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  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 1

    Heart Failure Update for Primary Care Providers: Recognition and Treatment of Systolic (HFrEF) vs Diastolic Heart Failure (HFpEF):

    Kristine Anne Scordo PhD, RN, ACNP-BC, FAANP Professor and Director Adult Gero-Acute Care Nurse Practitioner Program Wright State University Dayton, Ohio ACNP Schuster Cardiology and Associates, Dayton Ohio kscordo@cinci.rr.com

    Get with the Guidelines…

    https://doi.org/10.1016/j.jacc.2017.11.025

    GDMT=goal directed medical

    therapy

  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 2

    Why worry about heart failure in primary care?

    Epidemiology of HF 1in 9 death certificates in the US mentioned heart failure.

    Prevalence increased form 5.7 million to 6.5 million in Americans >20yrs of age

    5 year survival after MI improved from 54% (2001) to 61% (2000)

    Seventy-five percent of HF cases have antecedent hypertension

    Hospitalized HF events: 53% had HFrEF and 47% had HFpEF

    ~$34.4 billion per year in health care costs

    Circulation. 2017;135:00–00. DOI: 10.1161/CIR.0000000000000485

  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 3

    All Cause Mortality After Each Subsequent Hospitalization for HF

    Time Since Admission

    0.0

    0.2

    K ap

    la n-

    M ei

    er C

    un . M

    or ta

    lit y

    0.8

    1.0 CHF 1st Admission (n = 14,374) 2nd Admission (n = 3,358) 3rd admission (n = 1,123) 4th Admission (n = 417)

    1st hospitalization: 30 d mortality = 12%; 1 yr = 34%

    0.6

    0.4

    0.0 0.5 1.0 1.5 2.0

    Key is to prevent hospitalizations

    But first…..What’s in a name?

    Definition of Heart Failure* Classification Ejection

    Fraction Description

    I. Heart Failure with Reduced Ejection Fraction (HFrEF)

    ≤40% Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFrEF and it is only in these patients that efficacious therapies have been demonstrated to date.

    II. Heart Failure with Preserved Ejection Fraction (HFpEF)

    ≥50% Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified.

    a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFpEF.

    b. HFpEF, Improved ~1/3 cases Few clinical trails to guide care

    >40% It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients.

    *2013 ACCF/AHA Guideline for the Management of Heart Failure

  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 4

    Common Causes of HF • HFrEF

    • DCM • CAD/AMI • Valvular • Hypertensive heart disease • Congenital heart disease

    • HFpEF • Old age • Hypertension with LVH • Proinflammatory etiology

    • Diabetes Mellitus, obesity

    • Restrictive cardiomyopathy • Hypertrophic states

    Characteristics of Patients with HFpEF vs HFrEF

    Characteristic HFpEF HFrEF

    Age Frequently elderly All ages, typically 50-70 yr

    Sex Frequently female More often male

    LVEF Preserved or normal, 50% or higher

    Depressed ~40% or lower

    LV Cavity size Usually normal, with LVH Usually dilated

    CXR Congestion with or without cardiomegaly

    Congestion & cardiomegaly

    Gallop S4 S3

    Symptomatic HF is only the tip of the iceberg

  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 5

    PRIMARY PREVENTION!!!

    The Cardiovascular Continuum Risk Factors and HF: The Link*

    Obesity Diabetes

    Hypertension

    Smoking Dyslipidemia

    LVH

    MI

    Systolic dysfunction

    Diastolic dysfunction

    HF

    Normal LV structure & function

    LV remodeling Subclinical LV dysfunction

    Overt heart failure

  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 6

    Prevention is the Key

    • Treat HTN • Treat insulin resistance/metabolic syndrome • Treat lipid disorders • Smoking cessation • Regular cardiovascular exercise • Weight loss

    • OBESITY INDEPENDENT RISK FACTOR • ACEI/ARBS/Beta blockers with DM/CVD/HTN • Periodic surveillance of EF

    Treating Hypertension to Prevent HF

    • Aggressive blood pressure control:

    • Aggressive BP control in patients with prior MI:

    Decreases risk of new HF

    by ~ 80%

    Decreases risk of new HF

    by ~ 50% 56% in DM2

    Lancet 1991;338:1281-5 (STOP-Hypertension JAMA 1997;278:212-6 (SHEP) UKPDS Group. UKPDS 38. BMJ 1998;317:703-713

    HF Risk Factor Treatment Goals

    Risk Factor Goal

    Hypertension Generally < 130/80 (ACEI/ARB)

    Diabetes ADA guidelines

    Hyperlipidemia GDMT

    Inactivity 20-30 min. aerobic 3-5 x wk.

    Obesity Weight reduction < 30 BMI

    Alcohol Men ≤ 2 drinks/day, women ≤ 1

    Smoking Cessation

    Dietary Sodium Maximum 2-3 g/day

  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 7

    Diagnosing HF: Early Recognition is KEY

    Differential Diagnosis for HF Symptoms and Signs

    • Myocardial ischemia • Pulmonary disease

    (pneumonia, asthma, chronic obstructive pulmonary disease, pulmonary embolus, primary pulmonary hypertension)

    • Sleep-disordered breathing

    • Obesity • Deconditioning

    • Malnutrition • Anemia • Hepatic failure • Chronic kidney disease • Hypoalbuminemia • Venous stasis • Depression • Anxiety and

    hyperventilation syndromes

    • Hyper or hypo-thyroidism

    Diagnostic Tests

    Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, and thyroid-stimulating hormone.

    Serial monitoring, when indicated, should include serum electrolytes and renal function.

    I IIa IIb III

    I IIa IIb III

  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 8

    Class I for dx and establishing prognosis/disease severity; IIa BNP post discharge prognosis

    BNP Level

    Maisel, Alan S., et al. “Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction: Results from the Breathing Not Properly Multinational Study.” Journal of the American College of Cardiology (JACC), v. 41 issue 11, 2003, p. 2010-2017.

    Causes for Elevated Natriuretic Peptide Levels

    Cardiac Noncardiac  Heart failure, including RV

    syndromes  Acute coronary syndrome  Heart muscle disease,

    including LVH  Valvular heart disease  Pericardial disease  Atrial fibrillation  Myocarditis  Cardiac surgery  Cardioversion

     Advancing age  Anemia  Renal failure  Pulmonary causes: obstructive

    sleep apnea, severe pneumonia, pulmonary hypertension

     Critical illness  Bacterial sepsis  Severe burns  Toxic-metabolic insults,

    including cancer chemotherapy and envenomation

  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 9

    Signs to Evaluate in Patients Suspected of Having HF

    Cardiac Abnormality Sign

    Elevated cardiac filling pressures and fluid overload

    Elevated JVP, S3 gallop, rales, +HJ reflux, ascites, edema

    Cardiac enlargement Laterally displaced or prominent apical impulse, murmurs suggesting valvular dysfunction

    Reduced cardiac output Narrow pulse pressure, cool extremities, tachycardia with pulsus alternans

    Arrhythmia Irregular pulse suggestive of atrial fibrillation or frequent ectopy

    In office determination of suspicion of heart failure

    Square valve response to Valsalva

    • Check BP and hold~ 15mmHg above systolic- perform Valsalva --normal response-hear for a few beats and disappears

    • Abnormal hear sounds continuously = increased LA pressure • Patients with severely depressed EF unable to

    alter stroke output in response to acutely increased intrathoracic pressure. A square wave pressure response is a likely consequence of a fixed stroke output during the strain maneuver.

  • Systolic vs Diastolic Heart Failure :Dx and Treatment Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

    Page 10

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