for the treatment of angina in patients with HF.with HF.

Coronary revascularization in patients who have Coronary revascularization in patients who have both HF and angina.both HF and angina.

Anticoagulants in patients with HF who have Anticoagulants in patients with HF who have paroxysmal or chronic atrial fibrillation or previous paroxysmal or chronic atrial fibrillation or previous thromboembolic event.thromboembolic event.

Control of the ventricular response in patients Control of the ventricular response in patients with HF and atrial fibrillation with a beta-blocker with HF and atrial fibrillation with a beta-blocker (amiodarone, if BB is contraindicated or not (amiodarone, if BB is contraindicated or not tolerated).tolerated).

Beta-adrenergic in patients with HF to reduce the Beta-adrenergic in patients with HF to reduce the risk of sudden death. risk of sudden death.

Management Goals - Management Goals - Chronic ManagementChronic Management Goals are to prevent the development of acute decompensated heart Goals are to prevent the development of acute decompensated heart

failure, to counteract the effects of cardiac remodeling, and to minimize failure, to counteract the effects of cardiac remodeling, and to minimize the patient’s symptoms. the patient’s symptoms.

Pharmacologic agents (e.g., oral loop diuretics, beta blockers, ACE Pharmacologic agents (e.g., oral loop diuretics, beta blockers, ACE inhibitors or ARBs, vasodilators, and in severe cardiomyopathy inhibitors or ARBs, vasodilators, and in severe cardiomyopathy aldosterone receptor antagonists).aldosterone receptor antagonists).

Behavioral modification (e.g., dietary modifications, exercise as tolerated Behavioral modification (e.g., dietary modifications, exercise as tolerated and smoking cessation).and smoking cessation).

To prevent and treat myocardial ischemia (e.g., revascularization via To prevent and treat myocardial ischemia (e.g., revascularization via percutaneous techniques or coronary artery bypass grafting (CABG).percutaneous techniques or coronary artery bypass grafting (CABG).

With severe cardiomyopathy, implantation of an automatic implantable With severe cardiomyopathy, implantation of an automatic implantable cardioverter-defibrillator (AICD). cardioverter-defibrillator (AICD).

A select population may benefit from ventricular resynchronization. A select population may benefit from ventricular resynchronization. In select cases, cardiac transplantation can be considered or left In select cases, cardiac transplantation can be considered or left

ventricular assist device (LVAD).ventricular assist device (LVAD). Palliative care and hospice in those with Stage D heart failure.Palliative care and hospice in those with Stage D heart failure.

Ventricular Assist Ventricular Assist DeviceDevice

A ventricular assist device (VAD) is an implantable mechanical pump that helps pump blood from the ventriclesto the rest of your body. VADs are used in people who have weakenedhearts or heart failure. A left ventricular assist device (LVAD) is implanted under the skin. It pumps blood from the left ventricle of the heart to the body. A control unit andbattery pack are worn outside the body and are connected to the LVAD through a port in the skin. VADs are implanted as a bridge to heart transplant or long-term treatmentFor heart failure and not a good candidate for a heart transplant.

Heart Failure Heart Failure PrognosisPrognosisThe The 'EFFECT rule''EFFECT rule' is a clinical prediction rule for is a clinical prediction rule for

prognosing acuteprognosing acuteheart failure, identifying those at low risk of death during heart failure, identifying those at low risk of death during hospitalization or within 30 days of hospitalization. Easy hospitalization or within 30 days of hospitalization. Easy

methodsmethodsfor identifying low risk patients are: for identifying low risk patients are: ADHERE TreeADHERE Tree rule rule indicates that patients with blood indicates that patients with blood

urea nitrogen < 43 mg/dl and systolic blood pressure urea nitrogen < 43 mg/dl and systolic blood pressure at least 115 mm Hg have less than 10% chance of at least 115 mm Hg have less than 10% chance of inpatient death or complications. inpatient death or complications.

BWH ruleBWH rule indicates that patients with systolic blood indicates that patients with systolic blood pressure over 90 mm Hg, respiratory rate of 30 or less pressure over 90 mm Hg, respiratory rate of 30 or less breaths per minute, serum sodium over 135 mmol/L, breaths per minute, serum sodium over 135 mmol/L, no new ST-T wave changes have less than 10% no new ST-T wave changes have less than 10% chance of inpatient death or complications. chance of inpatient death or complications.

Heart Failure Heart Failure PrognosisPrognosis The The cardiopulmonary exercise testingcardiopulmonary exercise testing (CPX (CPX

testing) is used to assess prognosis in testing) is used to assess prognosis in advanced heart failure patients . CPX testing is advanced heart failure patients . CPX testing is usually required prior to heart transplantation usually required prior to heart transplantation as an indicator of prognosis. Cardiopulmonary as an indicator of prognosis. Cardiopulmonary exercise testing involves measurement of exercise testing involves measurement of exhaled oxygen and carbon dioxide during exhaled oxygen and carbon dioxide during exercise. The peak oxygen consumption (VO2 exercise. The peak oxygen consumption (VO2 max) is used as an indicator of prognosis. As a max) is used as an indicator of prognosis. As a general rule, a VO2 max less than 12-14 general rule, a VO2 max less than 12-14 cc/kg/min indicates a poorer survival and cc/kg/min indicates a poorer survival and suggests that the patient may be a candidate suggests that the patient may be a candidate for a heart transplant. Patients with a VO2 for a heart transplant. Patients with a VO2 max<10 cc/kg/min have clearly poorer max<10 cc/kg/min have clearly poorer prognosis. prognosis.

Facts and ComparisonsFacts and Comparisons

Women are less likely than men to have systolic heart failure Women are less likely than men to have systolic heart failure Symptoms of systolic heart failure are less severe in women Symptoms of systolic heart failure are less severe in women

than in menthan in men Men have double the risk of developing blood-pumping (systolic) Men have double the risk of developing blood-pumping (systolic)

problems compared with womenproblems compared with women In women the pumping chamber wall thickens but the pumping In women the pumping chamber wall thickens but the pumping

chamber itself doesn't enlarge; in men, the chamber stretches chamber itself doesn't enlarge; in men, the chamber stretches and enlarges but the wall doesn't thicken, leading to reduced and enlarges but the wall doesn't thicken, leading to reduced blood-pumping function.blood-pumping function.

Women usually have better blood-pumping function and a Women usually have better blood-pumping function and a higher ejection fraction higher ejection fraction

Women are more likely to have diastolic heart failure, in which Women are more likely to have diastolic heart failure, in which the thickened wall can't relax for the chamber to expand and fill the thickened wall can't relax for the chamber to expand and fill with enough blood. with enough blood.

Women with long-term systolic heart failure are more likely than Women with long-term systolic heart failure are more likely than men to have symptoms such as swollen ankles, elevated jugular men to have symptoms such as swollen ankles, elevated jugular venous pressure and shortness of breath resulting from fluid venous pressure and shortness of breath resulting from fluid buildup in the lungs buildup in the lungs

JCAHO Core Performance JCAHO Core Performance Measures for Heart Measures for Heart FailureFailurePerformance MeasurePerformance MeasureHF-1: Discharged patients with heart failure with written instructions or education HF-1: Discharged patients with heart failure with written instructions or education materials given to the patient or caregiver at discharge or during the hospital materials given to the patient or caregiver at discharge or during the hospital stay that address all of the following: activity level, diet, discharge medications, stay that address all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, what to do if symptoms worsen.follow-up appointment, weight monitoring, what to do if symptoms worsen.

HF-2: Patients with heart failure with documentation in the hospital record that LV HF-2: Patients with heart failure with documentation in the hospital record that LV function was assessed before arrival or during hospitalization or that it is planned function was assessed before arrival or during hospitalization or that it is planned after discharge.after discharge.

HF-3: Patients with heart failure with left ventricular systolic dysfunction (LVSD) HF-3: Patients with heart failure with left ventricular systolic dysfunction (LVSD) and without ACE inhibitor contraindications who are prescribed an ACE inhibitor and without ACE inhibitor contraindications who are prescribed an ACE inhibitor at discharge.at discharge.

HF-4: Patients with heart failure with a history of smoking cigarettes who are HF-4: Patients with heart failure with a history of smoking cigarettes who are given smoking cessation counseling during the hospital stay.given smoking cessation counseling during the hospital stay.

JCAHO identified standardized, evidence based performance measures “Core Measures” for adultpatients admitted with a main diagnosis of HF. The Core Measures support the HF Guidelinesdefined by the ACC/AHA.

Abbreviations: JCAHO=Joint Commission on Accreditation of Healthcare Organizations; HF= heart failure; LVSD= left ventricular systolic dysfunction; ACE= angiotension converting enzyme

Case Vignette Number Case Vignette Number 1: Heart Failure1: Heart Failure An 80 year old woman with a past An 80 year old woman with a past

medical history of hypertension medical history of hypertension and type 2 diabetes is and type 2 diabetes is hospitalized with progressive hospitalized with progressive exertional dyspnea and exertional dyspnea and orthopnea. orthopnea.

Case Vignette Number 1: Case Vignette Number 1: Physical Exam and Physical Exam and DiagnosticsDiagnostics Her examination reveals an elevated Her examination reveals an elevated

jugular venous pressure to the jaw, jugular venous pressure to the jaw, pitting peripheral edema, warm pitting peripheral edema, warm extremities, normal blood pressure extremities, normal blood pressure and clear mental status. and clear mental status.

She is treated with a loop diuretic. She is treated with a loop diuretic. After four days of treatment she After four days of treatment she appears euvolemic with a JVP of 7 cm appears euvolemic with a JVP of 7 cm H2O. Her serum creatinine has risen H2O. Her serum creatinine has risen from 1.6 mg/dL to 2.3 mg/dL since from 1.6 mg/dL to 2.3 mg/dL since admission.admission.

Case Vignette Number Case Vignette Number 1: Facts1: Facts Each of the following statements

about this patient’s condition is correct EXCEPT:

A.A. Diabetes and hypertension predispose to the Diabetes and hypertension predispose to the development of cardiorenal syndrome.development of cardiorenal syndrome.

B.B. Worsening renal function during hospitalization for acute Worsening renal function during hospitalization for acute heart failure is an important predictor of early hospital heart failure is an important predictor of early hospital readmission and mortality.readmission and mortality.

C.C. Decreased renal venous pressure contributes to the Decreased renal venous pressure contributes to the cardiorenal syndrome.cardiorenal syndrome.

D.D. High-dose loop diuretic therapy activates High-dose loop diuretic therapy activates neurohormones that contribute to the cardiorenal neurohormones that contribute to the cardiorenal syndrome.syndrome.

E.E. A disproportionate rise in blood urea nitrogen compared A disproportionate rise in blood urea nitrogen compared with serum creatinine is a sign of renal hypoperfusion.with serum creatinine is a sign of renal hypoperfusion.

Case Vignette Number Case Vignette Number 2: Heart Failure2: Heart Failure A 68 year old woman with long-standing A 68 year old woman with long-standing

hypertension presents to the emergency hypertension presents to the emergency room complaining of progressive room complaining of progressive exertional dyspnea and fatigue over the exertional dyspnea and fatigue over the last few months. She has noticed that last few months. She has noticed that her shoes are too tight due to ankle her shoes are too tight due to ankle edema and sleeps in recliner at night edema and sleeps in recliner at night cause lying on one pillow causes a cause lying on one pillow causes a cough. She denies any chest discomfort cough. She denies any chest discomfort or palpitations. pain. Current or palpitations. pain. Current medications include hydrochlorathiazide medications include hydrochlorathiazide (HCTZ) and atenolol. (HCTZ) and atenolol.

Case Vignette Number 2: Case Vignette Number 2: Physical Exam and Physical Exam and DiagnosticsDiagnostics On examination, she is overweight with a HR of On examination, she is overweight with a HR of

70 BPM, respirations 20, and BP 170/90mmHg. 70 BPM, respirations 20, and BP 170/90mmHg. The jugular venous pressure is 14 cm H2O. The jugular venous pressure is 14 cm H2O. There are basilar rales over the lower third of There are basilar rales over the lower third of the lung fields. The cardiac exam reveals normal the lung fields. The cardiac exam reveals normal S1, physiological split S2 and S4 gallop. There is S1, physiological split S2 and S4 gallop. There is a loud S4 and moderately loud S3. The is no a loud S4 and moderately loud S3. The is no audible murmur. There is bilateral pitting edema audible murmur. There is bilateral pitting edema to midcalf.to midcalf.

The chest radiograph shows a normal cardiac The chest radiograph shows a normal cardiac silhouette with bilateral pleural effusions with silhouette with bilateral pleural effusions with mild pulmonary edema. The ECG shows voltage mild pulmonary edema. The ECG shows voltage criteria consistent with LV hypertrophy. A 2 D criteria consistent with LV hypertrophy. A 2 D echocardiography reveals concentric LV echocardiography reveals concentric LV hypertrophy. Her EF is estimated at 70%.hypertrophy. Her EF is estimated at 70%.

Case Vignette Number Case Vignette Number 2: Treatment Options2: Treatment Options Which of the following

pharmacologic agents has been shown to improve survival in this condition?

A.A. DigoxinDigoxinB.B. PerindoprilPerindoprilC.C. VerapamilVerapamilD.D. CandesartanCandesartanE.E. None of the aboveNone of the above

Case Vignette Number Case Vignette Number 3: Heart Failure3: Heart Failure A 52 year old businessman presents to A 52 year old businessman presents to

the office complaining of increasing the office complaining of increasing fatigue and SOA. He sleeps on 3 pillows fatigue and SOA. He sleeps on 3 pillows at night. He denies any chest or at night. He denies any chest or pleuritic pain. Current medications pleuritic pain. Current medications include HCTZ 25 mg and atenolol 50 mg include HCTZ 25 mg and atenolol 50 mg daily, for hypertension of 10 years, daily, for hypertension of 10 years, controlled. Social history includes ½ controlled. Social history includes ½ PPD of tobacco use, drinks whisky PPD of tobacco use, drinks whisky socially and 2 martinis daily. Family socially and 2 martinis daily. Family history noncontributory for CAD.history noncontributory for CAD.

Case Vignette Number 3: Case Vignette Number 3: Physical Exam and Physical Exam and DiagnosticsDiagnostics His physical exam reveals HR of 104 BPM, His physical exam reveals HR of 104 BPM,

respirations 20, and BP 134/84mmHg. There respirations 20, and BP 134/84mmHg. There are basilar rales over the lower third of the are basilar rales over the lower third of the lung fields. The apical impulse is laterally lung fields. The apical impulse is laterally displaced and sustained. S1 and S2 are displaced and sustained. S1 and S2 are normal. There is a loud S4 and moderately normal. There is a loud S4 and moderately loud S3. Present is a grade 2/6 holosystolic loud S3. Present is a grade 2/6 holosystolic murmur that radiates to the axilla. There is murmur that radiates to the axilla. There is trace pedal edema.trace pedal edema.

The chest radiograph shows left ventricular The chest radiograph shows left ventricular (LV) enlargement. The ECG is consistent with (LV) enlargement. The ECG is consistent with LV hypertrophy. LV hypertrophy.

Case Vignette Number Case Vignette Number 3: Differential 3: Differential DiagnosisDiagnosis The most likely cause for

this man’s heart failure is:

A.A. HypertensionHypertension

B.B. Alcoholic cardiomyopathyAlcoholic cardiomyopathy

C.C. Coronary atherosclerosisCoronary atherosclerosis

D.D. Hypertrophic cardiomyopathyHypertrophic cardiomyopathy

E.E. Excessive beta-blocker dosageExcessive beta-blocker dosage

Question (1)Question (1)

All of the following statements about heart failure are true EXCEPT.A.A. Over the past decade, the incidence and Over the past decade, the incidence and

prevalence of HF has increased.prevalence of HF has increased.B.B. HF occurs in 10% of patients older than age HF occurs in 10% of patients older than age

75 years but only in 1% to 2% of patients ages 75 years but only in 1% to 2% of patients ages 45 to 54 years.45 to 54 years.

C.C. Orthopnea is a symptom that is specific for Orthopnea is a symptom that is specific for the diagnosis of heart failure.the diagnosis of heart failure.

D.D. Pulses alternans occurs more commonly in Pulses alternans occurs more commonly in systolic than diastolic HF.systolic than diastolic HF.

E.E. HF with preserved EF is more common in HF with preserved EF is more common in women than in men.women than in men.


Each of the following statements about physical findings in HF is true EXCEPT:

Hydrothorax in heart failure is most often bilateral, but when unilateral is usually confined to the right side

The absence of pulmonary rales on examination excludes the presence of an elevated pulmonary capillary pressure

Hepatomegaly frequently precedes the development of overt peripheral edema


Which of the following conditions is likely to

precipitate symptomatic HF in patients with

previously compensated left ventricular contractile dysfunction?A.A. Atrial fibrillationAtrial fibrillationB.B. Marked sinus bradycardiaMarked sinus bradycardiaC.C. Atrioventricular dissociationAtrioventricular dissociationD.D. Right ventricular apical pacingRight ventricular apical pacingE.E. All of the aboveAll of the above


All of the following questions about diuretics in All of the following questions about diuretics in HF are true except:HF are true except:

A.A. Mannitol is an effective diuretic in cardiac Mannitol is an effective diuretic in cardiac surgical patients with decompensated heart surgical patients with decompensated heart failurefailure

B.B. Carbonic anhydrase inhibitors improve the Carbonic anhydrase inhibitors improve the alkalemia caused by other diuretic agentsalkalemia caused by other diuretic agents

C.C. Aldosterone receptor antagonists may cause Aldosterone receptor antagonists may cause clinically significant hyperkalemiaclinically significant hyperkalemia

D.D. Loop diuretics often result in hypokalemia and Loop diuretics often result in hypokalemia and metabolic alkalosismetabolic alkalosis

E.E. The effectiveness of loop diuretic agents is The effectiveness of loop diuretic agents is reduced by nonsteroidal anti-inflammatory reduced by nonsteroidal anti-inflammatory drugsdrugs


Each of the following statements therapy of patients

with LV dysfunction is true EXCEPT:A. Amiodarone consistently reduces mortality in patients

with Class II or Class III heart failureB. Implantation of a cardiovertor-defibrillator is indicated in

patients with the combination of LV dysfunction and unexplained syncope or resuscitated cardiac arrest

C. Patients with LV dysfunction and a transient or correctable cause of ventricular tachycardia remain at high risk for sudden death

D. Prophylactic implantation of a cardiovertor-defibrillator is effective in reducing mortality in patients with CAD and severe LV dysfunction

E.E. Use of dronedarone in patients with moderate or severe Use of dronedarone in patients with moderate or severe heart failure is associated with increased mortalityheart failure is associated with increased mortality

Question (6) Question (6)

Each of the following statements regardingtherapy for systolic HF is correct EXCEPT:

A.A. Digoxin therapy decreases hospitalizations and Digoxin therapy decreases hospitalizations and mortality in patients with chronic heart failure.mortality in patients with chronic heart failure.

B.B. ACE inhibitors improve survival in HF more than the ACE inhibitors improve survival in HF more than the combination of hydralazine plus isosorbide dinitratecombination of hydralazine plus isosorbide dinitrate

C.C. ARBs provide morbidity and mortality benefits ARBs provide morbidity and mortality benefits comparable with ACE inhibitors in patients with HF.comparable with ACE inhibitors in patients with HF.

D.D. Spironolactone reduces mortality in patients with Class Spironolactone reduces mortality in patients with Class III to IV heart failure symptoms. The aldosterone III to IV heart failure symptoms. The aldosterone antagonist eplerenone reduces mortality in patients antagonist eplerenone reduces mortality in patients with Class II to III heart failure.with Class II to III heart failure.


All of the following statements about acuteheart failure are correct EXCEPT:A.A. Most patients with acute HF present with Most patients with acute HF present with

normal or elevated blood pressure.normal or elevated blood pressure.B.B. Milrinone does not improve in-hospital Milrinone does not improve in-hospital

mortality.mortality.C.C. Serum vasopressin levels are elevated in Serum vasopressin levels are elevated in

acute HF and contribute to hyponatremia, a acute HF and contribute to hyponatremia, a marker of poor prognosis.marker of poor prognosis.

D.D. Tolvaptan, an argitine vasopressin antagonist, Tolvaptan, an argitine vasopressin antagonist, reduces the risk of death and heart failure reduces the risk of death and heart failure rehospitalization.rehospitalization.

E.E. Noninvasive ventilation in patients with acute Noninvasive ventilation in patients with acute pulmonary edema does not reduce short-term pulmonary edema does not reduce short-term mortality compared with O2 alone.mortality compared with O2 alone.

Question (8) Question (8)

True statements about cardiac physical findings

in patients with HF include all of the following

EXCEPT:A.A. Cardiomegaly is usually absent in primary restrictive Cardiomegaly is usually absent in primary restrictive

cardiomyopathy.cardiomyopathy.B.B. Elevated jugular venous pressure and an S4 gallop in Elevated jugular venous pressure and an S4 gallop in

patients with heart failure are each associated with patients with heart failure are each associated with poor prognosis. poor prognosis.

C.C. Pulsus alternans results from variation of the stroke Pulsus alternans results from variation of the stroke volume, likely owing to incomplete recovery of volume, likely owing to incomplete recovery of contracting myocardial cells.contracting myocardial cells.

D.D. Low-grade fever may occur in advanced HF in the Low-grade fever may occur in advanced HF in the absence of underlying infection.absence of underlying infection.

E.E. Sleep-disordered breathing is common in patients with Sleep-disordered breathing is common in patients with HF.HF.


All of the following statements about All of the following statements about natriuretic peptides are true EXCEPT:natriuretic peptides are true EXCEPT:A.A. Circulating levels of both atrial natriuretic peptide Circulating levels of both atrial natriuretic peptide

and brain natriuretic peptide (BNP) are elevated in and brain natriuretic peptide (BNP) are elevated in patients with heart failure.patients with heart failure.

B.B. Elevated plasma BNP levels predict adverse Elevated plasma BNP levels predict adverse outcomes in patients with acute coronary outcomes in patients with acute coronary syndromes.syndromes.

C.C. Plasma BNP level is useful in distinguishing cardiac Plasma BNP level is useful in distinguishing cardiac from noncardiac causes of dyspnea in the ER setting.from noncardiac causes of dyspnea in the ER setting.

D.D. Prohormone BNP is cleaved into the biologically Prohormone BNP is cleaved into the biologically inactive N-terminal (NT) proBNP and biologically inactive N-terminal (NT) proBNP and biologically active BNP.active BNP.

E.E. Circulating levels of BNP and NT-proBNP levels Circulating levels of BNP and NT-proBNP levels decrease with age and worsening renal function.decrease with age and worsening renal function.


Each of the following statements concerning therapy Each of the following statements concerning therapy of of

patients with left ventricular (LV) dysfunction is true patients with left ventricular (LV) dysfunction is true EXCEPT:EXCEPT:A.A. Amiodarone consistently reduces mortality in patients with Amiodarone consistently reduces mortality in patients with

Class II or III heart failure.Class II or III heart failure.B.B. Implantation of a cardioverter-defirillator is indicated in Implantation of a cardioverter-defirillator is indicated in

patients with the combination of LV dysfunction and patients with the combination of LV dysfunction and unexplained syncope or resuscitated cardiac arrest.unexplained syncope or resuscitated cardiac arrest.

C.C. Patients with LV dysfunction and transient or correctable Patients with LV dysfunction and transient or correctable cause of ventricular tachycardia remain at high risk of cause of ventricular tachycardia remain at high risk of sudden death.sudden death.

D.D. Prophylactic implantation of a cardioverter-defirillator is Prophylactic implantation of a cardioverter-defirillator is effective in reducing mortality in patients with coronary effective in reducing mortality in patients with coronary artery disease and severe LV dysfunction.artery disease and severe LV dysfunction.

E.E. Use of dronedarone in patients with moderate or severe Use of dronedarone in patients with moderate or severe heart failure is associated with increased mortality.heart failure is associated with increased mortality.

ReferencesReferences

Jessup, M., et al. (2009). 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation 119 (1977-2016). Retrieved from http://circ.ahajournals.org/content/119/14/1977.full.pdf

Joint Commission on Accreditation of Healthcare Organizations. (2013). Core measure sets for heart failure. Retrieved from http://www.jointcommission.org/heart_failure

Cannon, C., & O’Gara, P. (2007). Critical Pathways in Cardiovascular Medicine. In C. Cannon & P. O’Gara (Eds.). Heart failureHeart failure (pp. 190-223). Lippincott Williams & Wilkins (pp. 190-223). Lippincott Williams & Wilkins

Braunwald,. E. et al. (2008). In Braunwald’s Heart Disease: A Braunwald,. E. et al. (2008). In Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. In E. Braunwald (Ed.). Textbook of Cardiovascular Medicine. In E. Braunwald (Ed.). Mechanisms of cardiac contraction and relaxationMechanisms of cardiac contraction and relaxation: : Heart Heart failurefailure (pp. 509-724). Saunders Elsevier (pp. 509-724). Saunders Elsevier

Documents

Systolic and Diastolic Heart Failure Barbara Brown, DNP, MSN, RN, ACNP-C, FNP Barbara Brown, DNP, MSN, RN, ACNP-C, FNP FOCUS Conference The Gaylord Opryland