Outpatient management of heart failure
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Outpatient management of heart failure. Dr. Rob Wu Feb 2008. Case. 86 year old woman recently discharged from Team with heart failure arrives at clinic for follow up Echo done in hospital – EF 58%, normal valves PMH: HTN, osteoporosis, osteoarthritis, DM2

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Case

  • 86 year old woman recently discharged from Team with heart failure arrives at clinic for follow up

  • Echo done in hospital – EF 58%, normal valves

  • PMH: HTN, osteoporosis, osteoarthritis, DM2

  • Meds: ASA, tylenol, ramipril 5 mg daily, metoprolol 25 mg po bid *, spironolactone 25 mg po daily *, furosemide 40 mg po bid *, arthrotec 75mg po bid, diabeta 5mg bid, avandia 4mg daily , fosamax

  • Currently, feels ok, no orthopnea, PND or ankle swelling

    * - new medications, started in hospital


Case cont
Case cont

  • Exam: BP 130/68 HR 72

    • Chest – clear, no crackles

    • CV JVP 2 cm ASA, normal HS

    • Extremities – no pedal edema

  • Labs on discharge:

    • CBC Normal, Na 140 K 5.5 Cl 108 Cr 140

  • How would you manage her ?


Some questions
Some questions

  • LVEF>50%! Was it really heart failure?

    • Maybe not. But diagnosis of HF is clinical

      • including symptoms (PND, orthopnea), signs (elevated JVP, S3, crackles), investigations (CXR, BNP)

    • If so, likely diastolic dysfunction or preserved systolic function

  • How would you optimize the meds?

  • Further investigations?

  • When to see her back?


Resources
Resources

  • CCS Heart failure guidelines 2007, 2006


  • Definition

  • Epidemiology

  • Diagnosis

  • Management

  • Quality


Some terminology
Some terminology

What is Heart Failure (HF)?

  • HF is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion

  • HF is common and reduces quality of life, exercise tolerance and survival

    NB: calling it CHF is considered inaccurate and uncool

Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.


Heart failure mortality
Heart Failure Mortality

  • Canada’s average annual in-hospital mortality rate is:

    • 9.5 deaths/100 hospitalized patients >65 years of age

    • 12.5 deaths/100 hospitalized patients >75 years of age

  • HF patients have a poor prognosis, with an average 1-year mortality rate of 33%

Lee DS et al. Can J Cardiol 2004;20(6):599-607.


HF – An epidemic ?

Projected number of incident hospitalizations for CHF patients, using high, medium and low population growth projections in Canada 1996-2050

Johansen et al. Can J Cardiol 2003;19(4):430-5.


Hf readmissions
HF Readmissions

  • Hospital readmission rates are high, and mainly due to recurrent heart failure

Canadian Hospital Readmission Rates for Any Heart Failure

Lee DS et al. Can J Cardiol 2004;20(6):599-607.


Management overview
Management Overview

  • Management of HF requires

    • an accurate diagnosis

    • aggressive treatment of known risk factors(e.g. hypertension, diabetes)

    • rational combination drug therapy

  • Care should be individualized for each patient based on:

    • symptoms

    • clinical presentation

    • disease severity

    • underlying cause


Diagnosis and investigations
Diagnosis and investigations

  • Clinical history, physical examination and laboratory testing

    • BNP (available at UHN, cost $65, ~2d turnaround)

  • Transthoracic echocardiography (ventricular size and function, valves, etc.)

  • Coronary angiography in patients with known/suspected CAD

  • NYHA classification should be used to document functional capacity in all patients

Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.


Management
Management

CCS HF guidelines 2006. Can J Cardiol 2006;22(1):23-45.


Non pharmacologic therapy
Non pharmacologic therapy

  • I am supposed to counsel what again ?

    • Diet

      • How much salt – no added or low salt

      • Is that 1gm, 2gm?

      • Is fluid restriction necessary ?

    • Symptoms of heart failure

    • Self care including daily weights


Salt and fluid
Salt and Fluid

  • Salt

    • All patients with heart failure

      • No added salt diet (2-3 gm / day)

    • If difficult to control, low salt diet 1-2 gm/day

      • May just need some educational literature for ~ 2gm/day

      • Likely needs to see a dietitian (TWH referral) for <2gm/day

  • Fluid restriction

    • Not necessarily all patients, just those with difficult to control HF or sodium issues (1.5 – 2 L / day)


Medications
Medications

  • ACE

  • ARB

  • BB

  • Spironolactone

  • Digoxin

  • Diuretics


ACE

  • All HF patients with LVEF <40% should be treated with an ACE-I and a beta-blocker, unless a specific contraindication exists (Class I, Level A)


Practical tips for ace i arb use
Practical Tips for ACE-I/ARB Use

  • Check supine and erect BP for symptomatic hypotension

  • If symptomatic hypotension persists, separate timing of dose from other medications that could also lower BP

  • Reduce dose of diuretic if patient stable and reassess need for other vasodilators (e.g., long-acting nitrates)

  • An increase in creatinine of up to 30% is not unexpected after introduction of an ACE-I/ARB

  • Adding spironolactone to an ACE-I plus an ARB is discouraged, unless followed closely in a specialist HF clinic

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


When to use beta blockers
When to Use Beta-blockers?

  • All HF patients with LVEF 40%

    • (use clinically proven beta-blocker) (Class I, Level A)

  • In stabilized HF patients with NYHA Class IV symptoms

  • (Class I, Level C)

MERIT-HF Study Group. Lancet 1999;353:2001-7. CIBIS II Investigators. Lancet 1999;353:9-13. Packer M et al. Circulation 2002;106:2194-9.

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


Practical tips for bb use
Practical Tips for BB Use

  • Dose of BB should be increased slowly, e.g., double dose every 2-4 weeks if stable

  • If bradycardia or AV block is present, reduce or stop digoxin or amiodarone (where appropriate)

  • If hypotensive, consider reducing other medications or change timing of doses

  • Objective improvement in LV function may not be apparent for 6-12 months or longer

  • Major reduction of BB dose or abrupt withdrawal should generally be avoided

  • Consider using beta blocker proven effective in HF trials

    • Bisoprolol, carvedilol (or long-acting metoprolol but not available in Canada)

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


When to use aldosterone blockers
When to Use Aldosterone Blockers?

Spironolactone:

  • Patients with LVEF 30% and severe symptoms despite optimized other therapies (and Creat <200, K <5.2)(Class I, Level B)

Pitt B et al. N Engl J Med 1999;341:709-17.

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


When to use digoxin
When To Use Digoxin?

  • To relieve symptoms and reduce hospitalizations in patients in sinus rhythm who have persistent moderate-to-severe symptoms despite optimized HF medical therapy

    (Class I, Level A)

The Digitalis Investigation Group. N Engl J Med 1997;336:525-33.

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


When to use nitrates hydralazine
When To Use Nitrates + Hydralazine?

  • Other HF patients unable to tolerate ACE inhibitors and ARBs (Class IIb, Level B)

  • African-Americans with systolic dysfunction in addition to standard therapy (Class IIa, Level A)

Cohn et al. N Engl J Med 1986;314:1547-52. Taylor AL et al. N Engl J Med 2004;351:2049-57.

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


Drug interactions and additive adverse effects of common medications
Drug Interactions and Additive Adverse Effects of Common Medications

(Class I, Level B)

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


Hf with preserved systolic function
HF with Preserved Systolic Function Medications

  • Diagnosis is generally based on typical signs and symptoms of HF in patient with normal LVEF and no valvular abnormalities

  • Important to control comorbidities, such as hypertension and diabetes, which are often associated with HF with PSF

  • Systolic and diastolic hypertension should be controlled according to published guidelines (Class I, Level A)

  • The ventricular rate should be controlled in patients with atrial fibrillation at rest and during exercise (Class I, Level C)

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


Hf with preserved systolic function1
HF with Preserved Systolic Function Medications

  • Diuretics should be used to control pulmonary congestion and peripheral edema(Class I, Level C)

  • ACE inhibitors, ARBs, and beta-blockers should be considered for most patients (Class IIa, Level B)

  • Coronary revascularization may be considered for patients with symptomatic or demonstrable ischemia that is judged to have an adverse effect on cardiac function(Class IIa, Level C)

  • Excessive diuresis should be avoided as this can easily lead to reduced CO and renal dysfunction

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


Remainder of slides are optional

Remainder of Slides are Optional…. Medications

Review if time permits….


Heart failure and renal dysfunction
Heart Failure and Renal Dysfunction Medications

A Caution (and a recommendation)

• Routine use of ACE-I, ARBs or spironolactone in the setting of severe renal dysfunction (serum creatinine >250 µmol/L or an increase of > 50% from baseline) is not recommended due to a lack of evidence for efficacy in HF patients

(Class IIa, Level C)

Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.


Geriatric hf
Geriatric HF Medications

  • (this is us)

  • Frailty score

    • predicts

      • Death

      • Need for institution


Other evidence based therapies
Other evidence-based therapies Medications

  • Multidisciplinary heart failure clinics

    • Reduces readmissions and mortality

    • Most have RNs doing monitoring, counselling

    • But…

    • Most only see systolic dysfunction

    • Many wont see older patients who may not benefit from devices


Which patients should be referred to a heart failure specialist
Which Patients Should be Referred to Medicationsa Heart Failure Specialist?

  • New onset HF

  • Recent HF hospitalization

  • HF associated with ischemia, hypertension, valvular disease, syncope, renal dysfunction, other multiple comorbidities

  • HF of unknown etiology

  • Intolerance to recommended drug therapies

  • Poor compliance with treatment

  • First degree family members if family history of cardiomyopathy or sudden cardiac death

    (Class I, Level C)

CCS HF guidelines, Can J Cardiol 2006;22(1):23-45.


Practically which referrals will be accepted by a heart failure specialist
Practically, which referrals will be accepted by a Heart Failure Specialist?

Definitely pre-transplant candidates

Age <60

Candidates for devices (AICD, biventricular pacer, LVAD)

LV systolic dysfunction (LVEF <40%)


Conclusions
Conclusions Failure Specialist?

  • Make an accurate and timely diagnosis

  • Initiate treatment to

    • Reduce HF risk factors

    • Reduce HF symptoms

    • Reduce hospitalizations

    • Improve quality of life

    • Prolong survival

  • Refer patients at higher risk to specialist or HF clinic

  • Continue to translate new knowledge into practice

  • Combine available healthcare resources to improve delivery of best care and practices to HF patients

  • Improve HF outcomes in Canada

  • Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.


    Case Failure Specialist?

    • 86 year old woman recently discharged from team with heart failure arrives at clinic for follow up

    • Echo done in hospital – EF 58%, normal valves

    • PMH: HTN, osteoporosis, osteoarthritis, DM2

    • Meds: ASA, tylenol, ramipril 5 mg daily, metoprolol 25 mg po bid *, spironolactone 25 mg po daily *, furosemide 40 mg po bid *, arthrotec 75mg po bid, diabeta 5mg bid, avandia 4mg daily , fosamax

    • Currently, feels ok, no orthopnea, PND or ankle swelling

      * - new medications, started in hospital


    Case cont1
    Case cont Failure Specialist?

    • Exam: BP 130/68 HR 72

      • Chest – clear, no crackles

      • CV JVP 2 cm ASA, normal HS

      • Extremities – no pedal edema

    • Labs on discharge:

      • CBC Normal, Na 140 K 5.5 Cl 108 Cr 140

    • How would you manage her ?


    Some answers
    Some answers? Failure Specialist?

    • Management

      • Etiology – consider ischemia

      • Counseling – daily wts, NAS diet, symptoms, meds

      • Meds – D/C NSAID, rosiglitazone, spironolactone, try titrate down diuretic

    • Further investigations

      • Lytes, Creat, ECG

    • When to see her back?

      • High risk of readmission (elderly, recent admit)

        • 1-2 weeks would be reasonable


    Web resources
    web resources Failure Specialist?

    • www.heartfunction.com

      • Counseling info

      • HF guidelines

      • Flow sheets for your hf patients


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