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Heart Failure 101out of the lab, into the clinic

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Objectives today Provide an overview of clinical aspects of heart failure

diagnosis assessment management

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

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 HF symptoms range from none to an inability

to complete basic ADLs

HF patients may not appear ill, but have profound symptoms; unable to function in the way family members feel they should

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

Lloyd-Jones et al, Lifetime Risk for Developing Congestive Heart FailureCirculation 2002; 106: 3068 - 3072.

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Heart failure: not going away

Arnold Can J Cardiol 2007

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The cost of heart failure

9%

8% 10%

7%

13%

52%

Hospitalization$15.4

Lost Productivity/Mortality*

$2.8

Home Healthcare$2.4

Drugs/Other Medical Durables

$3.1

Physicians/Other Professionals

$2.0

Nursing Home$3.9

Total Cost$40 billion

AHA. 2006 Heart and Stroke Statistical UpdateAHA. 2006 Heart and Stroke Statistical Update

$3-4 billion

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Heart failure: the numbers Prevalence 600,000 Canadians Incidence 50,000 / year Hospitalization #1 cause Average stay 7 days

1.4 million days Death

in hospital 2-22% 30 days post discharge 10% 1 year 30% 5 year 50%

J. Ezekowitz CMAJ 2009, EJHF 2008

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Modes of death in HF

50% of HF patients “DROP” sudden cardiac death

40% of HF patients “DROWN” progressive 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

04/21/23 1 12Rosa Gutierrez 2006

Mechanisms of heart failure

mechanical abnormalities

myocardial injury electrical

disorders

left ventricular dysfunction

loss of pump

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Chemical mediators of HFAngiotensin I / II Aldosterone ADH-antidiuretic hormone Epinephrine / Norepinephrine Endothelins

Natiuretic peptidesAtrial NPB-type NPC-type NP

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Modes of heart failure

Systolic (pumping dysfunction) vs Diastolic (filling dysfunction)

Compensated vs Decompensated Right sided HF vs Left sided HF Forward HF vs Backward HF

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

fatigue weakness/lack of energy cognitive dysfunction decreased exercise tolerance

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Backword flow HF symptoms

“Plumbing”—related to congestion 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

Dao Q et al J Am Coll Cardiol 2001;37:379-85

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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 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 2007BNP -CCS 2007

BNP / NT-proBNPBNP / NT-proBNP … should be measured to … should be measured to confirm or rule out a diagnosis of heart failureconfirm or rule out a diagnosis of heart failure in in the acute or ambulatory care setting in patients the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt in whom the clinical diagnosis is in doubt

(class I, level A)(class I, level A)

currently the most practical use of this testcurrently the most practical use of this test under cut-off point—HF unlikelyunder cut-off point—HF unlikely above cut-off point—HF very likelyabove cut-off point—HF very likely

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BNP (CCS 2007)BNP (CCS 2007)Age Age

(years)(years)Heart Heart

failure is failure is unlikelyunlikely

Heart failure Heart failure possible but other possible but other

diagnosesdiagnoses must be must be consideredconsidered

HeartHeart failure failure is very likelyis very likely

BNPBNP AllAll < 100 < 100 pg/mlpg/ml

100-500 pg/ml100-500 pg/ml > 500 pg/ml> 500 pg/ml

NT-proBNPNT-proBNP < 50< 50 < 300 < 300 pg/mlpg/ml

300-450 pg/ml300-450 pg/ml > 450 pg/ml> 450 pg/ml

50 - 7550 - 75 < 300 < 300 pg/mlpg/ml

450-900 pg/ml450-900 pg/ml > 900 pg/ml> 900 pg/ml

> 75> 75 < 300 < 300 pg/mlpg/ml

900 - 1800 900 - 1800 pg/mlpg/ml

> 1800 pg/ml> 1800 pg/ml

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HF Management

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HF treatment goals (quality and quantity)

Slow progression of syndromeControl symptoms Prolong Life

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CCS on HFPSF (Diastolic HF) Guideline based medications should be

considered in HF with preserved EF** (diastolic HF) for:

relief of HF symptoms Pulmonary congestion Peripheral edema

treatment of HF risk factors 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 Medical Therapy

ACE inhibitors Beta-blockers Spironolactone Diuretics Digoxin Nitrates Statins ASA, Warfarin

Device Therapy ICD CRT

Other Therapy Multidisciplinary clinics Exercise rehab Dietary referral Review of co-morbidity Review of other drugs

LIFESTYLE!

www.hfcc.ccs.ca

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HF treatment is guided by…

EFx-ejection fractionventricular systolic function

NYHA functional classsymptom status

Patient/Family 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”

Patients who have an EFx of 10% may have NYHA FC I symptoms 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 a patient can have HF with a normal EFx

(preserved LV function)

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ICD-internal cardiac defibrillator many HF patients at risk

for sudden cardiac death primary / secondary

prevention quantity of life selection criteria:

EFx NYHA functional class prognosis medications maximized

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CRT-cardiac resynchronization mechanical dys-synchrony

impacts pump function third lead attempts to

improve synchrony quality (and quantity) of life selection criteria:

EF ( 30%) QRS width on ECG (120 ms) NYHA functional class (II-IV) medications maximized

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Nutrition management of HF

Limit Sodium Intake

Avoid Excessive Fluids

Daily Morning Weights

Liz Woo MHI HFC 2009

35

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Salt / Sodium restriction: Less than 3 gm Na/day most HF patients Less than 2 gm Na/day severe edema

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 stable1-1.5 liters / day with severe edema

Fluid is: “anything wet” tea, juice, coffee, milk,

water, watermelon, ice keep a diary adjust for hot weather,

illness

Rosa Gutierrez 2006

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Weight accuracy

same scale shoes / no shoes

compare home / prior clinic weight 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

Diabetes COPD Renal disease HTN Thyroid disorder Cancer

HF rarely exists in a vacuum

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Self care in HF “YOU have the most power over your condition”

“AVOID behaviors that make heart failure worse”

“PAY ATTENTION, act EARLY”

“you can’t ignore your heart failure…”

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HF assessment Thorough patient history & physical exam

Establish baseline data and monitor trends

Appropriate surveillance ongoing

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Patient history Symptom status / most limiting factor:

SOB Fatigue

NYHA FC 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: Palpitations Dizziness Lightheadedness Syncope Angina Depression GI / appetite

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1

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HF de-compensation triggers

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 Weight Edema JVP Heart rate / rhythm Blood pressure HS auscultation Lung auscultation

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Fluid balance assessment 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 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 crackles throughout expiratory wheezes decreased AE bases quiet breath sounds

who is wet? who is euvolemic?

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What’s the plan? Self care teaching / reinforcement

What has or could de-stabilize this patient’s HF? Guideline based treatment options

Medications ICD / CRT Interventions ie. Angiogram, Sx

Follow up What surveillance level does this patient require?

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MHI Heart Function Clinic Clinic #s:

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