Congestive Heart Failure:Not for the Weak of Heart: Access

1
Congestive Heart Failure (Not for the) Weak of
Heart Access

• Glen Drobot, MD, FRCPC
• Assistant Professor, Department of Internal
  Medicine, University of Manitoba St. Boniface
  General Hospital
• Co-director consultant WRHA Heart Failure Clinic

Annual Scientific Assembly 2006, Manitoba College
of Family Physicians
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Objectives

• Outline the make-up of the Heart Failure clinic,
  sited at St. Boniface General Hospital
• Review current access issues
• Testing
• HF services
• How you can help your patients

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HF Clinic

• Inter-disciplinary clinic based in ACF Medicine
• Physicians
• Dr. James Tam
• Dr. Glen Drobot
• Dr. Patrick Griffin
• Soon to be August 2006 Dr. Shelley Zeiroth
• Nurse clinician Estrellita Estrella-Holder
• Pharmacist ? Dietician
• Physical and occupational therapists
• Social worker

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HF Clinic

• Currently 2 half-day clinics/week
• Increasing to 3 half-day clinics upon arrival of
  Dr. Zeiroth
• Waiting list should be within 4 weeks
• Some ability to prioritize on basis of severity
  of illness ? goal is to improve accessibility
  with increased staffing

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HF Clinic

• Referrals directed to ACF Medicine
• FAX [phone]
• Urgent calls cardiologist on-call
• Inquiries about existing HF clinic patients
  during the weekdays [phone]

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Case Mr. Y.

• 63-year-old male with DM 2, myocardial infarction
  4 years ago
• 1 month history of fatigue, increasing shortness
  of breath on exertion and some peripheral edema
• Medications
• ASA 325 mg OD
• Atenolol 25 mg OD
• Metformin 750 mg tid

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Case Mr. Y.

• O/E BP 130/80, HR 90, SaO2 93
• chest bibasilar crackles
• Heart sounds decreased, no (M)
• JVP 6 cm, edema to mid-shins
• abdomen unremarkable

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Case Mr. Y.

• Initial investigations
• CBC
• Na, K, Cl, TCO2, urea, creatinine
• all normal
• glucose 10
• ECG
• Chest x-ray

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Case Mr. Y.

• Large group

• Old inferior MI, LAD, LVH

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Case Mr. Y.

• Interstitial pulmonary edema, cardiomegaly

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Mr. Y. what should be done?

• Assess for precipitants of HF
• Salt and fluid intake
• Non-compliance with medications
• Active ischemia
• Intercurrent infection
• Determine the type of HF
• Systolic vs. diastolic dysfunction
• (L) and/or (R) heart failure

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Other Investigations

• Assessment of LV function
• Nuclear medicine (MUGA) weeks
• Echocardiography 6 months
• If no significant valvular pathology suspected,
  MUGA is a reasonable first test
• Either test will distinguish between preserved LV
  function (diastolic) vs. systolic dysfunction

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Mr. Y. what should be done?

• While waiting for investigations
• Treat congestion with loop diuretics to aim for
  euvolemia (accept creatinine elevations of 50
  above normal baseline, or 30 above mild-moderate
  creatinine elevation)
• Can start ACE-I, even if ends up having diastolic
  dysfunction (likely has HTN)
• Is there isolated (R) HF? If so, do pulmonary
  investigations as well.

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Facilitating Consultations

• Detailed history and last physical exam
• Current list of medications
• ECG, CXR
• Echo or MUGA result, or date for test
• Basic BW
• Main reason for consult stabilization, further
  work-up of cardiac problems, consideration for
  biventricular pacing

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Questions about Device Therapy

• Implantable cardioverter-defibrillators
• Still go through arrhythmia service
• Biventricular pacemakers for cardiac
  resynchronization
• Wide QRS, gt140 msec
• EF lt 35
• Persistent class III-IV symptoms
• Screened by HF clinic, we do special echo looking
  for inter-/intra-ventricular asynchrony

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Questions

• Big Buddha, Koh Samui, Thailand