3/27/2017 1 Identifying Advanced Heart Failure and Treatment Options Lisa Smith MS, APRN, CCNS Clinical Nurse Specialist Minneapolis Heart Institute Advanced Heart Failure Section Disclosure Information I have the following financial relationships to disclose: None Objectives • Explain characteristics of Advanced/Stage D HF patients and how to recognize • Discuss importance of referrals for patients with Stage D HF patients to advanced HF programs • Identify possible treatment strategies for patients with Advanced/Stage D HF patients.
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Identifying Advanced Heart Failure and Treatment Options · •Heart Failure has high mortality •Medical and device therapies have improved QOL and survival •Inotropes, MCS, transplant
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3/27/2017
1
Identifying Advanced Heart Failure and
Treatment OptionsLisa Smith MS, APRN, CCNS
Clinical Nurse SpecialistMinneapolis Heart Institute
Advanced Heart Failure Section
Disclosure Information
I have the following financial relationships to disclose:
None
Objectives
• Explain characteristics of Advanced/Stage D HF patients and how to recognize
• Discuss importance of referrals for patients with Stage D HF patients to advanced HF programs
• Identify possible treatment strategies for patients with Advanced/Stage D HF patients.
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Stages of HF — ACC/AHA Guidelines 2013
AHigh-risk patients
Hypertension, diabetes, coronary disease, family history, cardiotoxic drugs
BStructural heart disease
LVH, MI, low LVEF, dilatation, valvular disease
C
Prior, current symptoms
D
Refractory
Heart Failure
Jessup M et al, NEJM 2003.
What is Maximal Medical Therapy?
ACE inhibitor or ARB - titrated to goal or tolerance
Beta Blocker - titrated to goal or tolerance
Spironolactone - NYHA class II or III patients
Digoxin - NYHA class III patients
Diuretics - symptoms of congestion
Vasodilators: Hydralazine/Imdur - intolerant to ACE-I/ARB or persistently normotensive to hypertensive on maximal ACE-I & beta-blocker; African American population
ICD +/- CRT (QRS duration key, class IV too late)
European Heart Journal. 2008; 29 (19): 2388-2442
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Signs that a patient may be progressing to stage D HF
Lee 4031 Age, low BP, high RR, high BUN, low Na 69.5
Kittleson 259 No ACE, low BP, low Na, Cr
Felker 949 Age, low BP, NYHA IV, high BUN, low Na
Fonarow 37,772 BUN > 43, SBP < 115, Cr > 2.75
Rector 769 Age, low BP, low Hgb, low Na, high BUN 50
Rohde 779 SBP < 124, Cr > 1.4, BUN > 37, Na < 136, age > 70
Outpatient Risk Studies
Study n Markers
Mahon 585CrCl, 6MW < 262, low EF, recent admit,
diuretic dose
Eshaghian 1354Low EF, low Na, low Hg, high BUN/Cr,
diuretic dose
Greenberg 4280 NYHA III/IV, HF admit, angina
Levy 1125
Diuretic dose, low BP, % lymph, Hgb < 16,
ischemic CM, EF, low cholesterol, high
uric acid/allopurinol, Na < 138, NYHA,
age, male sex
Teuteberg 160High BUN/Cr, low Na, low Hct,
recent admit, no ACE/BB
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Clinical Events/Findings
• >2 hospitalizations or ED visits for HF in past year
• Cardiac Cachexia
• Intolerance to ACEi/ARB or beta blockers
• Dyspnea with bathing or dressing requiring rest
• Unable to walk 1 block on level ground due to dyspnea or fatigue
• Frequent ventricular arrhythmias or ICD shocks
When “optimal medical therapy” fails, what are the options?
• Inotropes
• Mechanical circulatory support
• Transplant
• End of life/palliative measures
Continuous Outpatient Support with Inotropes
• High rates of hypotension, arrhythmia, syncope.
• PROMISE: 53% increase in mortality• Infection/sepsis common• Survival 3.4 months; most died at home• Milrinone as bridge to transplant
– 60 milrinone-dependent patients, listed for transplant
– 76% successfully bridged with milrinone (waited 59 days for txp)
– 24% required LVAD (waited 93 days for txp)– 5 died (waited 130 days for txp)
J Card Fail 2008;14(10): 839-843
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Intermittent Outpatient Inotrope Infusion
• No clinical benefit in randomized trials
– No significant improvement in NYHA class
– No change in 6-min walk distance
– No survival benefit
• High early mortality
– Hypotension
– Arrhythmia
– Ischemia
Circulation 2003; 108:492-497
Hershberger RE, Nauman D, Walker TL, et al. J Cardiac Failure 2003;9:180-7.Rose EA et al. NEJM 2001; 345:1435
Long-Term Inotropic Therapy is Associated with High Rates of Mortality
.
Advanced Cardiac Therapies
Miller LW, Guglin M; JACC 2012
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Ventricular Assist Devices
• Bridge to transplant
• Bridge to recovery
• Bridge to decision/candidacy
• Destination therapy
INTERMACS Profiles(Interagency Registry for Mechanically Assisted Circulatory Support)
1 Critical Cardiogenic Shock
2 Progressive decline on inotropes
3 Stable on inotropes
4 Resting symptoms on oral Rx
5 Exertion intolerant and housebound
6 Exertion limited; “walking wounded”
7 Advanced NYHA class III
Proposed LVAD Candidate “Triggers”
1. Acute cardiogenic shock (temporary device)
2. Refractory ventricular arrhythmia
3. Need for inotrope >24 hours
4. Intolerant or refractory to ACEi/ARB/BB
5. QRS > 140 ms without or refractory to CRT therapy
6. Inability to walk one block without SOB despite adequate medical therapy
7. Multiple HF-related hospital admissions
8. Diuretic dose > 1.5 mg/kg/day
9. Serum sodium < 135 mmol/L
10. BUN > 40 mg/dl or Serum Creatinine > 1.5 mg/dL
Russell SD, et al. Advanced Heart Failure: A Call to Action. Congestive Heart Failure 2008.
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Patient Selection
• Major advantage to elective implant; crisis management should be as a bridge to decision or temporary device
• No penalty for early referral• Nobody is sorry to hear “You don’t need this…yet”• Pre-operative pulmonary hypertension a good sign RV
can pump effectively: worry about the dilated RV with low PA pressures and high PCWP
• Significant pulmonary venous hypertension tends to respond very well
• Most patients need time to digest the concept
Do’s and Don’t’s• DO:
– Discuss and consider VAD when NYHA III– Consider with poor functional capacity and frequent
decompensations and hospital admission– Consider if frequent arrhythmias– Have a low threshold for RHC
• DON’T:– Wait for progressive renal dysfunction– Wait for multiple pressors– Wait for cardiac cachexia– Necessarily assume PA pressures contraindicate
Cardiac Transplant
• Gold standard for treatment of refractory end-stage HF
• First successful transplant done in 1967
• Advances in immunotherapy have significantly improved longterm survival