Heart Failure 2011 Cardiac Issues Robert A. Ortiz, M.D., F.A.C.C. Yakima Heart Center.

Heart FailureHeart Failure2011 Cardiac Issues2011 Cardiac Issues

Robert A. Ortiz, M.D., F.A.C.C.Robert A. Ortiz, M.D., F.A.C.C.Yakima Heart CenterYakima Heart Center

Heart Failure Definition

Syndrome Caused by Cardiac Dysfunction:Myocardial Muscle Dysfunction or Loss.

LV dilatation and/or hypertrophy.

Neurohormonal and Circulatory Abnormalities:

Fluid Retention.

Dyspnea.

Fatigue.

Progressive decline if left untreated.

Symptoms vary with time and sometimes do not correlate with the degree of heart dysfunction.

Subgroups of HF

Heart Failure with a Reduced LVEFDilated Cardiomyopathy

Ischemic Cardiomyopathy

Commonly associated with Chamber Enlargement

Heart Failure with a Preserved LVEFCommonly Non-Dilated LV

Potential Causes

Valvular disease, Cardiac Ischemia (RVMI), Pericardial disease, HTN, Renal disease, Hypertrophic HD, Rhythm problems, …

To Do ListFirst - Make the Diagnosis

Second - Determine the Potential Causes

Third - Clinical Assessment (Brief)

Forth - Initiate Early TreatmentFrequent Reevaluation (Treatment Adjustment)

Fifth - Transition to Chronic TreatmentSurgery, Bi-V pacing, ICD, Sleep Apnea Rx, …

Sixth - Patient Education

Diagnosis

* Primarily on Signs and Symptoms *

If uncertain BNP or pro-BNP may help support the diagnosis

BNP or pro-BNP should not be viewed in isolation to make the diagnosis of heart failure.

Treat the Cause Not Just the Symptoms

This is especially True for HF with Preserved LV systolic function, since there may be a structural problem that requires surgical intervention.

The History is frequently the Key to determining the Cause. Diagnostic Tests just help confirm the initial impression. ECG, Echo, Cath, X-rays and Labs.

Look for things that don’t make sense:Expect the Unexpected.Heart Failure is a Syndrome with many potential causes, which may occur simultaneously.

Heart Failure with Preserved LVEF

Dilated LVDilated LV NonNon --dilated LVdilated LV

Valvular diseaseValvular diseaseAR; MRAR; MR

No valvular No valvular diseasedisease

High output HFHigh output HF

Increased thicknessIncreased thickness Normal thicknessNormal thickness Right Ventricular Dysfunction*Right Ventricular Dysfunction*

Mitral obstructionMitral obstructionMS; Atrial myxomaMS; Atrial myxoma

Normal or Increased Normal or Increased QRS voltage QRS voltage

Hypertrophic diseaseHypertrophic disease

No mitral No mitral obstructionobstruction

Pulmonary Pulmonary HypertensionHypertension

Hypertensive Hypertensive HxHx or PEor PE

HypertensiveHypertensive --hypertrophichypertrophiccardiomyopathycardiomyopathy

Isolated or Isolated or predominant RVMIpredominant RVMI

Low QRS voltageLow QRS voltageInfiltrative myopathyInfiltrative myopathy

No Aortic valve No Aortic valve diseasedisease

Inducible ischemiaInducible ischemiaIntermittent/activeIntermittent/active

ischemiaischemia

No inducible ischemiaNo inducible ischemiaFibrotic; collagenFibrotic; collagen --vascular;vascular;Restrictive CM; carcinoid; Restrictive CM; carcinoid;

Reconsider diagnosis of HFReconsider diagnosis of HF

No pericardial No pericardial diseasedisease

Pericardial diseasePericardial diseaseTamponade /ConstrictionTamponade /Constriction

Aortic valve diseaseAortic valve diseaseAortic stenosisAortic stenosis

No Hypertensive No Hypertensive HxHx or or PEPE

Hypertrophic Hypertrophic cardiomyopathycardiomyopathy

LVEF=left ventricular ejection fraction; HF=heart failure; QRS= electrocardiographic ventricular depolarization; AR= aortic regurgitation; MR= mitral regurgitation; MS= mitral stenosis ; RVMI=right ventricular myocardial infarction; Hx=history; PE= physical examination.

* Some patients with right ventricular dysfunction have LV dysfunction due to ventricular interaction.

References: 1. Stevenson LW. Tailored therapy to hemodynamic goals for advanced heart failure. Eur J Heart Fail. 1999;1:251-257. Available at: http://www.sciencedirect.com/science/journal/13889842. 2. Fonarow GC. The treatment targets in acute decompensated heart failure. Rev Cardiovasc Med. 2001;2(suppl 2):S7-S12.

Warm & DryPCWP* normal

CI† normal(compensated)

Warm & WetPCWP elevated

CI normal

Cold & DryPCWP low/normal

CI decreased

Cold & WetPCWP elevatedCI decreased

Congestion at rest

Low perfusionat rest

Vasodilators,diuretics

No

No

Yes

Yes

Normal SVR High SVR

*Pulmonary capillary wedge pressure.†Cardiac index.

Clinical Assessment

Initial TreatmentEarly Treatment leads to better outcomes and shorter hospital stays. Treatment should begin immediately following the clinical assessment. Oxygen therapy, IV access.

ABC of CHF - This is a heart failure CODE.

Don’t Assume the Initial Treatment will work. Early reassessment at 15 minute intervals until clinical improvement becomes apparent.Use Tests and Labs to guide treatment!

Even better - Use your brain to guide treatment.

Initial TreatmentLoop Diuretic Therapy - For elevated volume status.

At least the home dose in an IV bolus or drip.

ACE Inh, ARB, Hydralazine, NTG/Nipride - Perfusion?

IV versus Oral versus Topical?

How stable? Is the BP low or high?

Beta blockers - Appropriate or not?Is their elevated HR their method for compensation?

Is the HR already too slow?

What other medical problems do they have?

Initial TreatmentInotropic support?

Poor perfusion or shock?

Hemodynamic monitoring - Art line?

ECG, Oxygen saturation and ICU monitoring.

Monitor urine output - Foley catheter is not always needed.

Central venous line is not always needed.

Ultrafiltration or Dialysis?Sodium and water removal or is more needed.

Initial TreatmentRhythm Support?

Temporary Pacing?

Atropine, Dobutamine, Dopamine?

IABP/Impella support?

Revascularization - PCI?

Intubation and Mechanical Ventilation?

Other Treatments?

Blood transfusion, phlebotomy, SCD, CPAP/Bipap, narcotics or reversing agents, …

Initial TreatmentConcepts to Remember:

Stabilize first. Monitor vitals, urine output and Wt.

Prioritize and treat the various problems.

Example: If they are volume overloaded and anemic, get the fluid off first then transfuse.

First do no harm.

If the patient is still unstable avoid adding a treatment that might make them better but has a significant risk of causing an acute decompensation - commonly seen with Beta blocker therapy for a compensatory sinus tachycardia.

Non-invasive test are preferred to tests that might impair kidney function or respiratory status.

Keep the patient as informed as possible, given the circumstances. Patient comfort is also key to recovery.

Chronic TreatmentThe goal now is to transition from acute care management to chronic therapy:

Stable oral meds for at 24 hours prior to discharge.

Arrange any surgical referrals if needed:

CABG, valve surgery, pericardial surgery, pacing/ICD therapy, dialysis catheter, …

Chronic outpatient treatments to be arranged:

Sleep apnea evaluation.

Dialysis.

Cardiac rehab and diet education.

Out patient follow-up and Home Health Care.

Patient EducationWhat Questions Should Patients be Asking?

What is Heart Failure? (Their type)

What is the Prognosis? (For them)

What can they do to Prevent further problems?

Would any Surgery help?

What Special Treatments might help?

Pacemakers/ICD, Dialysis, CPAP/Bipap, …

Would Rehab and additional Education help?

Understanding the Patient and their problems are key to finding the right answers.

Death due to Heart Failure

50% due to progressive multisystem failure.

50% due to sudden cardiac death.

Presumably V-fib or V-tach.

Other causes: Pulmonary emboli, aortic dissection, stroke.

“Yes, but how soon before I die?!”Depends!

Clinical Trials and the Clinical Trials and the Real WorldReal World

Clinical TrialsClinical Trials

Demographics:Demographics:

80% Male.80% Male.

Average age 60 years.Average age 60 years.

Low LVEF.Low LVEF.

Few Co-morbidities.Few Co-morbidities.

Yearly mortality:Yearly mortality:

About 20%.About 20%.

Real WorldReal World

Demographics:Demographics:

60% Female.60% Female.

Average age 80 years.Average age 80 years.

Half the patients had Half the patients had preserved LVEF.preserved LVEF.

5 or more Co-morbidities.5 or more Co-morbidities.

Yearly mortality:Yearly mortality:

About 35%.About 35%.

Goals for Medical Treatment

Address the Risk Factors. Predictors of Higher Mortality:

BUN >43, Creatinine >2.75, SBP <115

Is Sleep Apnea or Renal Failure present?

Is there a need for CRT and/or ICD?

CRT can improve symptoms and possibly survival.

ICD may improve survival but not symptoms.

Determine if Surgery is needed:

PCI or surgical revascularization.

Valve surgery or pericardial stripping.

Heart transplant or a cardiac assist device.

Determine if Hospice is Appropriate.

HFSA 2006 Practice Guideline (3.2)

HF Risk Factor Treatment Goals

Maximum 2-3 g/dayDietary Sodium

CessationSmoking

Men ≤2 drinks/day, women ≤1Alcohol

Weight reduction < 30 BMIObesity

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

See NCEP guidelines2Hyperlipidemia

See ADA guidelines1Diabetes

Generally < 130/80Hypertension

GoalRisk Factor

Adapted from: Adams KF, Lindenfeld J , et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

1. Diabetes Care 2006; 29: S4-S42.2. J AMA 2001; 285:2486-97.

CRT: Bi-Ventricular CRT: Bi-Ventricular PacingPacing

ACC Update for 2009ACC Update for 2009

ACC Update for 2009ACC Update for 2009

ACC Update for 2009ACC Update for 2009

Old and New IdeasWhat’s more important Pulmonary Artery Pressure or Cardiac Index in determining outcome? The rational for medical therapy.

Atrial Fibrillation: Is rhythm control better than rate control? Equivalent.

What is Ultrafiltration and is there any measurable benefit beyond the rapid removal of fluid and a potentially shorter hospital stay?

Drug Therapy may vary based on Race.

Blacks may benefit from Fixed dose Hydralazine/Isosorbide on top of standard drug therapy.

Side effects of medical therapy may also vary between races.

Old and New IdeasWhat ever happened to Nesiritide?

The IV drug nesiritide isn't especially better than standard treatment for patients with acute decompensated heart failure (ADHF), nor does it seem to hurt the kidneys or increase mortality, suggests a >7000-patient trial now published in the July 7, 2011 issue of the New England Journal of Medicine.

FUSION 2: No advantage to outpatient nesiritide infusions in advanced chronic heart failure, but no harm either.

"Clearly," Yancy said, "an unmeasured, but we think very substantial, benefit of intensive heart-failure disease management—based on the once- or twice-weekly clinic visits, four to six hours at a time, with a concomitant observed improvement in medical therapy during the initial 12-week assessment period—mattered. We believe that the patients in FUSION-2 received not standard care but extraordinary care."

PCWP predicts mortality1

CI† does not predict mortality1

1-year survival rate for patients with PCWP <16 mm Hg was 80.8% vs 64.1% in patients with PCWP >18 mm Hg1

*Pulmonary capillary wedge pressure.†Cardiac index.

Hemodynamic assessment of 456 heart failure patients after tailored therapy.

Reference: 1. Fonarow GC. The treatment targets in acute decompensated heart failure. Rev Cardiovasc Med. 2001;2(suppl 2):S7-S12.

n=236

n=220 p=NS

241812600

10

20

30

40

50

60

Time (months)

Mor

talit

y ris

k (%

)

Cardiac index >2.6 L/min-M2

Cardiac index ≤2.6 L/min-M2

n=199

n=257 p=0.001

241812600

10

20

30

40

50

60

Time (months)

Mor

talit

y ris

k (%

)

PCWP >16 mm HgPCWP ≤16 mm Hg

Adapted from: Fonarow GC. Rev Cardiovasc Med. 2001.

Rational for Vasodilator TherapyRational for Vasodilator Therapy

EpilogHeart Failure is the common final pathway of Life.

Many effective treatments have been developed to correct the acute problem, but real success in the form of decreased morbidity and mortality is likely to depend on chronic outpatient management.

This problem really is too big for Cardiology or Internal Medicine or Family Practice to manage without some help.

The patient’s willingness to take responsibility for their own health is the factor that will likely determine their long-term outcome.

The education that they receive in the process of being treated will hopefully empower them to control their own destiny.