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Tim Sutton, Cardiologist Counties-Manukau DHB and Auckland Heart Group Exertional dyspnoea Orthopnea Paroxysmal nocturnal dyspnoea Oedema Third heart sound Elevated JVP Basal rales Swollen ankles Temporal trend Effort tolerance – NYHA classification Functional class Symptoms I No limitation of physical activity : II Slight limitation of physical activity : III Marked limitation of physical activity : IV Unable to carry on any physical activity without discomfort : Ordinary physical activity does not cause undue breathlessness, fatigue or palpitations Comfortable at rest, but ordinary physical activity does not cause undue breathlessness, fatigue or palpitations Comfortable at rest, but less than ordinary physical activity does not cause undue breathlessness, fatigue or palpitations Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased ECG Chest X-ray Nt-proBNP : ◦ best done pre diuretic Rx / good renal function “Baseline bloods” ◦ FBC, U+Es, Glu, LFTs, INR, Albumen, TFTs and ferritin 1) Assess LV size and function ◦ Systolic and diastolic ◦ Regional vs global 2) Assess LV wall thickness 3) Assess valve function 4)Assess RV function Dilated heart Normal size Preserved EF Reduced EF Above 50-55% Mild 40-50% Moderate 30-40% Under 30% severe Under 20% very severe Regional Gobal Symptoms typical of HF Signs of typical HF Reduced EF Symptoms typical of HF Signs of typical of HF Normal of mildly reduced EF and LV NOT dilated Relevant structural heart disease (LVH / LA enlargement) and / or diastolic dysfunction Sudden decompensation ◦ Patient often euvolaemic – right amount of fluid, just in the wrong place ◦ Transient rise in left atrial pressure causing lungs to flood with fluid (acute pulmonary oedema) Sub-acute / chronic decompensation Did the patient previously have a normal heart? ◦ Gradual accumulation of fluid – congestive state with ◦ Yes….. Ischaemia generalised fluid retention (oedema) ◦ No…… Ischaemia / arrhythmia / increased afterload etc ◦ Hypervolaemia – too much fluid all over the place What is the cause of the heart failure? What has triggered the presentation? ◦ De novo diagnosis ◦ Decompensation secondary to: Natural history of underlying condition Intercurrent factor Anaemia Infection Drugs Diagnosis : usually a chronic disease What is our treatment goal? ◦ “Our aim is to keep you as well as we can for as long as we can, ideally leading as normal life as possible with no restrictions on what you can do, with as few pills as possible, but as many as are needed” Non pharmacological Exercise Diet – weight loss in the obese, but beware the malnourished obese patient Salt “restriction” – stick to the RDA! Minimise / avoid environmental cardiotoxins ◦ Alcohol Metamephetamine Smoking No place for fluid restriction except in exceptional situations Is essential – regular : daily exercise improves well being and survivalshould put aside some “A person part of the day for the care of his Avoid extremes of dynamic exercise – only body. He should always make sure mild static exercise that he gets enough exercise especially before a meal." Patient can engage in a formal exercise program – moderate intensity aerobic vs high intensity interval training Diagnosis : usually a chronic disease What is our treatment goal? “Our aim is to keep you as well as we can for as long as we can, ideally leading as normal life as possible with no restrictions on what you can do, with as few pills as possible, but as many as are needed” Non pharmacological Pharmacological Loop diuretics ◦ Use dose that maintains the patient oedema free ◦ Relieve dyspnoea, but usually do not need high doses ◦ Monitor for side effects Renal dysfunction / electrolyte derangement / gout ACE inhibitor / Angiotensin receptor blocker ◦ Any patient with impaired systolic function ◦ Optimal dose – depends on agent Cilazapril 2.5mg (od) Quinapril 10mg (bd) Losartan 50mg (od) Candesartan 16mg (od) ◦ Monitor renal function and electrolytes ◦ Start when euvolaemic ◦ Start low and go slow (increase every 2 weeks) ◦ Warn patient may feel slight worse for a few days If more breathless increase diuretic dose : sx should settle ◦ Aim for maximum tolerated dose Metoprolol CR 190mg (od) Carvedilol 25mg (bd) Bisoprolol 10mg (od) When is dose optimised for an individual? ◦ When maximum dose reached ◦ When heart rate in low 50s ◦ Hypotensive symptoms Can Beta-blockers be used in airways disease? ◦ Generally yes – survival benefit offsets risk : see improvement in lung function ◦ Not in brittle asthmatics / marked airway hyper-reactivity Fatigue – but you can still do more than pre Rx? Hypotensive Sx – try and cut the other meds Erectile dysfunction – agents to assist Who: Anyone with symptomatic heart failure due to impaired systolic function Dose : ◦ Spironolactone (12.5mg), 25mg aim 50mg ◦ Eplerenone (25mg) 50mg aim 100mg Monitor for side effects ◦ Renal dysfunction / hyperkalaemia Maximum tolerated doses of ◦ ACEi / ARB ◦ Beta blocker ◦ Aldosterone receptor antagonist ◦ +/- diuretic Fluid status Weight JVP Lungs Oedema Postural BP Renal function Hypervolaemia Climbing High Rales Present May be a rise with standing Stable / worse Euvolaemia Stable Stable – may be high if TR Clear Absent No drop Stable Hypovolaemia Falling Low Clear Absent Present Climbing Digoxin ◦ reduces hospitalisation, but not survival Amiodarone ◦ only for symptomatic arrhythmia, otherwise shortens life Ivabradine (not in NZ yet) ◦ improves survival in those on optimal dose beta-blocker and HR >77bpm at rest Nitrate and hydralazine ◦ Very old school! Is more common in:- ◦ Elderly ◦ Females ◦ Obesity / diabetes / hypertension Is the commonest cause of pulmonary hypertension in the elderly Prognosis just as bleak as for systolic dysfunction ◦ Stiff, non compliant heart : squeezes OK, but does not fill well ◦ At rest is usually fine, but anything that increases heart rate can causes symptoms Infection / anaemia / metabolic derrangement Exercise Atrial arrhythmias Prevention is better than needing to actually treat! No proven Rx once established ◦ Low dose diuretics ◦ Negative chronotropes to slow heart ◦ Spironolactone if Nt-BNP high (>300) and symptoms Polypharmacy with potential side effects Takes 3-6 months to get right ◦ Drs much better with HF-ReF than HF-PeF! Treatment is usually for life ◦ There is a risk to suddenly stopping medication ◦ There is a risk to not taking pills and then taking OMT doses Multiple contacts with medical system ◦ Nurse / primary and secondary care Diagnosis : usually a chronic disease What is our treatment goal? “Our aim is to keep you as well as we can for as long as we can, ideally leading as normal life as possible with no restrictions on what you can do, with as few pills as possible, but as many as are needed” Non pharmacological Pharmacological Prognosis /general issues that may not be apparent initially In the absence of contraindications offered to ◦ Anyone who has survived a sudden cardiac death ◦ Has poorly tolerated VT / LV impairment and syncope that is unexplained ◦ Anyone who has been on and adherent to OMT for three months and has EF of under 30% if non ischaemic CM EF of under 35% if ischaemic CM ◦ Malignant familial history / genotype An ICD is permanent It is not an active therapy : it will not make the patient feel better An ICD does not alter the natural history of the underlying disease – one day pump failure will predominate and consideration should be given programming shock therapy off Not everyone wants an ICD – they do come with risks ◦ The patient should contact / attend their ICD clinic ICD will be read and rhythm reviewed May be a change in ICD settings ◦ The patient cannot drive a car for 6 months ◦ There may be a period of emotional lability / depression or even post traumatic stress disorder (more common after ICD storms) Not very common to see, but this will change over time Improves symptoms and survival Wairua (Spiritual health) Tinana (Physical Health) Whanau (Family) Hinengaro (Mental health) Class 1 or 6: Driving OK unless very symptomatic Class 2,3,4,5 or P endorsement: Generally individuals will be unfit to drive – special dispensation is available ”If can mount 2 flights of stairs, reasonably quickly, without too much problem then sex should be fine.” Keep GTN available (not with Viagra though). Activity is least likely to cause symptoms if engaged in after a good night’s sleep and with the least affected partner doing most of the work” Viagra is safe Patient plus website – www.patient.co.uk Uncontrolled AF can cause heart failure ◦ AF induced tachycardiomyopathy ◦ Rate Rx vs restoration of SR The onset of AF can cause decompensation of a previously stable cardiac condition Anticoagulation (in the absence of contraindications) is a must ◦ Warfarin NOAC: Dabigatran, Rivaroxiban, Apixiban Good rate Rx important ◦ ◦ ◦ ◦ ◦ Beta blocker Digoxin Amiodarone Ideally avoid diltiazem Interventional Rx : pulmonary vein isolation / CRT and AV nodal ablation Only Rx aspirin / clopidogrel if proven vascular disease Anticoagulation with warfarin (INR 2-3) or NOAC for ◦ Any proven AF ◦ Any patient with impaired EF and embolic event when in SR ◦ Documented LV thrombus Renal dysfunction is common in patients with heart failure (Cardiorenal syndrome) Multiple factors contribute Renal dysfunction can improve with treatment of heart failure Renal dysfunction in heart failure is not a contraindication for an ACEi / ARB, but a reason for caution – can use spironolactone, but only with specialist input due to risk of hyperkalaemia Balance risk of a slight worsening in renal function against benefits of cardioprotective agents Actively treat iron deficiency ◦ Oral iron replacement may not be effect ◦ Iron infusion excellent way of treating ◦ No clear role for EPO or analogues as yet – may be harmful Commonly coexist Central sleep apneoa common in CHF and treatment of CHF can improve it OSA common – cannot easily assess until on OMT Baseline and post Rx ESS can be useful Variable data Reasonable to continue if one is on a statin Start if have ACS / high CV risk But otherwise… just another pill, especially in advanced heart failure Address the underlying cause as best as possible – often multifactorial Correct the reversible – especially hypoxia Optimise Rx for left heart disease Aries Taurus Gemini Cancer Avoid incisions in the head and face and cut no vein in the head. Leo Avoid incisions of the nerves, lesions of the sides and bones,and do not cut the back either by opening and bleeding. Virgo Libra Avoid opening a wound in the belly and in the internal parts. Scorpio Sagittarius Avoid cutting the testicles and anus. Capricorn Aquarius Pisces Avoid cutting the knees or the veins and sinews in these places. Avoid incisions in the neck and throat and cut no veins there. Avoid incisions in the shoulders, arms or hands and cut no vein. Avoid incisions in the breasts, sides, stomach and lungs and cut no vein that goes to the spleen. Avoid opening wounds in the umbellicus and parts of the belly and do not open a vein in the back or do cupping. Avoid incisions in the thighs and fingers and do not cut blemishes and growths. Avoid cutting the knees or the veins and veins in these places. Avoid cutting the feet. Address the underlying cause as best as possible – often multifactorial Correct the reversible – especially hypoxia Optimise Rx for left heart disease Diuretics ◦ ◦ ◦ ◦ ◦ Best taken on empty stomach, 30 minutes before food Frusemide vs bumetanide Oral vs IV Spironolactone Metolazone – use cautiously and watch electrolytes Important to identify disease progression Review medications – any room to push further Acknowledge disease progression – this is not a failure of treatment, rather the natural history of the underlying disease Any non essential medications that could be stopped Advanced care planning : review ICD status if present Advanced stages of heart failure are unpredictable and patients can survive months to years with advanced Sx / poor prognostic markers – aim is to ensure they remain well, but not to prolong suffering Patients with suspected heart failure – newly diagnosed Patients with known heart failure who are ◦ Deteriorating – sub-acute vs chronic ◦ Running into problems with medication side effects ◦ New onset AF Help further establish diagnosis and cause of heart failure Help initiate Rx and optimise Rx Discuss diagnosis and provide education Help establish chronic management plan Offer support through the early phase of the disease management Provide follow up once on OMT – usually annual Community ◦ Review patients in their own enviroment / clinic Check for polypharmacy – drug inconsistencies ◦ Once stable – 3 monthly review : Check adherence to Rx and side effects Review obs and weight chart Lifestyle and psychosocial issues Preventative programme : flu jab
