Download 450 pg/ml - Alberta Heart

Heart Failure 101
out of the lab, into the clinic
5/24/2017
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Objectives today
Provide an overview of clinical aspects of heart failure
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diagnosis
assessment
management
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Interacting with a HF patient
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Definition of heart failure

state in which the heart cannot pump a
sufficient supply of blood to meet the
physiological requirements of the body, or
requires elevated filling pressures to do so
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a pathological condition leading to a
debilitating illness characterized by poor
exercise tolerance, chronic fatigue, along with
high morbidity and mortality
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Some truths about HF
 HF
is a chronic, progressive condition
that is life limiting
 HF is a terminal condition—eventually
it leads to the patient’s death
 There is no “cure”
 HF is common
 HF prevalence is on the rise
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Implications for the patient
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HF symptoms range from none to an inability
to complete basic ADLs
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HF patients may not appear ill, but have
profound symptoms; unable to function in the
way family members feel they should
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HF clinical progression is cyclical, and
unpredictable—patients have no control over
what they can and cannot do on any given day
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What is your risk?
1 in 5 will develop heart failure
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Lloyd-Jones et al, Lifetime Risk for Developing Congestive Heart
6 Failure
Circulation 2002; 106: 3068 - 3072.
Heart failure: not going away
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Arnold Can J Cardiol 2007
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The cost of heart failure
Hospitalization
$15.4
Total Cost
$40 billion
52%
$3-4
billion
13%
Nursing Home
$3.9
7%
9%
Physicians/Other
Professionals
$2.0
Drugs/Other
Home Healthcare Medical Durables
$2.4
$3.1
Lost Productivity/
Mortality*
$2.8
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8%
10%
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AHA. 2006 Heart and Stroke Statistical Update
Heart failure: the numbers
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Prevalence
600,000 Canadians
Incidence
50,000 / year
Hospitalization
#1 cause
Average stay
7 days
1.4 million days
Death
 in hospital
 30 days post discharge

1 year 30%
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J. Ezekowitz CMAJ 2009, EJHF 2008
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2-22%
10%
5 year 50%
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Modes of death in HF
 50%
of HF patients “DROP”
 sudden
 40%
cardiac death
of HF patients “DROWN”
 progressive
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HF
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HF etiology
ISCHEMIC (50% HF)
 CAD-ischemia+/-MI
 HTN (diastolic and systolic HF) (25%)
 NON ISCHEMIC (25 % HF)
 Dilated
 Hypertrophic
 Restrictive
 Valvular

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Mechanisms of heart failure
myocardial
injury
mechanical
abnormalities
electrical
disorders
left ventricular dysfunction
loss of pump
Rosa Gutierrez 2006
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Chemical mediators of HF
Angiotensin I / II
Aldosterone
ADH-antidiuretic hormone
Epinephrine / Norepinephrine
Endothelins
Natiuretic peptides
Atrial NP
B-type NP
C-type NP
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Modes of heart failure

Systolic (pumping dysfunction) vs Diastolic (filling dysfunction)
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Compensated vs Decompensated
Right sided HF vs Left sided HF
Forward HF vs Backward HF
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
A HF patient can have one or several of these
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Types of heart failure
compensated


if the force of the
contraction is
moderately
decreased the heart
can meet the
metabolic demands
temporary
improvement CO
decompensated
occurs when the force
of the contraction is
decreased further
resulting in the
appearance of clinical
signs & symptoms
Rosa Guterriez 2006
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Forward flow HF symptoms
“Out
of gas”—related to O2
delivery
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fatigue
weakness/lack of energy
cognitive dysfunction
decreased exercise tolerance
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Backword flow HF symptoms
“Plumbing”—related to congestion
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shortness of breath
orthopnea
paroxysmal nocturnal dyspnea (PND)
edema
fluid retention / weight gain
decreased exercise tolerance
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Diagnostic accuracy of traditional HF
work-up
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Dao Q et al J Am Coll Cardiol 2001;37:379-85
Diagnosis of HF-CCS 2006
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Disease progression
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Echocardiogram
WHY in HF: useful for
 assessing chamber size
 volume of cavity
 thickness of walls, valves
 assessing pumping function (systolic)
 assessing filling function (diastolic)
 determining LVEFx within 10%
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Additional testing in HF
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BNP (and other biochemistry eg. TSH, Cr)
MIBI/Thallium (viability scan)
Coronary Angiogram
24/48 hr Holter monitor; Event Monitors
VO2 Max
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BNP -CCS 2007
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BNP / NT-proBNP … should be measured to
confirm or rule out a diagnosis of heart failure in
the acute or ambulatory care setting in patients
in whom the clinical diagnosis is in doubt
(class I, level A)
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currently the most practical use of this test
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under cut-off point—HF unlikely
above cut-off point—HF very likely
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BNP (CCS 2007)
Heart
failure is
unlikely
Heart failure
possible but other
diagnoses must be
considered
Heart failure
is very likely
All
< 100
pg/ml
100-500 pg/ml
> 500 pg/ml
< 50
< 300
pg/ml
300-450 pg/ml
> 450 pg/ml
50 - 75
< 300
pg/ml
450-900 pg/ml
> 900 pg/ml
> 75
< 300
pg/ml
900 - 1800
pg/ml
> 1800 pg/ml
Age
(years)
BNP
NT-proBNP
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HF Management
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HF treatment goals (quality and quantity)
Slow
progression of syndrome
Control symptoms
 Prolong Life
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CCS on HFPSF (Diastolic HF)
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Guideline based medications should be
considered in HF with preserved EF**
(diastolic HF) for:
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relief of HF symptoms
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Pulmonary congestion
Peripheral edema
treatment of HF risk factors
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HR, atrial fibrillation
BP (as per HTN guidelines)
**overall lower level of evidence associated with HFPSF
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CCS on Systolic Heart Failure
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Medical Therapy
 ACE inhibitors
 Beta-blockers
 Spironolactone
 Diuretics
 Digoxin
 Nitrates
 Statins
 ASA, Warfarin
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Device Therapy
 ICD
 CRT
Other Therapy
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Multidisciplinary clinics
Exercise rehab
Dietary referral
Review of co-morbidity
Review of other drugs
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LIFESTYLE!
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www.hfcc.ccs.ca
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HF treatment is guided by…
 EFx-ejection
fraction
 ventricular systolic function
 NYHA functional class
 symptom status
 Patient/Family
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Perspectives !!
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Ejection Fraction
EFx—its all about the LV (and RV !)
how much blood is ejected per ventricular
contraction is measured by percentage and is
indicative of pump efficiency
 the normal heart will pump out 60-70% of the
blood that enters the left ventricular chamber
---never 100%
 the LV’s normal shape is the perfect pump
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New York Heart Association
Functional Classification-NYHA
NYHA I: no physical activity limitation
NYHA II: slight limitation of physical activity
NYHA III: marked limitation of physical
activity
NYHA IV: unable to carry out any physical
activity or HF symptoms at rest
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“You are not your EFx”
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Patients who have an EFx of 10% may have
NYHA FC I symptoms
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an asymptomatic patient may be at risk for a sudden
cardiac death, or arrhythmic event if their EFx is low
HF diagnosis may be missed if patient asymptomatic
Patients with a normal or near normal EFx may
have NYHA FC II-III symptoms
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a patient can have HF with a normal EFx
(preserved LV function)
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ICD-internal cardiac defibrillator
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many HF patients at risk
for sudden cardiac death
primary / secondary
prevention
quantity of life
selection criteria:
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EFx
NYHA functional class
prognosis
medications maximized
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CRT-cardiac resynchronization
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mechanical dys-synchrony
impacts pump function
third lead attempts to
improve synchrony
quality (and quantity) of life
selection criteria:
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EF ( 30%)
QRS width on ECG (120 ms)
NYHA functional class (II-IV)
medications maximized
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Nutrition management of HF
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Limit Sodium Intake
Avoid
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Excessive Fluids
Daily Morning Weights
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Liz Woo MHI HFC 2009
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Salt / Sodium restriction:
Less than 3 gm Na/day most HF patients
Less than 2 gm Na/day severe edema
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do not add salt
remove the salt shaker
from the table
avoid pickles, luncheon
meats, can soup, can
tomatoes
read labels for “hidden
salt”
less than 5% of total
Rosa Gutierrez 2006
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Fluid restriction:
2 liters / day if clinically stable
1-1.5 liters / day with severe edema
Fluid is: “anything wet”
 tea, juice, coffee, milk,
water, watermelon, ice
 keep a diary
 adjust for hot weather,
illness
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Weight
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accuracy
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compare home / prior clinic weight
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same scale
shoes / no shoes
does this number make sense?
what is the ideal, “dry weight”?
**NEW PTs: record discharge wt on chart
if admission if within 2-3 months of initial
clinic visit
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HF co-morbidity
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Diabetes
COPD
Renal disease
HTN
Thyroid disorder
Cancer
HF rarely exists in a vacuum
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Self care in HF
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“YOU have the most power over your condition”
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“AVOID behaviors that make heart failure
worse”
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“PAY ATTENTION, act EARLY”
“you can’t ignore your heart failure…”
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HF assessment
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Thorough patient history & physical exam
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Establish baseline data and monitor trends
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Appropriate surveillance ongoing
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Patient history
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Symptom status / most limiting factor:
 SOB
 Fatigue
NYHA FC
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We use patient specific activities to measure—link to
frequently done tasks ie. vacuuming, stairs
Patient may avoid activities that provoke symptoms—
helpful to ask “what are you not doing now that you
would like to, or could do before?”
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history cont…
New or changed:
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Palpitations
Dizziness
Lightheadedness
Syncope
Angina
Depression
GI / appetite
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HF de-compensation triggers
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Dietary indiscretion #1 (with a bullet)
 salt / fluid lapse
Medications
 new / dose stopped / changed / forgotten / skipped
OTC / PRN
Infection
Co-morbidity interplay
Ischemia
Arrhythmia
Disease progression
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Physical exam
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Weight
Edema
JVP
Heart rate / rhythm
Blood pressure
HS auscultation
Lung auscultation
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Fluid balance assessment
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Weight increase
Edema
Orthopnea / PND (Paroxysmal nocturnal dyspnea)
HS cough
JVP elevation
+ Hepatojugular reflex
Respiratory auscultation-crackles, rales
CXR
Heart auscultation-S3
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Edema
“where do you keep your water?”
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Edema
 swelling
in legs, feet, ankles?
 bloating in abdomen—ascites?
 swelling anywhere else?
pitting / non-pitting?
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Jugular Venous Pressure
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JVP reflects pressure and volume changes
in the right atrium
most proximal location to view
9-10 cm column of blood supported to
clavicle from right atrium when upright
observe at 90 degrees, 30-45 degrees
measured in cm ASA
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Lung auscultation
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crackles throughout
expiratory wheezes
decreased AE bases
quiet breath sounds
who is wet?
who is euvolemic?
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What’s the plan?
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Self care teaching / reinforcement
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Guideline based treatment options
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What has or could de-stabilize this patient’s HF?
Medications
ICD / CRT
Interventions ie. Angiogram, Sx
Follow up
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What surveillance level does this patient require?
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MHI Heart Function Clinic
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Clinic #s:
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700 active patients
25 new referrals/month
120 patient visits/month
83000 minutes on the telephone
66000 minutes in clinic
45000 minutes reviewing test results
support for this clinic is backed by extensive local data
collection, clinical trials and ongoing quality
improvement
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