1 / 60

Heart Failure Orthopedic Nurses Education Day

Heart Failure Orthopedic Nurses Education Day. Jeffrey P Schaefer MSc MD FRCPC October 30, 2006. Objectives. Heart Failure definition epidemiology prognosis diagnosis management. What is Heart Failure?.

crystal
Download Presentation

Heart Failure Orthopedic Nurses Education Day

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Heart FailureOrthopedic NursesEducation Day Jeffrey P Schaefer MSc MD FRCPC October 30, 2006

  2. Objectives • Heart Failure • definition • epidemiology • prognosis • diagnosis • management

  3. What is Heart Failure? A complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. American College of Cardiology 2001

  4. Cardinal Manifestations of HF dyspnea fatigue fluid retention “and / or” limits exercise tolerance peripheral edema pulmonary congestion impairment of Functional Capacity and QOL

  5. Incidence of CHF

  6. Staging of Heart Failure NYHA Cardiac Status • Class I: uncompromised • Class II: slightly compromised • Class III: moderately compromised • Class IV: severely compromised • updated from old NYHA Classification • ‘usual activities’ ‘minimal exertion’

  7. Specific Activity ScaleGoldman Circulation 64:1227, 1981 Stage I • patients can perform to completion any activity requiring 7 metabolic equivalents • can carry 24 lb up eight steps • carry objects that weigh 80 lb • do outdoor work [shovel snow, spade soil] • do recreational activities [skiing, basketball, squash, handball, jog/walk 5 mph]

  8. Specific Activity ScaleGoldman Circulation 64:1227, 1981 Stage II • patients can perform to completion any activity requiring 5 metabolic equivalents • have sexual intercourse without stopping • garden, rake, weed, roller skate • dance fox trot, walk at 4 mph on level ground • but cannot and do not perform to completion activities requiring 7 metabolic equivalents

  9. Specific Activity ScaleGoldman Circulation 64:1227, 1981 Stage III • patients can perform to completion any activity requiring 2 metabolic equivalents • dress, shower without stopping, strip and make bed, clean windows • walk 2.5 mph, bowl, play golf, dress without stopping • but cannot and do not perform to completion any activities requiring 5 metabolic equivalents

  10. Specific Activity ScaleGoldman Circulation 64:1227, 1981 Stage IV • patients cannot or do not perform to completion activities requiring 2 metabolic equivalents • CAN’T: • dress without stopping • shower without stopping • strip and make bed • walk 2.5 mph • bowl, play golf

  11. Prognosis of HF = generally poor JACC 1993;22:6A-13A

  12. Progression of Cardiac Status • most patients do not show an uninterrupted and inexorable deterioration • deterioration may be independent of LV function

  13. Drug Therapy Improves Outcome

  14. Diagnosis of Heart Failure • Heart Failure is mainly a clinical diagnosis • HF is correctly diagnosed initially in 50% of affected patients. Eur Heart J 1991 • High Index of Suspicion • is your patient at risk??? • “““Rapid Onset Heart Failure””” … • did we under appreciate the findings?

  15. Symptoms of Heart Failure • pulmonary • resting or exertional dyspnea • orthopnea • paroxysmal nocturnal dyspnea • cough • wheezes ‘Cardiogenic Asthma’

  16. Symptoms of Heart Failure • other volume issues • nocturia • lower limb edema • gastrointestinal symptoms • abdominal bloating • anorexia • fullness in the right upper quadrant • fatigue • cachexia

  17. Signs of Heart Failure • delirium • vital signs - normal or abnormal • fluid weight gain • peripheral edema • detected when extracellular volume > 5 l • stasis dermatitis • chronic venous stasis • hyperpigmentation • ulceration

  18. Signs of Heart Failure elevation of JVP > 4.5 cm spec = 90% sens = 30% Distinguishing JVP/CP variation with respiration variation with position varies with hepatic pres occludes non-palpable wave form Palpate Contralateral Carotid Artery - if what you FEEL is not= to what you SEE --> JVP

  19. Signs of Heart Failure • S3 (Ken-tuc-ky) • sensitivity for HF = 24% • specificity for HF = 99% • S4 (Ten-nes-see) • reduced ventricular compliance • pulmonary examination • crackles (may be absent even with edema) • signs of pleural effusion • wheezes

  20. B-type Natriuretic Peptide (BNP)

  21. Post-op HF Labs CBC exclude anemia, adequate platelets Electrolytes diuretic effect on potassium low sodium is c/w heart failure Creatinine diuretic response safety of ACE / ARB Mg arrhythmia risk Albumin edema issues Troponin T recent myocardial infarction? INR and PTT in case of heparin or thrombolytics Type & Screen in case transfusion needed

  22. Post-OP HF: labs • Chest Radiography • ‘the best chest examination’ • Electrocardiography • confirm rhythm • LVH? • ischemia? • Echocardiography • variably helpful • Thallium • variably helpful

  23. Diagnostic Imaging

  24. ‘Congestive’ heart failure Pulmonary Edema indistinct arteries interstitial markings increased redistributed peribronchial cuff pleural effusions Ventricle enlargedincreased CT ratio enlarged silhouette

  25. Interstitial Pulmonary Edema

  26. What’s wrong here? Small Cardiac Silhouette this effusion is from tuberculosis

  27. Common causes of Heart Failure • Heart Failure = High Operative Risk • patients should not go to OR if heart failure is not controlled Risk Calculator http://www.vasgbi.com/riskscores.htm • Poor left ventricular function • coronary artery disease • hypertension • Valvular heart disease • Fluid Retention

  28. Other causes of Heart Failure Infections (viruses (including HIV) bacteria, parasites) Pericardial diseases Drugs (alcohol, doxorubicin, cyclophosphamide, cocaine) Connective tissue disease Infiltrative disease (e.g., amyloidosis, sarcoidosis, hemochromatosis, malignancy) Persisting tachycardia Obstructive cardiomyopathy Neuromuscular disease (e.g., muscular or myotonic dystrophy, Friedreich's ataxia) Metabolic disorders (e.g., glycogen storage disease type 2 [Pompe's disease] and type 5 [McArdle's disease]) Nutritional disorders (e.g., beriberi, kwashiorkor) Pheochromocytoma Radiation Endomyocardial fibrosis Eosinophilic endomyocardial disease High-output heart failure (e.g., intracardiac shunt, atrioventricular fistula, beriberi, pregnancy, Paget's disease, hyperthyroidism, anemia) Peripartum cardiomyopathy Dilated idiopathic cardiomyopathy

  29. Approach to causes of Heart Failure • Cardiac causes • pericardium • myocardium • endocardium • neuro-electrical system • Non-cardiac causes • pre-load & after-load • other organ dysfunction • anemia, respiratory disease, sepsis… • iatrogenesis & adherence

  30. Cardiac Causes of HF • 1 Pericardium • tamponade, constrictive pericardial disease

  31. Cardiac Causes of HF • 2 Myocardium • ischemia • coronary, non-coronary ischemia (hypoxia / anemia) • cardiomyopathy • dilated: idiopathic, alcoholic, end stage CAD-HTN, peripartum, post-viral • hypertrophic obstructive cardiomyopathy • restrictive: hemochromatosis, amyloidosis, sarcoidosis • endocrinopathy • thyroid, adrenal disease (cortico / pheo)

  32. Cardiac Causes of HF • 3 Endocardium • valvular heart disease (including infective) • tumors (myxomas, sarcomas, melanomas)

  33. Cardiac Causes of HF • 4 Conducting System • tachycardia • mostly atrial fibrillation • hyperthyroidism • sepsis (use acetaminophen in vulnerable febriles) • bradycardia • excess medication effect • third degree heart block

  34. Atrial Fibrillation - with rapid rate

  35. Bradycardia - 28 / min

  36. Non-cardiac Causes of HF • Pre-load issues • too much (or too little) fluid to the heart • Afterload issues • too much (or too little) resistance to arterial flow • Examples of causes • saline, renal dysfunction versus blood loss • medication effect or lack of adherence • other organ dysfunctions • respiratory, sepsis, anemia, thyroid, liver, neuro...

  37. PreloadSalt + Water (Saline)=Pulmonary and Tissue Edema

  38. Fluid Shifts Post-Op

  39. Salt, NSAIDS, Coxibs, TZDs, Nephrotoxins --> Fluid Retention IV contrast (not po)

  40. Afterload --> Hypertension

  41. Medication • Bioavailability • Adherence • we didn’t give • patient didn’t take

  42. 20 mg IV twice as useful as 40 mg po in Heart Failure • Clin Phar Ther 1995

  43. Management of Heart Failure Post-operative Period versus Chronic Ambulatory

  44. Management of Chronic HF A high risk normal heart no HF B abnormal heart no HF C abnormal heart prior or current HF D refractory HF A smoking hypertension lipid / DM lifestyle B ‘A’+ ACE / ARB BB valve dx revascularize C ‘B’ + diuretics digoxin salt restrict D ‘C’ + transplant mech assist IV inotrope hospice

  45. Management of Post-op Heart Failure • Diagnose It !!! • Determine the cause(s) !!! • Remove things that make it worse • cardiac related • non-cardiac related • Initiate things that make it better • cardiac related • non-cardiac related

More Related