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Outpatient management of heart failure

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Title: Outpatient management of heart failure


1
Outpatient management of heart failure
  • Dr. Rob Wu
  • Feb 2008

2
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

3
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 ?

4
Some questions
  • LVEFgt50! 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?

5
Resources
  • CCS Heart failure guidelines 2007, 2006

6
  • Definition
  • Epidemiology
  • Diagnosis
  • Management
  • Quality

7
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 200622(1)23-45.
8
Heart Failure Mortality
  • Canadas average annual in-hospital mortality
    rate is
  • 9.5 deaths/100 hospitalized patients gt65 years
    of age
  • 12.5 deaths/100 hospitalized patients gt75 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 200420(6)599-607.
9
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 200319(4)430-5.
10
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 200420(6)599-607.
11
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

12
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 200622(1)23-45.
13
Management
CCS HF guidelines 2006. Can J Cardiol
200622(1)23-45.
14
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

15
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 lt2gm/day
  • Fluid restriction
  • Not necessarily all patients, just those with
    difficult to control HF or sodium issues (1.5 2
    L / day)

16
Medications
  • ACE
  • ARB
  • BB
  • Spironolactone
  • Digoxin
  • Diuretics

17
ACE
  • All HF patients with LVEF lt40 should be treated
    with an ACE-I and a beta-blocker, unless a
    specific contraindication exists (Class I,
    Level A)

18
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
200622(1)23-45.
19
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
19993532001-7. CIBIS II
Investigators. Lancet 19993539-13.
Packer M et al. Circulation
20021062194-9.
Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
20
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
200622(1)23-45.
21
When to Use Aldosterone Blockers?
  • Spironolactone
  • Patients with LVEF ?30 and severe symptoms
    despite optimized other therapies (and Creat
    lt200, K lt5.2) (Class I, Level B)

Pitt B et al. N Engl J Med 1999341709-17.
Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
22
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
1997336525-33. Arnold JMO, Liu P et al. Can J
Cardiol 200622(1)23-45.
23
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 19863141547-52.
Taylor AL et al. N Engl J Med 20043512049-57.
Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
24
Drug Interactions and Additive Adverse Effects of
Common Medications
(Class I, Level B)
Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
25
HF with Preserved Systolic Function
  • 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
200622(1)23-45.
26
HF with Preserved Systolic Function
  • 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
200622(1)23-45.
27
Remainder of Slides are Optional.
  • Review if time permits.

28
Heart Failure and Renal Dysfunction
  • A Caution (and a recommendation)
  • Routine use of ACE-I, ARBs or spironolactone
    in the setting of severe renal dysfunction (serum
    creatinine gt250 µmol/L or an increase of gt 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
200723(1)21-45.
29
Geriatric HF
  • (this is us)
  • Frailty score
  • predicts
  • Death
  • Need for institution

30
Other evidence-based therapies
  • 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

31
Which Patients Should be Referred to a 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 200622(1)23-45.
32
Practically, which referrals will be accepted by
a Heart Failure Specialist?
  • Definitely pre-transplant candidates
  • Age lt60
  • Candidates for devices (AICD, biventricular
    pacer, LVAD)
  • LV systolic dysfunction (LVEF lt40)

33
Conclusions
  • 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
200622(1)23-45.
34
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

35
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 ?

36
Some answers?
  • 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

37
web resources
  • www.heartfunction.com
  • Counseling info
  • HF guidelines
  • Flow sheets for your hf patients
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