Tom's case historyTom, aged 76 has a 10 year history of IHD, AF, NIDDM, COPD and OA. He lives with his wife, Norma, aged 72, who has HPT and RA. Their 2 sons live interstate.Tom has had 2 MIs, 1994
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1. Chronic Heart Failure check
Tom’s case history
Tom, aged 76 has a 10 year history of IHD, AF, NIDDM, COPD and OA. He lives with his wife, Norma, aged 72, who has HPT and RA. Their 2 sons live interstate.
Tom has had 2 MIs, 1994 & 1997, followed by CABG in 1998. Also repair AAA in 1999 and femoral angioplasty for claudication in 2000.
Because of recurrent chest pain, Tom recently underwent coronary angiography which failed to demonstrate any native vessel or graft stenosis amenable to either stenting or redo bypass surgery. Over the last 12/12 he has had 3 admissions to hospital of exacerbations CHF.
He is constantly tired, SOB on walking 20m on the flat, and gets angina on cold or windy days at similar distances.
Clinical examination revealed the following features:
Radial pulse 68, reg
AB 12cm from midline in the 6th IC space
Loud pansystolic murmur at the apex
Occasional crackles in lung bases
Slight pitting oedema of the ankles
3. Tom’s current medication (daily unless otherwise stated):
Metoprolol 50mg bd
Glyceryl trinitrate patch 50m
Glucosamine suophate 1500mg
Paracetamol 1g qid prn
Fluticasone 150 mcg
4. Definitions, epidemiology, aetiology and pathogenesis
Heart failure is a growing public health problem causing considerable financial and health management difficulties within the community. Aging, the high prevalence of HPT, IHD, and the increasing prevalence of NIDDM, all contribute to the growing burden of CHF. There is also an increase in the rate of diagnosis of the condition as a result of greater recognition and the use of echocardiography.
Although the exact figures are not known, it is estimated that over 300,000 Australians are being treated for CHF, with 30,000 new cases diagnosed each year. Because of the difficulties in obtaining accurate epidemiological data the exact number may be up to half a million Australian. In 2002 heart failure accounted for a little over 2700 deaths in Australia, or 20% of all deaths. Death rates among indigenous Australians were almost three times as high as that for other Australians and affected this population at a much younger age group.
Definitions, epidemiology, aetiology and pathogensis
What is the definition of heart failure?
How many patient such as Tom are being treated for CHF in your practice?
How would you determine this number more accurately?
List 3 factors which have contributed to Tom’s CHF.
Define systolic heart failure and diastolic failure.
How are systolic and diastolic heart failure reliably diagnosed?
List 3 conditions causing systolic heart failure and 3 conditions causing diastolic heart failure.
What type of heart failure do you believe Tom has?
What is the role of the neuroendocrine system in the pathogenesis of cardiac failure?
6. Classification of severity and prognosis in heart failure
The New York Heart Association (NYHA) classification of CHF is the most widely used means to classify the severity of symptoms and relate these to prognosis.
The New York Heart Assocation (NYHA) classification of CHF and approximate 1 year mortalities (%) derived from trials
Class I No symptoms* but LVF 5%
Class II Symtpoms on ordinary activity (moderate exertion) 10%
Class II Symptoms at less than ordinary activity (mild exertion) 20%
Class IV Symptoms at rest 50%
* Dyspnoea, fatigue, chest tightness
Classification of severity and prognosis in heart failure
Based on Tom’s history, which classification applies to him, using the NYHA criteria?
What signs of heart failure does Tom have and how well is his CHF controlled?
8. Clinical manifestations of heart failure
The 2 pathophysiological factors that lead to clinical symptoms in CHF are:
Reduction in cardiac output
These factors cause the symptoms of cardiac failure.
Fluid retention and accumulation cause:
Paroxysmal nocturnal dyspnoea
Hepatic congestion, and
Reduction in cardiac output causes:
9. Clinical manifestations of heart failure
What are the 3 typical presentations of patients who have cardiac failure?
List 3 signs of left heart failure and 3 signs of right heart failure.
You are called to visit Tom in the early hours of the morning because of sudden onset of SOB and cough. As you are aware, Tom also suffers from COPD. How would you clinically assess whether he is having an exacerbation of his heart failure or a sudden deterioration in his COPD?
10. Investigation of patients with symptoms of heart failure
Investigations are used to confirm the diagnosis, assess the severity of the condition, and identify precipitating factors. Results provide baseline to gauge response to treatment.
The National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand have produced clinical practice guidelines for the management of CHF. The diagnostic algorithm provided in Appendix 1 summarises the diagnostic approach and is reproduced from the guidelines which are also available at www.heartfoundation.com.au/downloads/cont.mangement.pdf
11. Investigation of patients with symptoms of heart failure
In regard to the routine management of Tom, list investigations which you might perform/arrange in assessing his ongoing cardiac function and associated management.
What changes might you note on CXR in a patient such as Tom?
What changes might you note on Tom’s ECG?
Does Tom require an echocardiogram?
List 6 parameters which would be reported on if you arrange an echocardiogram on Tom.
An important role for GPs involved in the care of patients with chronic and complex diseases such as Tom’s, s to be vigilant about possible complications that may arise as a result of these conditions and have preventive strategies in place to foreshodow and manage these complications. Therefore appropriate management involved appreciation of the biopsychosocial model of care and applications of the principles of interdisciplinary care. This is discussed further in the Management section.
It is beyond the scope of this check program to discuss in detail the management of every possible complication. However acute heart failure is common and Tom has already had 3 admissions in the past 12/12 for acute heart failure. You have just been called out to a further episode that requires hospitalisation.
Acute heart failure is usually accompanied by acute pulmonary oedema (APO) caused by increased pulmonary arterial wedge pressure and leakage of fluid from the pulmonary capillaries into the alveoli. The reduced diffusing capacity of oxygen causes SOB.
List 10 possible complications Tom may experience as a result of his condition.
List 5 factors that may have precipitated Tom’s acute heart failure.
List the 5 essential management strategies in acute heart failure.
14. Management of chronic heart failure
Considerable improvement in the quality of life of patients with CHF may be made through early detection of at risk patients (eg. Hypertensives, those with IHD, diabetics), aggressive management of all cardiac risk factors and associated comorbidities, and achieving an optimal therapeutic relationship with the patient through appropriate education to maximise compliance with therapy.
In patients with Class II – IV, studies have demonstrated the benefits of integrated multidisciplinary patient management programs. General practitioners should take advantage of the chronic disease item numbers and Medicare Plus Package in managing patients with CHF. The management team may consist of the GP, cardiologist, practice nurse or local CHF nurse, pharmacist, carer, and NHF telephone support system (currently being trialled) These care systems have been shown to reduce hospital readmission rates.
Application of the knowledge gained from research into the pathophysiology of CHF and the role played by the sympathetic nervous system and the renin-angiotensin-aldosterone system has vastly improved the efficacy of tretment in CHF. This applies particularly to the introduction of beta blockers, ACE inhibitors, angiotensin recepetion blockers (ARB) and aldosterone antagonists into the formulary. Although most of the clinical trials have been done in systolic heart failure patients with LVEF <40%, these drugs are used more widely in all forms of heart failure.
As many patients with CHF have a range of comorbidities and received polypharmacy, the potential for drug interactions as well as side effects is great.
15. Management of chronic heart failure
List five nonpharamacological measures you would strongly encourage Tom to adopt to improve control of his CHF.
Given your knowledge of CVD risk factors, which 2 drugs are notably omitted from Tom’s drug list?
In view of Tom’s clinical symptoms and recent episode of acture heart failure, some adjustments to this therapy may be needed. What adjustments would you make?
16. Terminal care of patients with heart failure
Six months later, despite seemingly optimal therapy, Tom suffers a further myocardial infarct and is admitted to hospital in acute heart failure. He remains in hospital for 3 weeks with ClassIV symptoms and requires high doses of diuretics to maintain euvolaemia. His renal function deteriorates. He remains SOB at rest. The hospital contacts you as they plan to discharge Tom and feels that palliative care support may be needed.
17. Terminal care of patients with heart failure
What factoris relating to both Tom and his wife, Norma, need to be considered at this stage to support Tom at home? What organisations, services or individuals may be able to help?
What measures could assist Tom with symptoms control?