September 29,2010Karen Harkness RN CCNC PhD

DefinitionNot a clinical diagnosisHeart failure 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. (CCC guidelines, 2006)

Incidence: 10-23% Age > 80 years

Ontario: 9943 patients hospitalized between 1999-2001 ( F/up 6 yrs)Mean age: 76 years (SD 11.5) (60% >75 yrs of age)Female: 50%1 yr mortality: 33%5 yrs mortality: 69%Median survival: 2.4 yrs

Age 70-75 male: median life expectancy 3.5 yrs. ( US population 12 yrs)Age 70-75 female: median life expectancy 2.9 yrs (US population 14.6 yrs)

Most common diagnosis for patients admitted to hospital (Age >65 yrs)Most of the costs due to hospitalization

Ko et al., Am Heart J 2008

Pathophysiology of HF

Baroreceptors

Cardioregulatory centres

AVP

Aldosterone

Angiotensin II releasePeripheral

Vasconstriction

Sympathetic nervous system

Renal SNS activation

Salt and water retention

LV Ejection Fraction (< 35%, <40%)

• Heart failure with reduced ejection fraction

• Systolic dysfunction

Normal LV Ejection Fraction (> 40%)

• Heart failure with preserved ejection fraction (HF/PEP)

• Diastolic Dysfunction

Stages

A- No cardiac structural abnormalities, presence of risk factors (Hypertension, diabetes, obesity, smoking, CAD, excessive ETOH intake)

B- No symptoms, cardiac structural changes

C- Symptoms, structural changes

D- Refractory symptoms, despite optimal management

New York Heart Association Classification

I- No symptoms

II- Symptoms with moderate activity

III- Symptoms with regular activity

IV- Symptoms at rest

Grade LV Systolic Dysfunction

Grade I- Ejection Fraction >50%

Grade II- Ejection Fraction 35-50%

Grade III- Ejection Fraction 20-34%

Grade IV- Ejection Fraction <20%

Predictors of Heart FailureLVEF ≤ 25% LVEF ≥ 55%

Age 68 yrs 74 yrs

Women* 34% 69%

Diabetes 39% 44%

Hypertension* 63% 80%

Atrial fibrillation* 28% 32%

Chronic Renal Impairment

27% 31%

Based on ADHERE registry* Based on Framingham Criteria

Coronary Artery Disease – most common reason for HF

Aging and Heart FailureCardiovascular ChangesAbility to respond to stress - physiological- exercise or

pathological -hypertension, ischemia

1. responsiveness to Beta stimulation

2. vascular stiffness (isolated systolic hypertension)

3.Heart muscle stiffer- impaired relaxation – major filling occurs in late diastole (atrial kick really important for CO)

4.Altered myocardial energy metabolism in mitochondria

Aging and Heart FailureOther system changesKidneys-

GFR (8 cc/min/ decade) Capacity to respond to intravascular volume changes

- More likely to get electrolyte imbalances with diuretics- Less responsive to diuretics

Lungs- Respiratory reserve (increased sense of SOB

secondary to CO)- V/Q mismatch- Sleep disordered breathing

Nervous System- Impaired thirst mechanisms (watch get ‘too dry’)- Impaired auto regulation (cerebral changes)- Impaired reflex responses (orthostatic hypotension)

Common Clinical Presentations of Heart Failure

DyspneaOrthopneaPNDFatigueAbdominal distensionCoughEdemaWeight gain

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

Uncommon Clinical Presentations of Heart Failure

Cognitive impairment*Delirium*Nausea*Abdominal discomfortNocturiaOliguriaAnorexiaCyanosis

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

* May be more common presentation in elderly patients.

Physical exam

JVP elevated

Enlarged apical impulseS3

Murmur of mitral regurgitation

Peripheral edema

Other:

HJR

Ascites

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

Diagnosis of Heart Failure

Howlett Can J Cardiology, July 2008

AHF diagnosed, treatment based on symptoms and signs

Mild overload

Volume overload Volume overload + low cardiac output

Mod. –severe overload

Mild- Mod low output

Very low output

• Inadequate response to IV diuretics• Increase oxygen req• CPAP and BIPAP req•fatigue

• consider PA line•Add vasodilator after BP stabilized

IV diureticsIV lasix bolus

IV diuretics+ IV vasodilators

SBP > 90 mmHg

SBP < 90 mmHg

• Cr < 200 umol/L 40 mg•Cr > 200 umol/L 80 mg

• consider lasix infusion•Add IV nitrates

• Milrinone •Dobutamine

•Dobutamine•Vasopressors

Lab Tests- Decompensation

Electrolytes, Urea, Creatinine

Creatinine can be elevated due to AHF (improves with Rx)

Decreased renal perfusion, renal venous congestion

Hyponatremia - dilutional from increased ADH

Potassium

CBC- Anemia, WBC

Liver Function

Hepatic congestion: increased bilirubin, ALP, INR

Other : TSH, Glucose

BNP

Palazzuoli et al., Intern Emerg Med Sept 2010

• Hormone synthesized in the heart- response to wall distension• Oppose vasoconstriction, sodium retention and anti-diuretic effects of RAAS•“Natural” vasodilator and diuretic

BNP and NT-pro BNP

BNP < 100pg/mlNT-proBNP < 400 pg/ml

BNP 100-400 pg/mlNT-proBNP 400-2000

pg/ml

BNP > 400pg/mlNT-proBNP > 2000

pg/ml

HF unlikely HF uncertainNeed echo evaluation

High HF probability

Other causes of BNP- Acute PE, Pulmonary hypertension, Anemia, Cor pulmonale, Renal insufficiency, Septic Shock, Hyperthyroidism

Why Decompensation? Cardiac in OriginAtrial fibrillation or flutter (new, uncontrolled)Sinus Tachycardia Ischemia/infarction (HF usually stubborn and/or acute onset)HypertensionSuboptimal pharmacological regimen for HF

Non-cardiac Infections (urinary, resipratory) Anemia/ Blood lossMedication interaction (pharmacological, non-

pharmacological)

BehavioralMedication non-compliance (unintentional ?)

Excessive salt or fluid intake (unintentional ?)

Goals of Therapy1. Relieve symptoms / congestion (find and

address ‘trigger’)

2. Stabilize condition and lower risk for (re) hospitalization

1. Initiate treatments that will slow disease progression and improve long-term survival

2. Limit significant adverse effects (arrhythmia, renal failure, over-diuresis )

Management HF with Preserved LV Systolic Function

Control blood pressureControl heart rateDiuresis if congestionRevascularize if reversible ischemia

Management of HF (EF<40%)

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

Pharmacological managementACE (Ramipril, Enalapril), Betablocker (Bisoprolol, Carvedilol)

ARB (ACE intolerant. Candesartan)Diuretics (furosemide)

NYHA I

NYHA II

NYHA IIIARB (hypertension)

Spirolonlactone (right sided HF)DIGOXIN (atrial fib, K+ too high for other choices)

Nitrates (orthopnea, CAD)

NYHA IV Combination of diuretics (metolazone, Hcthz)IV diuretics

Clinical tipsACE inhibitor e.g. RamiprilStart low 1.25 mg daily Try BID dosing if concerned of low bpARB- Candesartan Start low ( 4 mg daily) Beta BlockersCoreg- renal excreted, more effect on bp than other

BBLowest dose 3.125 mg BID

Bisoprolol- daily, start 2.5 mg OD (1.25 mg really tiny), Beta 1 selective

Clinical tipsLasix Try alternate days if a nuisance to patientIf BID, second dose before 4 pmIf IV, try infusion if concerned about low bp or not

responding to bolus dosingBumetanideBetter GI absorption in gut edema1 mg = 40 mg lasixMetolazoneBe very careful with over diuresis Tiny dose- 1.25 mg OD prnMaintenance- 1-2 times a week vs. daily

Clinical tipsAldactoneTiny dose– 12.5 mg alternate daysDo not add if already taking ACE and ARBHelpful with right sided HFBreast tenderness in men, especially if taking Digoxin EplerenoneLike aldactone, haven’t tried yet (no breast

tenderness)NitratesApply when they are most symptomatic with SOBDigoxin- keep level 0.5-1.0 Start tiny – 0.625 mg OD to alternate days

Hydralazine and nitratesStart low ( Hydralazine 5 mg q 8h)

( Isordil 10 mg q8h)

Calcium Channel BlockersAvoid Diltiazem unless you know normal LV

systolic functionPrefer Amlodipine for ongoing hypertension

Clinical tips