Pharmacological Therapy of Heart Failure: Case presentations

Steven W. Harris MHS, PA-C

Heart Failure

Complex diagnosis that results from structural or functional disorder(s) which impair the ability of the ventricle to fill with or eject blood. – ACC 2005

Epidemiology Prevalence

Affects 5+ million Americans currently, >600,000 new cases diagnosed each year. 23 million people worldwide.

Estimates are based only on symptomatic HF.

Cost Annual direct cost is >10 billion dollars

Frequency It is the most common inpatient

diagnosis in the US for patients over 65 years of age

In 2004, there were over one million hospitalizations in the US with a first listed discharge diagnosis of HF

Major Determinants of Cardiac Function

Ventricular systolic function Ventricular diastolic function   Ventricular preload Ventricular afterload Cardiac rate and conduction Myocardial blood flow

Ventricular Systolic Function

Systolic dysfunction accounts for 60-70% of all cases of HF

Ejection fraction decreased 55-65% normal 40-50% mild 30-40% moderate <30% severe systolic dysfunction

NYHA Classification

Class I - symptoms only at activity levels that would limit normal individuals

Class II – symptoms with ordinary exertion (moderate exertion)

Class III - symptoms with less than ordinary exertion (minimal exertion)

Class IV - symptoms at rest

Heart Failure Stages

Stage A — High risk for HF, without structural heart disease or symptoms

Stage B — Heart disease with asymptomatic left ventricular dysfunction

Stage C — Prior or current symptoms of HF

Stage D — Advanced heart disease and severely symptomatic or refractory HF

Classification of HF severity

1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

2New York Heart Association/Little Brown and Company, 1964.

Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.

ACC/AHA HF Stage1 NYHA Functional Class2

A At high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)

B Structural heart disease but withoutsymptoms of heart failure

C Structural heart disease with prior orcurrent symptoms of heart failure

D Refractory heart failure requiringspecialized interventions

I Asymptomatic

II Symptomatic with moderate exertion

IV Symptomatic at rest

III Symptomatic with minimal exertion

None

Treatment Objectives

Decrease Symptoms Improve tissue perfusion Increase exercise tolerance Quality of/Prolong Life /Survival Correct aggravating/precipitating factors:

Arrhythmias Pregnancy Infections Hyperthyroidism Thromboembolism

Endocarditis Obesity Hypertension Physical activity Dietary excess Medications

Preload Afterload Ionotropy Optimize

chonotropy

Neurohormonal activity

Vicious CycleChronic HF

SOB, Wt gain

Providers office

PO Lasix

ER

IV Lasix +/-admit

Home

Case 1

76 y/o moderately obese male with a history of CAD with associated CABG x 4, presents to your clinic c/o dyspnea on exertion, 2 pillow orthopnea, bilateral lower extremity edema.

Case 1 Meds:

Simvastatin 80mg po qhs

Synthroid 125 mcg po qd

Lisinopril 5 mg po qd Metoprolol 50 mg po qd ASA 81 mg 2 tabs po qd

PMH ??

Physical exam: Vitals

BP: 146/78 HR: 78 regular RR: 12 bpm T: 98.6 F SPO2: 95% on

RA JVD at 5 cm

above sternal angle

Bilateral rales to mid lung fields

1+ bilat pedal edema

Case 1

Plan: Diagnostics: Treatment: Patient

Education: Follow-up/

Referrals:

Echocardiogram BMP BNP Lasix 20 mg po

qd KCL 10 meq po

qd f/u in 1 wk

Case 2

65 y/o female who is 6 months s/p AWMI c/o 10 lb weight gain over 72 hours. Associtated sx include orthopnea, pnd, dyspnea at rest and abdominal “fullness”. At the time of discharge 6 months prior she had an ischemic cardiomyopathy with an EF of 50%

Case 2 Meds:

Quit meds ASA 81 mg 1 tab po qd

PMH DM HTN Dyslipidemia

Physical exam: Vitals

BP: 130/78 HR: 100 regular RR: 18 bpm T: 98.7 F SPO2: 90% on

RA JVD at 10 cm above

sternal angle Hepato-Jugular

reflux to angle of mandible

Bilateral rales 2/3 up 1+ bilat pedal

edema

Case 2

Plan: Diagnostics: Treatment: Patient

Education: Follow-up/

Referrals:

Admit to hospital Echocardiogram CMP, BNP, CBC… Lasix 40 mg IV x

1 Then 40 mg po

BID Enalapril 2.5 mg

BID Simvastatin 20

mg qhs Morning labs

Case 2

Morning Results: Diuresed 3 liters Feeling much

better EF 45% BNP 550 Vitals:

BP 122/76 HR 78 RR 12 T 98.6 SPO2 98 % on 2

L Plan

Plan: Wean O2 Carvedilol 3.125

mg BID Continue

Furosemide dose Morning labs

Beta blockers

Case 3

65 y/o male with known history of prior MI and CABG, ischemic cardiomyopathy with an EF of 30% presents to the ER with dyspnea at rest. He states that over the last week he has gained “at least 10 lbs” and has been sleeping in his armchair.

Case 3 Meds:

Carveidolol 12.5 mg BID Lisinopril 5 mg qd Atorvastatin 40 mg qhs Furosemide 80 mg qAM ASA 81 mg 1 tab po qd

PMH HTN, Dyslipidemia ??

Physical exam: Vitals

BP: 110/78 HR: 110 regular RR: 22 bpm T: 98.7 F SPO2: 88% on

RA Sitting upright JVD above angle of

the mandible Hepato-Jugular

reflux to angle of mandible

Diffuse bilateral rales

2+ bilat pedal edema

Case 3

Plan: Diagnostics: Treatment: Patient

Education: Follow-up/

Referrals:

Admit to hospital Echocardiogram CMP, BNP, CBC… Bumetanide 1

mg IV then 0.5 gtt

KCL repletion 2 gm sodium

diet

Case 3 Results

Diuresed 4 liters Weaned from IV

to PO Furosemide 80 mg po qd

Cr 1.5 Slowly gaining

H2O weight What can you

do? Sequential

nephron blockade.

Addition of aldosterone antagonist

Sequential nephron blockade with: Metolazone 2.5

mg po qd Aldosterone

antagonist Spironolactone

25 mg daily f/u labs

K+ in 3 days and one week.

Increased Risk of hyperkalemia if Cr >1.6

Case 3 Consideration of positive inotropes

Dobutamine 2-20 mcg/kg/min IV Indications: insufficient cardiac output Effect: Increase Cardiac output and stroke

volume Comment: Tachycardia, hypertension,

hypotension Dopamine. 2-20 mcg/kg/min IV

Indications: Insufficient cardiac output, hypotension, reduced renal perfusion

Effect: Increase cardiac output, stroke volume, and renal blood flow

Digoxin

Digoxin

Mildly positive inotropic effects Associated with symptomatic

improvement, increase exercise tolerance, and clinical stability

Pts taking digoxin are less likely to be hospitalized (25% reduction) due to CHF.

Additive benefits to Diuretic, ACE, Beta blocker therapy

Case 4

60 y/o male with known history of CAD and prior MI presents to your clinic to establish care. He states that over the last month he has had to double his water pill to keep his legs thin and breathe well at night. His most recent EF was 50% one year ago. Currently he is feeling fine, but has SOB with riding his road bike.

Case 4 Meds:

Enalapril 20 mg qd Cardizem CD 180 mg qd Atorvastatin 40 mg qhs HCTZ 25 mg 2 tabs po

qd ASA 81 mg 1 tab po qd Naproxen 220 mg qd

PMH HTN, Dyslipidemia ??

Physical exam: Vitals

BP: 118/78 HR: 64 regular RR: 12 bpm T: 98.7 F SPO2: 97% on

RA JVD 3 cm above

sternal angle Clear lung fields Trace bilateral pedal

edema

Case 4

Plan: Diagnostics: Treatment: Patient

Education: Follow-up/

Referrals:

DC Cardizem Start:

Carvedilol 6.25 mg BID and uptitrate to 12.5 mg BID in two weeks

DC Naproxen Consider

acetaminophen BMP to eval K+ Echocardiogram F/u 2 weeks

Case 5

80 y/o female c/o of 1 week h/o palpitations and 3 days of SOB and orthopnea

Considerations

African Americans CRF ACE intolerant