CHRONIC HEART FAILURE (CHF)

2012

Jennifer Burgess

Some Facts Fastest rising cardiovascular condition in

Canada affects 1 – 2% of the population (>350,000) 1.4 million hospital days per year Up to $2.3 billion per year Prevalence tripled over past decade

Increasing numbers of elderly Improved survival rates of cardiac and other chronic

conditions

Some Facts Cannot be “Cured” by relieving symptoms

Often progresses without signs or symptoms Changes occur that lead to chronic debility

33% mortality within first year of diagnosis 50% mortality within five years 3:1 males:females

Heart Failure – What is it? Inability of the heart to supply sufficient blood flow to meet

the body's needs Therefore not enough oxygen and nutrients supplied Can lead to fluid overload

Results from any heart problem that impairs ability of ventricle to fill with or eject blood Due to low cardiac output (“Congestive” HF) or increased needs

(“high output” HF) – now referred to as Heart Failure (HF) Can be acute or chronic (or acute on chronic) Can be left sided, right sided, or both (L leads to R)

It is not a heart attack, or cardiac arrest

What is Heart Failure?

CausesCongestive heart failure can be caused by

diseases that:cause stiffening, or weakening of, the heart

muscle e.g.. MI, HTNincrease oxygen demand by the body tissue

beyond the capability of the heart to deliver.

Main Risk Factors Ischemic heart disease/MI (62%) Smoking (16%) Hypertension (10%) Obesity (8%) Diabetes (3%) Valvular heart disease (2%, higher in elderly)

The heart

Classic Indicators of CHF

Shortness of Breath

Wet sounding chest due to excess fluid in and around the lungs

Coughing

Significant swelling in lower legs or abdomen

Fatigue

Signs And SymptomsLEFT HEART FAILURE(LOW OUTPUT/PULMONARY

CONGESTION) Dyspnea Orthopnea Paroxysmal nocturnal dyspnea

(PND) Fatigue* Reduced exercise tolerance* Cough Confusion (Especially in elderly)*

* May be earliest presentation

RIGHT HEART FAILURE(SYSTEMIC VENOUS CONGESTION)

Peripheral edema Weight gain Anorexia Abdominal discomfort Fatigue* Reduced exercise tolerance*

Additional Signs & Symptoms RR (>20) and effort Low blood pressure (<90mmHg) Heart rate > 100 Lung crackles (+/- wheeze) Elevated JVP Heart murmur Pleural effusion Cyanosis (late sign)

Assessing JVP and abdominal jugular reflex

Atypical Features in Frail Elderly Delirium Falls Malnutrition Sudden functional decline Sleep disturbances Nocturia or nighttime incontinence NOTE: Dyspnea and/or crackles +/- present

Diagnosing HF

Chest x-ray ECG Bloodwork, +/- BNP (cardiac vs pulmonary) Echocardiogram +/- angiography, nuclear imaging, MRI

Differential Diagnosis Heart – valvular, CAD Renal failure with volume overload Lung disease Liver cirrhosis Obesity Deconditioning Anemia

New York Heart Association Classification (NYHA) Class l (Mild)

No limitation of physical activity Class ll (Mild)

Slight limitation of physical activity Class lll (Moderate)

Marked limitation of physical activity Class lV (Severe)

Unable to carry out any physical activity without discomfort

Medications ACE Inhibitors

Ramipril, etc. Improve hearts pumping action Prevent disease from getting worse S/E: decreased renal function, hypotension, dizziness, cough

Beta Blockers Metoprolol, etc. Reduce heart rate and work of heart Prevent and treat irregular heart beat Prevent disease from getting worse S/E: may make HF worse for first few months, bradycardia,

bronchospasm, fatigue, dizziness

Medications Diuretics

Lasix, etc. Improve symptoms by relieving fluid overload S/E: Hypokalemia, dehydration, weakness,

muscle cramps.

Others ARB’s, Digoxin, Nitrates, anticoagulants,

Aspirin, etc.

Management Decrease sodium

Na+ not efficiently excreted in HF We need 500 mg/day, we consume 5-6- gm/day Aim for 2 – 3 gm/day if stable 1 – 2 gm/day if advanced HF and fluid retention

Fluid restriction 1.5 – 2 L/day if fluid retention, or if renal dysfunction or

hyponatremia 1 – 1.5 L/day if severe edema

Management Daily weight log

when Class lll/lV or med changes after emptying bladder, before eating, same clothes, same

scale Report weight when 2.5 kg increase in a week, or 2 kg in

2 days

Physical activity Consider when stable and not fluid overloaded Individualized – up to, but just short of, significant Sx’s

Prevention BP goal <140/90

<130/80 if DM +/or chronic kiney disease Correct anemia Medications – proper use of recommended

meds can drastically reduce morbidity and mortality. E.g. ACE–I use decreases death or new HF by 29% (SOLVD Prevention study)

Acute Decompensated HF (ADHF) Presentation:

Dyspnea - 89% Crackles - 68% Peripheral edema - 66% SBP <90 MMHG - 3%

These residents may need immediate hospitalization for I.V. diuretics, etc.

End of Life Care Consider in residents who have advanced,

persistent HF with symptoms at rest despite optimal pharmacological and nonpharmacological therapy: Three or more hospitalizations per year Chronic poor quality of life – unable to do ADL’s Need for IV support Needing assistive devices for breathing etc.

(2006 HFSA Comprehensive HF Practice Guideline)

The Good News We can help our residents who have Heart

Failure to have maximal quality and quantity of life by helping them to optimally manage their disease!

ReferencesAronow, W. (2004). Evidence for the Use of Beta-blockers in

Congestive Heart Failure Treatment in Older Persons. Geriatrics & Aging. 7(2), 28-32.

Canadian Cardiovascular Society. (2009). Pocket reference card: Is it Heart Failure and What should I do? Retrieved from: http://www.hfcc.ca/downloads/educational_tools/pocket_card/pocket_card.html

Canadian Heart Failure Network. (2009). Running a Heart Failure Clinic. Retrieved from http: //www.chfn.ca/ on May 18, 2010.

References Con’tHeart Failure Society of America. (2006). 2006 HFSA

Comprehensive Heart Failure Practice Guideline: Key Recommendations. Retrieved from: http://www.heartfailureguideline.org/index.cfm?id=150&s=1

Howlett, J.G., McKelvie, R.S., Arnold, J.M.O., et al. Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: Diagnosis and management of right sided heart failure, myocarditis, device therapy and recent important clinical trials. Can J Cardiol, 25(2), 85-105.

Kostuk, W. (2004). Initial Evaluation of the Older Patient with Suspected Heart Failure. Geriatrics & Aging, 7(2), 13-16.