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Heart Failure in the Transplant Patient

Heart Failure in the Transplant Patient. Presented by: Bethany Westerfeldt RN, CCRN, MSN, NP-C, ANP, BC For WITNS October 13, 2012. Objectives. 1. Discuss types of Heart Failure LV systolic dysfunction HF with preserved LV systolic function ( HFpEF ) aka diastolic dysfunction

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Heart Failure in the Transplant Patient

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  1. Heart Failure in the Transplant Patient Presented by: Bethany Westerfeldt RN, CCRN, MSN, NP-C, ANP, BC For WITNS October 13, 2012

  2. Objectives • 1. Discuss types of Heart Failure • LV systolic dysfunction • HF with preserved LV systolic function (HFpEF) aka diastolic dysfunction • 2. Discuss brief pathophysiology of Heart Failure • 3. Assessment of Heart Failure • 4. Treatments of Heart Failure

  3. Types of Heart Failure:Systolic Dysfunction • Many etiologies: • Most common etiologies: CAD, HTN, DM, substance abuse(cocaine, alcohol), chemo, peripartum, uncontrolled tachycardia, viral, valvular heart disease, severe illness • Affects cardiac output or quantity of blood pumped to rest of body • Can be improved or controlled with medication and lifestyle changes • Frequency of diagnosis increases with age, more prevalent after age 65 though affects pts at any age point • Syndrome of neurohormonal activation affecting many body systems

  4. Types of Heart Failure:Diastolic dysfunction • Defined as HF with preserved LV systolic function (normal LVEF) or EF more than 40% • LV often with hypertrophy, concentric remodeling with increased extracellular matrix, abnormal relaxation and filling, decreased diastolic dispensability • Shares activation of neurohormonal activation with systolic dysfunction • Prevalence: 40-50% of all pts diagnosed with HF, often seen in conjunction with systolic dysfunction • More commonly in elderly, females and pts with hypertension

  5. Heart Failure Classifications: • New York Heart Association (NYHA) functional classification of HF: • No limitations of physical activity, no symptoms with ordinary activity • Slight limitation, symptoms with ordinary activities • Marked limitation, symptoms with less than ordinary activities • Severe limitation, symptoms of HF at rest

  6. ACC/AHA classification

  7. Therapeutic Goals: • Prolong life • Slow/reverse cardiac remodeling • Reduce visits and admissions to hospital • Improve overall functional capacity and quality of life • Reduce dyspnea and fatigue • Control/minimize edema and fluid retention

  8. Transplant population: • At risk for conditions the increase HF risk (both types): • Hypertensive disease, DM, sleep apnea and CAD • Antirejection meds that increase BP, renal disease, risk DM • Solid weight gain: risk for DM, HTN, sleep apnea, atrial arrhythmias • Preexisting conditions: • Limiting activity: Gout, arthritis/DJD, other musculoskeletal disorders, obesity • Structural heart disease: valve disorders, storage diseases (amyloid, hemochromatosis, saroidosis)

  9. CKD and CV disease: • Known high risk of development of CVD in pt. with HTN • Systolic BP more significant than DBP on CV all cause mortality • Pulse pressure (SBP minus DBP) • Independent predictor of MI, HF and CV death • Reflects stiffness larger arteries • Increases with advancing age from 50 yr. on up • Reliable prognostic factor for mortality CKD • Pts on HD or renal transplant patients

  10. Neurohormonal effects of Heart Failure • SNS activity: “whipping a dying horse”-the catecholamine stimulation • Stimulation of Alpha 1 & Beta 1&2 receptors • Increases cardiac output by increasing heart rate& stroke volume • Prolonged stimulation leads to myocyte hypertrophy, dilation, ischemia, arrhythmias, deterioration and death of cardiac cells • Activates Renin-Angiotensin-Aldosterone System (RAAS)-> (further) vasoconstriction & sodium retention

  11. Prevalence of specific signs & symptoms in systolic & diastolic HF

  12. Signs & Symptoms • Dyspnea & fatigue • Limitation of exercise tolerance • Fluid retention-may lead to pulmonary edema • PND & orthopnea • Cough, can be primarily nocturnal • Poor appetite • Early satiety & bloating • Chest pain: not always in pts with CAD • Palpitations • Lightheadedness • Especially positional • Edema, ascites, anasarca • Poor sleep quality • Difficulty thinking clearly, or concentrating • These abnormalities can impair functional capacity & quality of life

  13. Clinical signs: • Increased adrenergic activity • peripheral vasoconstriction (cool extremities) • pallor &/or cyanosis of digits • diaphoresis • tachycardia • loss of normal sinus rhythm • distention (obvious) of peripheral veins due to vasoconstriction (prominent JVD) • narrowed pulse pressure

  14. Clinical signs • Pulmonary rales & /or wheezes: • usually an acute heart failure finding • Chronic HF pts mobilize pulm fluid into lymph nodes: • are enlarged on x-ray & CT • JVD: indication of right atrial pressure (preload) • Normal JVD is under 10 cm • HJR: compression over liver causes distention of JVD further • Indicates congested abdomen/liver and/or inability of right heart to accept or eject the transiently increased volume

  15. LV systolic dysfunction • Ischemic: CAD is the cause of approximately 2/3 of pts LV dysfunction • Remodeling: change in tissue & geometry of LV • Neurohormonal changes: • affect endothelium of vessels as well as cardiac muscle with deposition of fibrinous material • alters contraction and electrical pathways of myocardium • Neurohormonal activation of Renin-Angiotensin-Aldosterone system & Norepinephrine • Down-regulation of alpha, beta 1 & beta 2 adrenergic receptors

  16. Treatment of Systolic HF • Diuretics, ACE-Inhibitors, Beta blockers, Digoxin, Aldosterone blockers, Vasodilators & IV Inotropic agents • Value of these agents shown in multiple clinical trials • Shown to decrease symptoms & increase length/quality of life

  17. Diastolic Dysfunction • Abstracted charts from 37,500 Medicare pts from National Heart Failure Project database • Only 57% of pts had LV fxn assessed • Of 19,710 pts with documented EF, 1/3 had EF> 50% • This group was 79% women with mean age of 79.7 yrs

  18. Characteristics of Outpatient Diastolic HF • Overwhelmingly female (85%) & elderly(70 yo) • Marked increase in LV mass/volume ratio • Higher BMI • More likely to have HTN • Exercise limitation similar to systolic HF pts

  19. Diastolic Dysfunction • Increased myocardial stiffness • Ventricular interaction or pericardial restraint • Abbreviated LV filling time • Multifactorial: thyrotoxicosis, AV fistula, beriberi • Volume overload stress • Obesity • Impaired LV relaxation • Myocardial ischemia • Hypertrophy • Systolic dysfunction • DM • Hypothyroidism

  20. Diastolic Dysfunction Diagnostic Criteria • Required criteria: • Normal EF (> 50%) • Clinical Evidence of Heart Failure • Framingham of Boston Criteria • Plasma BNP &/or chest x-ray • Cardiopulmonary exercise testing • Confirmatory Criteria: • LVH or Concentric Remodeling • Left Atrial Enlargement (in absence of AF) • Echo Doppler or Cath Evidence of Diastolic Dysfunction • Exclusions: Non-Myocardial Disease

  21. Treatment of Diastolic HF • Class I • Control systolic & diastolic BP • Control ventricular rate in AF • Use diuretics to control edema • Class IIA • Coronary revascularization • Class IIB • Restore & maintain NSR • Beta blocker, ACE-I, ARB, Calcium antagonists, digitalis

  22. Treatment of DHF • General approach: • Symptom reduction • Control blood pressure • Decrease circulating volume • Salt & fluid restriction • Diuretics • Nitrates • Neurohormonal blockade (ACEI/ARB) • Treat tachycardia • Increase duration of diastole (slow HR) in select pts • Maintain synchronous atrial contraction

  23. Treatment DHF • Lifestyle modification & education • Salt & fluid restriction • Exercise program • Other dietary concerns • Weight control • Target underlying mechanisms • Drugs: • that improve calcium homeostasis • blunt hormonal activation • prevent & regress fibrosis are in existence or development

  24. Treatment of DHF • Look at underlying disease processes contributing to DHF & choose drug combinations to combat them • Eg: Diabetic elderly female • Angiotensin blocking drug • Diuretic • beta blocker • CCB if resting HR>70. • Most often requires antihypertensive • Lots of trial & error to finding right combination of meds that minimize symptoms & side effects

  25. Patient self care at home: systolic & diastolic HF • Weigh daily • same time • same clothing amount • Report daily gain of >3 lbs. or overall >5 lbs. • Low salt diet (2 grams) • Take all meds as prescribed • Report any side-effects or problems with meds • Know symptoms of HF & report worsening: • SOB or decreased activity tolerance • Increased fatigue, unable to sleep lying down • Swelling of ankles or abdomen • Frequent colds • Decreased urination, increase in weight

  26. Pt. care at home: • Participate in regular exercise & stress reduction • Plan daily activities in advance to conserve energy • Plan strategies to help reduce fatigue: • delegate jobs • take naps or rest periods • Withdrawal of meds known to affect clinical status: • NSAIDS • antiarrhythmic • most calcium channel blockers

  27. Lifestyle & monitoring • OTC medications to stay away from: • NSAIDS: • ASA (high dose) • ibuprofen • naproxen • Decongestants: • Sudafed • anything with ephedrine • Most diet pills

  28. Case Study • 44 yo male, previous hx DM and DD renal tx ‘05, no known CAD (negative stress prior to tx) • Presents with 4-6 wk hx progressive DOE, weight gain, decreased appetite, cough that worsens at night • States he’s having hard time at work, carries 60 lb. bags & other equipment road construction • Believes he has “bad cold”, treated by PCP for bronchitis/pneumonia without relief of symptoms

  29. Case study • Sx not improved after steroidsabx • History reveals change in appetite, bloating, PND-wakes up after 2 hrs coughing, sits on side of bed or walks around • Reports chest “soreness”, mid sternal area, no radiation, no palpitations, no diaphoresis, n/v • What would you suspect? • What would you do next?

  30. Case study • CXR shows cardiomegaly, pulmonary congestion • 12 lead ecg shows NSR • no evidence of acute MI • normal voltage • TTE shows • LV systolic dysfunction • LVEF 25% • moderately dilated RA & LA • normal RV function • LVEDD 65 mm (nl= 56) • no thrombus • Labs: lytes wnl, bun/cr:35/1.8, t bili 1.6, ast 66, alt 94, TSH 8.7 with normal fT4, TT3.

  31. Treatment • If possible: • Start or increase ACE inhibitor or ARB • Diurese • Once near euvolemic • Start or increase beta blocker (preferably carvedilol or metoprolol succinate)

  32. 6 months later… • Calls with SOB without weight gain • Appetite poor • Decreased activity tolerance • Increased fatigue • PND and orthopnea

  33. What to do next? • Assess over the phone: • What brings on SOB/activity limitations • Assess for edema • Other symptoms: • chest discomfort • palpitations • Early satiety, bloating, nausea… • Labs: • Creatinine rise from 1.4 to 1.8 • BUN rise from 28 to 36 • Serum potassium 3.6, sodium 130

  34. What do you do next? • Most likely, increased renal indices from volume overload • Diurese, based on symptoms and labs • Leave ACE-I unchanged • F/u labs in 3-7 days • If equivocal, get pt to be assessed in clinic • TTE can be done in pts difficult to assess volume status • Can always schedule for RH cath (may need anticoag management in pts on warfarin)

  35. Case study 2 • 78 yo female s/p OH Tx ‘02 presents with progressive SOB, weight gain • longstanding hx htn • obesity • swelling of her legs • bloating over past couple of months • Hx reveals: • poorly controlled BP for past 45 yrs • sedentary lifestyle • no DM • hypothyroid • States she’s been sleeping in her husband’s recliner for past 3 weeks • sleep quality poor r/t fatigue • poor quality of life “unable to do anything”

  36. What do you suspect? What questions do you want to ask her? What do you want to do with her?

  37. Case Study 2 • Physical exam: • JVP elevated to 15 cm above RA • No scleral icterus • Oropharynx pink, moist • Lungs with few basilar crackles & wheezes • Abdomen soft, obese; Liver WNL • Extremities +2 to knees bilaterally • Blood pressure: 178/92

  38. Findings • CXR shows pulmonary congestion • TTE shows: • concentric LV hypertrophy • abnormal E/a ratio (diastolic filling) • LVEF 75% • BNP elevated to 528 • lytes normal • creatinine 2.4 • LFT’s normal • 12 lead ecg shows: • increased voltage in precordial leads ( LV hypertrophy) • NSR • Left heart cath with minor luminal irregs • RHC with elevated PCWP, RA,RV and PA pressures

  39. CXR

  40. What do you do next? • Diurese • Helps relieve symptoms • Labs to evaluate lytes and renal function • Can schedule for clinic visit • Trend home monitoring data

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