Living with Heart FailureLiving with Heart Failure

Ayesha Hasan MD, FACCAdvanced Heart Failure and Transplantation Program

Medical Director Cardiac Transplant Program

Contact information: 614-293-6081 (heart failure office)

What is Heart Failure?

Heart failure is Heart failure is NOTNOT a heart attack a heart attack

Heart failureHeart failure means the heart is:means the heart is: WeakenedWeakened Cannot pump enough blood to supply the Cannot pump enough blood to supply the

body’s needsbody’s needs

. . . . . . It does not mean the heart has stopped It does not mean the heart has stopped working!working!

Heart Failure is Very Common

Heart failure affects nearly 5 million Americans 50% men and 50% women

An estimated ½ million new cases are diagnosed each year Expected to rise to 750,000 new cases by 2040 Related to aging population, better treatment of heart disease

and risk factors, awareness

Over one million heart failure hospitalizations annually Rising over past few decades Accounts for over 20% admissions in people 65 and over

Aorta

LA

LV

Normal

Thickened or stiffheart walls

Diastolic Heart Failure

Dilated

Systolic Heart Failure

Pg 238, Lilly 3rd edition

Types of Heart Failure: Difference Between Systolic and Diastolic Heart Failure

Weakened pump

Relaxation ± abnormal

Blood backs up and overloads the heart

Normal ejection

Abnormal relaxation: Stiff or scarred

Won’t allow enough blood to fill the heart before it squeezes

Normal ejection (squeeze)=Systolic functionNormal relaxation (filling)=Diastolic function

Normal Heart

Development of Heart Failure

Simplified View of Heart Failure

What Causes Heart Failure?

Heart failure results after injury to the heartHeart failure results after injury to the heartHigh blood pressureHigh blood pressureHeart attackHeart attackDamage to heart valvesDamage to heart valvesDiabetesDiabetesHigh cholesterolHigh cholesterolHeart muscle disease: damage Heart muscle disease: damage

from drugs, alcohol, or from drugs, alcohol, or infectionsinfections

Congenital heart diseaseCongenital heart disease

What Are The Symptoms of Heart Failure?

Think FACES...• Fatigue Constant lack of energy

• Activities limited Difficulty with everyday activities

• Chest congestion Dry cough or producing white or pink blood-tinged phlegm

• Edema or ankle swelling Swelling of the feet, ankles, legs, abdomen, or unexplained weight gain

• Shortness of breath Breathlessness during activity, at rest, or while sleeping

Additional symptoms: Lack of appetite, nausea, increased heart rate, irregular heart rhythm

How Severe is A Patient’s Heart Failure?

We measure the “We measure the “ejection fractionejection fraction” by echo” by echo The fraction of blood that the heart pumps with every beatThe fraction of blood that the heart pumps with every beat

We assess the patient’s We assess the patient’s symptomssymptoms No or mild symptomsNo or mild symptoms Do symptoms limit activity? If so, how much?Do symptoms limit activity? If so, how much?

High Blood Pressure

Left VentricularHypertrophy

Family History

CoronaryArtery Disease

Symptomatic Heart Failure

Diabetes

Risk Factors

High cholesterol

Treatment…Begins with Prevention!

Smoking Obesity

Poor DietLack of Exercise

How Do We Treat Heart Failure?

Lifestyle Changes Quit smoking Monitor diet: low-fat, low sodium Exercise regularly Lose weight Avoid alcohol Limit caffeine intake

Limiting Sodium or Salt Will Improve Your Heart Failure SymptomsSodium is a component of salt

Naturally occurring in many foods

Added during processing

In most foods eaten away from home

Your body needs only a small amount of sodium to

keep a normal fluid balance.

Too much sodium causes your body to hold onto fluid

and cause symptoms of weight gain, shortness of breath,

and fatigue.

Sodium attractsfluid

Fluid build-up in body

Extra work on heart &kidneys to get rid of fluid

Higher BP often results

Heart failure symptoms,heart attack, stroke

The more sodium (salt) you take in, the more fluid your body holds on to

In addition to heart failure patients, theAmerican Heart Association recommends

1) All adults older than 51

2) All African Americans

3) Anyone with high blood pressure

limit their daily intake to 1500 mg

Plan your meals for 2000 mg intake MEAL mg Sodium

Breakfast 600mgLunch 600mgDinner 600mg

Snack 200mg

Use alternative seasonings!

Basil ParsleyChives PaprikaDill weed PepperGarlic Sage Tarragon Mrs. DashThyme Lemon, lime juice

Patients Should Follow a 2000 mg Sodium Diet

How It Shakes Out

½ tsp salt = 1 serving = 3 slices of ham =2 packets of = 3 pickles = 14 green pretzels soy sauce olives

¼ tsp salt = 600 mg sodium½ tsp salt = 1200 mg sodium1 tsp salt = 2300 mg sodium More than daily recommendation

Even a small amount of salt counts!

Some common high sodium foods

Frozen meals Pickles

Canned foods Bacon

Breads, baked goods Anchovies

Lunch & smoked meats Soy sauce

Cheese Seasoning mixes

Condiments (salad dressing) Gravy

Olives Salted crackers

Pretzels FAST FOODRule of thumb: the more processed the food, the more sodium it contains

First step: Learn how to read sodium labels on all food

1. Look for SodiumListed as milligrams or mg

2. Next, look at serving sizeIf you eat 2 servings of a foodyou need to double what yousee on the label

3. Reduced-sodium products still contain sodium

Always read the label

Sodium Guidelines < 140 mg = low sodium Enjoy these foods!

140-400 mg = medium sodium Use food in moderation

> 400 mg = high sodium Use this food sparingly

Low sodium 140 mg or less sodium per serving

Very low sodium 35 mg or less sodium per serving

Sodium-free Less than 5 mg sodium per serving

1. Use salt substitute or other spices when cooking (watch for high potassium in some substitutes)

2. Don’t add salt at the table

Fluid intake & Daily Weights

Limiting fluid intake: important in managing heart failure

REMEMBER: Anything liquid at room temperature is considered a fluid

Daily weights: every morning at the same time using the same scale

Keep track of daily weights

REMEMBER: You might not see swelling until you are 8-15# up

Exercise: Get Off the Couch!

Exercise Will Improve Your Quality of Life

Pick a simple aerobic activity that you enjoy Start slowly and increase gradually

Need to move large muscle groups Walking is a great first choice Resume activities you stopped (gardening, bowling, fishing)

Work your way up to 30 minutes most days Doesn’t have to be 30 minutes in a row Warm up and cool down

Check with your physician first if You are really out of shape, uncertain about your abilities, or have

shortness of breath with very mild activity

Exercising & Precautions

Find an indoor location along with a partner

Build muscle (stretching, elastic bands, light weights)

Overexertion Shortness of breath that prevents you from completing a

sentence or doesn’t get better with rest Dizziness, chest pain, nausea, vomiting, severe sweating,

unusual fatigue (extreme)

What Medications Do We Use in Heart Failure and Why?

Diuretics Digitalis Beta-blockers ACE inhibitors Hydralazine/nitrates Spironolactone

1. To reduce symptoms

2. To prevent disease progression

3. Keep patients out of the hospital

4. Improve survival

Be careful about alternative therapy (chinese herbs, hawthorne, ginseng): No evidence they help & associated with some negative effects

Why Do We Use These Treatments?

Heart failure limits a patient's ability to perform the routine activities of daily living…

Diuretics, ACE Inhibitors

Reduce the number of sacks on the wagon (or load on the heart)

ß-Blockers

Limit the speed, thus saving energy

Spironolactone, Cardiac Resynchronization Therapy

Increase the heart’s efficiency

What if the Heart is Still Weak After Medications?

Risk of death from cardiac arrest Defibrillators can protect the heart from these

abnormal rhythms

Based on the ejection fraction

History of Pacemakers & Defibrillators

What if the Heart is Still Weak After Medications?

The heart “pump” worsensNewer devices can be implanted to help the heart’s contraction

1. Pacemakers (resynchronization)2. Ventricular assist devices3. Clinical trials: investigational

devicesHeart transplant

Pace both ventricles of the heart to make it stronger & more efficient

Ventricular Assist Devices

Try to be as active as possible with the following limitations: No driving No contact sports No high “bounce” activities like

running, jumping, or jumping jacks No submerging in water. Stay out

of bathtubs, hot-tubs, swimming pools, lakes & ponds

Do not drive or operate heavy machinery

Continue to follow heart failure recommendations: sodium and fluid restriction, daily weight

Indications for Mechanical Circulatory Support in Advanced HF

Bridge to Transplant (BTT) Non-reversible left heart failure High mortality risk Candidate for cardiac transplantation

Destination Therapy (DT) Not a candidate for cardiac transplantation

Bridge to Recovery Potentially reversible (post-heart attack, post-

pregnancy, myocarditis)

ADULT HEART TRANSPLANTATION % OF PATIENTS BRIDGED WITH MECHANICAL CIRCULATORY SUPPORT* (Transplants: 1/2000 – 12/2009)

0

10

20

30

40

50

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

% o

f p

ati

en

ts

* LVAD, RVAD, TAH

Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

History of Heart Transplantation at Ohio State University

Heart transplant program started in 1986 To date, have performed 382 transplants

Includes a joint heart/kidney transplant program Average 15 transplants per year

Around 2000-2500 transplants in the nation per year Approximately 3500 reported worldwide per year

Cardiac Transplantation:Are There Gender Differences in Transplant Rates?

Of total reported transplants, what % patients are women?a. 25-30%b. 50-60%c. 70-75%

International Statistics (ISHLT registry)

Of 22,387 reported heart transplants between 2002-2010, 77% were men

Improved to 31% women for Jan 2011 to Dec 2011

Is the OSU transplant program similar?

11 of 37 transplants are women – 27% (Past 3 yrs - 1/2010 to present)

Current waitlist – around 20% are womenTaylor DO, et al. JHLT 2009;28:1007-22 ISHLT online registry www.ISHLT.com

Increased load on the heart

Decreased output from the heart

Impaired kidneyfunction

Increased water& sodium retention

Diminished blood flow to the kidney

NeurohormonalActivation

The Heart-Kidney Relationship in Heart FailureDysfunction of one affects the other

Poor absorption of drugsand drug delivery to kidney

NeurohormonalActivation

Costanzo MR et al. JACC 2005;46:2047-2051.

Ultrafiltration for Acute Heart Failure

Mechanical removal of excess volume

Safe and effective Patients on high dose diuretic

(diuretic-resistance) Caution: Not a substitute for

dialysis as waste products are not removed with this method

Clinical Trials at OSU:Measuring Pressures in the Heart Invasively for HeartFailure Management

LARA

Modified PDAPowers through clothing

Alerts patient to monitor

‘DynamicRX®’ calculates

pressure and instructs patient

on management

Meds

Activity

Clinician contact Based on physician’s

prescription for specific values

obtained

Left Atrial Pressure SensorLeft Atrial Pressure Sensor

Measure pressures as an indication of fluid status

Clinical Trials at OSU:Measuring Pressures in the Heart Invasively for Heart Failure Management

Measure pulmonary artery pressuresfor assessment of fluid

15 mm

No batteryNo leads

Stem Cell Therapy and Heart Failure: Still being studied

Sleep Apnea and Heart Failure

People with heart failure have a high risk for sleep apnea

If not treated, sleep apnea can cause: Drop in oxygen levels The heart rate to speed up A rise in the blood pressure Changes to the heart rhythm Stroke Heart attack

or an episode of heart failure

Normal breathing pattern

Central sleep apnea: no breathing(apnea) alternates with rapid

breathing

Friends and Family Emotional support helps a patient have a more positive outlook on life

Allow the patient to make decisions regarding health care and lifestyle behaviors

Positive reinforcement

Discuss fears about heart failure

Discuss advanced care planning

Don’t forget to take care of yourself: eat healthy, exercise, sleep

Advanced Care Planning Not giving up Focus is on caring for the patient in a way that meets your

wishes Key is communication Goal is to reduce stress on the patient Consists of

Advanced care directive Do-not-resuscitate order Power of attorney Living will Financial plan

Advanced Care Planning Palliative care

Support program that focuses on comfort and reducing symptoms, pain. The disease is no longer responsive to curative treatment.

Hospice care Support program for the patient and family through the dying

process. Focus is also comfort and to help with bereavement. Nurses, chaplains, therapists, bereavement counselors, social

workers and physicians

Conclusion: Call your healthcare provider for these symptoms. . .

A change in shortness of breath, fatigue, or swelling

Requiring more pillows than usual to sleep comfortably at night or needing to sleep in a recliner

Chest pain

Near fainting or fainting

Weight gain of 2 lbs in one day or 5 lbs in one week

Conclusion: Living with Heart Failure

See your physician regularly

Weigh yourself daily & call your RN/MD if gaining

Limit salt and fluid intake

Exercise at a level recommended by your physician

Avoid smoking

Keep your flu and pneumonia vaccines current

Take your medications

Take an active role in managing your health!

For More Information About Heart Failure…

The Heart Failure Society of America via their website:

Patients and caregivers– www.abouthf.org