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Title: CCS%20Heart%20Failure%20Guidelines:%20Practical%20Implementation


1
CCS Heart Failure Guidelines Practical
Implementation
  • October 2014

2
  • Disclaimer
  • The Canadian Cardiovascular Society (CCS)
    welcomes reuse of our educational slide deck for
    medical institution internal education or
    training (i.e. grand rounds, medical
    college/classroom education, etc.).  However, if
    the material is being used in an industry
    sponsored CME program, permission must be sought
    through our publisher Elsevier (www.onlinecjc.com)
    .
  •  
  • If your reuse request qualifies as medical
    institution internal education, you may reuse the
    material under the following conditions
  • You must cite the Canadian Journal of
    Cardiology and the Canadian Cardiovascular
    Society as references.
  • You may not use any Canadian Cardiovascular
    Society logos or trademarks on any slides or
    anywhere in your presentation or publications.
  • Do not modify the slide content.
  • If repeating recommendations from the published
    guideline, do not modify the recommendation
    wording.

3
Overview
  • Who is this document primarily intended to reach?
    What is the format?
  • How soon should I see a newly referred heart
    failure patient?
  • How often should my heart failure patient be
    seen?
  • Who can I discharge from my heart failure clinic?
  • How quickly and in what order should standard
    heart failure therapy be titrated for most
    patients?
  • When should I measure electrolytes, serum
    Creatinine and BUN?
  • How should I manage hyper or hypokalemia in my
    patients?
  • I know I should get a baseline measure of left
    ventricular ejection fraction- but should I
    measure it again? If so, when should it be
    measured?
  • Can heart failure medications ever be stopped? If
    so, then when?
  • How should I manage an acute episode of gout?
  • In what ways do I care differently for frail
    elderly patients with heart failure?
  • How do I teach self care to my patients?

4
Self-care Tips
5
Case Study
  • Mr. M.
  • 71 year old man with an ischemic cardiomyopathy.
    NYHA III, LVEF 30.
  • COPD, diabetes, chronic renal failure, atrial
    fibrillation
  • Takes 12 different types of medications daily
    (blister pack)
  • Lives alone in an apartment- lady friend nearby
  • 4 admissions for heart failure in the past year

6
Nobody Ever Told Me
Excerpts from patient (Mr. M)s chart
July - ER with worsening SOB and orthopnea
August - ER with increasing SOB
September - 1 week follow up appointment post
hospital discharge
7
Self-care Maintenance
8
Self-care Monitoring and Management
9
Self-care Strategies
  • Patients define self-care not only by the actual
    performance of tasks but also by the emotional
    reactions and strategies necessary for learning
    how to adapt to living with HF.
  • Self-care is a process of learning, and self-care
    activities are often intentional, planned, and
    built on previous experiences.
  • Individualized approaches that emphasize how to
    self-care must be adopted for patients to develop
    the necessary HF self-care skills.

Harkness et al., 2014 J. Cardiovasc Nurs
10
Lay Clinical Trials Expert Approach
  • One patient described her strategy to improve her
    tolerance to a medication based on a past
    experience of symptomatic hypotension that
    prevented her from going to work.
  • She stopped the medication for a few days,
    reintroduced the medication at 1/2 the prescribed
    dose and then slowly titrated the medication
    depending on how she felt getting out of bed in
    the morning.
  • At the same time, she did not report this to her
    physician and actually lied to him about the
    dose she was taking, as she was too embarrassed
    to disclose her own approach to titrating the
    medication.38(p109)

Glassman KS. Older Persons Experience of
Managing Medication The Myth of Compliance
dissertation 2007 in Harkness et al., J
Cardiovasc Nurs 2014
11
Lay Clinical Trials Good Intentions
  • Increasing fluid intake to flush out the system
    to increase diuresis and improve symptoms
  • Choosing Kentucky Fried Chicken rather than Swiss
    Chalet when dining out (Swiss Chalet worsens
    edema)
  • I thought I was doing the right thing trying to
    lose weight, had no idea I was making my heart
    problem worse
  • Woman trying to lose weight and switched to low
    fat frozen dinners - but high in sodium

Gary R. Heart Lung. 2006 Harkness et al., J
Cardiovasc Nurs 2014
12
Past Experience
  • I dont take my Lasix when I am going out
    somewhere, I cant always get to a bathroom quick
    enough. I had an accident when I was out a few
    months ago and I was so embarrassed I could have
    died.
  • My weight just kept going up - I knew if I
    gained weight I would need to go back to the
    hospital. So I just stopped checking my weight.
  • The catch 22. She was afraid to call for help,
    based on past experiences, that she would call
    too soon, and so tended to wait until a crisis to
    ask for help.

Clark et al., Int J Nurs Studies 2012 Harkness
et al., J Cardiovasc Nurs 2014
13
Self-care Tips
  • Understand patient and caregiver beliefs about HF
    and its self-care, their expectations and
    aspirations for daily life
  • Harness cues in patients home environments and
    routines to increase adherence patterns
  • Plan ahead using a problem-solving approach that
    for supporting self-care when usual activities
    are altered
  • Involve caregivers - key source of support

Strachan et al., J Cardiac Fail, 2014 Clark et
al., BMJ, 2014
14
Self-care Tips
  • Personalize Signs and Symptoms- How do you know
    if you are starting to retain fluid?
  • Expect a large variety of vague descriptions from
    patients/family caregivers.
  • Highlight signs or symptoms that reflect HF
    decompensation.
  • Help clarify signs and symptoms that are probably
    not related to HF.

15
Self-care Tips
  • Try to determine the trigger with the
    patient/family.
  • Through story telling - pick out the details that
    seem relevant to heart failure.
  • Problem solving and experiential learning versus
    determining blame to help prevent feelings of
    guilt.
  • Watch for unintentional non-adherence
  • e.g. Restaurant food, holidays,
    over-the-counter-medications.

16
Nobody Ever Told Me
  • Teach back technique
  • I want to make sure I explained this in a way you
    could understand
  • Can you tell me
  • So when you go home to your (family) how are you
    going to explain
  • ? Sometimes the information is not clear to the
    patient, not 'clicking' with them, ensure they
    understand what it is you are explaining.

White et al., J Cardiovasc Nurs. 2013
17
Difficulty with Self-care
? Some self-care challenges/misunderstandings are
the result of minor cognitive impairment
consider administering a MoCA test
18
Summary
  • Self-care is a skill and needs practice and
    learning over time.
  • Do not expect HF patients to catch on to all
    the necessary instructions without repetition and
    reinforcement.
  • Teach back techniques help ensure understanding.
  • Involvement of family member/caregiver is often
    necessary.
  • Non-adherence may be unintentional and
    represent difficulty with the level of complexity
    associated with self-care.
  • Consider formal screening for underlying
    depression or subtle cognitive impairment in
    patient who have ongoing challenges with
    self-care.

19
Summary
  • People don't care how much you know until they
    know how much you care
  • Theodore Roosevelt

They listen like my input I feel so much
better. They dont argue with me respect me as a
person. That is really, really important to me
they are interested in me
Currie et al., Eur J Cardiovasc Nurs, 2014
20
Medications
21
Objectives
  • To highlight the importance of evidence-based
    medications (EBM) in the treatment of HF
  • To describe issues relating to the sub-optimal
    use of medication in the treatment of heart
    failure
  • To describe tools that are available to help
    front-line practitioners manage medications in
    patients with HF

22
HF Management
23
Incremental benefit in HF treatment
J Am Heart Assoc 2012116-26
24
Medications in HF Patients
  • Medications dont work in patients who dont
    take them
  • - C. Everett Koop

25
Medications in HF Providers
  • Medications dont work in patients

whose Health Care Professionals dont prescribe
them
whose HCP dont prescribe them optimally
whose HCP dont prescribe them safely
26
Medications in HF
50-90
40-60
30-70
40-80
?
Circ 2012 122585-96 Circ 2007 116737-44 Circ
Heart Fail 2013 668-75 Congest Heart Fail 2012
189-17 Arch Intern Med 2012 1721263-65
27
EBM Use Cardiology ClinicsIMPROVE HF n 34,810
ACEI/ARB 80 ß-blocker 86 MRA 34.5
Circ 2010122585-96
28
Dose Optimization IMPROVE HF
Figure 2. Absolute (AI) and relative improvement
(RI) in the percentage of treated patients with
dosing recorded who received target doses of
angiotensin-converting enzyme (ACE)
inhibitors/angiotensin baseline and 24 months
post-intervention for the 24-month follow-up
cohort.
Congest Heart Fail 2012 189-17
29
EBM Dose matters
ACEI
ARB
Arch Intern Med 2012172 1263-65
30
EBM Optimization
Multidisciplinary heart failure clinics improve
outcome in patients with HF. What components of
these specialized clinics are most beneficial?
Circ Heart Fail 2013668-75
31
Clinic Components
32
EBM Right patient for the right drug
33
Patient selection and follow-up are important
Hospital admissions hyperkalemia
3X
In-hospital deaths associated with hyperkalemia
3X
N Engl J Med 2004351543-51
34
Its complicated
Right drug?
Right dose?
Right follow-up?
Right patient?
Right monitoring?
How do you choose?
35
Practical tools
App specifically focused on medications
36
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37
Case Mrs. Tetley
38
Mrs. Tetley
  • ID 85 yr female referred from GP for new onset
    HF
  • HPI 3/12 progressive SOBOE, 2bilateral pitting
    edema, nocturnal cough, 2 pillow orthopnea. GP
    started furosemide 2 weeks ago SOBOE improved
    and orthopnea resolved.
  • PMHx
  • HTN (x 30 years, well controlled)
  • DM (x 15 years, diet controlled)
  • Atrial fibrillation (x 5 years)
  • GERD/PUD (UGIB x 3 years ago)
  • OA

39
Mrs. Tetley
Medications
HF Furosemide 40mg daily (started 2 weeks ago)
HTN HCTZ 25mg daily Potassium chloride 20MEq daily Amlodipine 5mg daily ECASA 81mg daily
DM Diet controlled Rosuvastatin 10mg daily
Atrial Fibrillation Metoprolol 25mg BID Dabigatran 150mg BID
GERD/PUD Pantoprazole 40mg daily
OA OTC Naproxen 220mg daily
Vitamin D 2000IU daily, Calcium 1500mg daily, multivitamin daily, Vitamin E 800IU daily, Vitamin C 1000mg daily, Vitamin B Complex 50mcg daily
40
Mrs. Tetley
  • Investigations
  • Echo LV dilation, dilated LA, EF 40,
    diastolic dysfunction, aortic sclerosis
  • MIBI normal perfusion
  • ECG atrial fibrillation, HR 68bpm
  • CXR mild pulmonary edema
  • Labs Scr 100umol/L K 4.8 mmol/L Na
    135mmol/L
  • Weight 40kg
  • BP 114/68 mmHg sitting 110/60 standing
  • CVS Exam JVP 5cm ASA Bilateral crackles II/IV
    MSM 2bilateral pitting edema to mid-shin

41
Mrs. Tetley
  • Plan
  • Furosemide
  • A) increase
  • B) decrease
  • C) maintain
  • Metoprolol
  • A) increase
  • B) decrease
  • C) maintain
  • D) discontinue
  • Plan
  • ACEI
  • A) yes
  • B) no
  • Other meds
  • A) stop amlodipine
  • B) stop HCTZ
  • C) stop potassium
  • D) stop ASA
  • E) stop vitamins
  • F) stop naproxen
  • G) all the above

SIMPLIFY
? Overall thoughts Complex case with the
opportunity to simplify her regimen outside of
her HF medications
42
Mrs. Tetley
  • Would your plan change with
  • Baseline Scr 40umol/L CrCl 68ml/min
  • Current Scr 100umol/L CrCl 27ml/min
  • Yes
  • No

43
Mrs. Tetley
  • Would your plan change with
  • Baseline K 3.2mmol/L
  • Current K 4.8mmol/L
  • Yes
  • No

44
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45
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46
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47
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48
? The app will warn you if the drug you selected
has a potential contraindication to therapy
49
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50
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51
Mrs. Tetley
  • Mrs. Tetley is followed up via telephone 1 week
    later
  • Furosemide and metoprolol were maintained and
    ramipril 1.25mg BID was started other
    medications were streamlined
  • She reports feeling better, but still has some
    SOBOE and mild peripheral edema
  • Blood work done the day prior reveals
  • SCr 101 umol/L (was 100 umol/L)
  • K 5.5 mmol/L (was 4.8 umol/L)
  • Plan
  • A) Hold ACEI, repeat BW in 3-5 days
  • B) Hold ACEI and give sodium polysterene
    (Kayexalate), repeat BW in 2 days
  • C) Assess dietary intake, ensure K supplement
    was discontinued, repeat BW in 5-7days

52
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53
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54
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55
Key Points
  • Evidence-based medications (EBM) are a major
    cornerstone in HF treatment
  • Poor CV outcomes in HF are correlated to
  • Underutilization of EBM
  • Poor optimization of EBM
  • Patient non-adherence and non-persistence to EBM
  • Under-intensification of EBM is common and
    results in poorer outcomes
  • Clinical tools exist to help improve the
    application of EBM in HF to front-line
    practitioners. For example the app can form the
    underpinning of a collaborative practice
    arrangement between nurses/physicians/pharmacists.

56
Timing of Visits and Whether to Stop
Medications
57
36 Year Old Female
  • Diagnosed with pre-ecclampsia at 24 weeks
  • Progressive edema
  • Dyspnea noted, thought to be normal and told to
    suck it up
  • Went into labour at 34 weeks
  • Pulmonary edema day 2 post natal
  • Nearly intubated

58
Mrs. Doe
  • ECHO LV 57 mm (EDD), EF 18, moderate MR
  • She was treated with vasodilators and diuretics
  • Improved
  • ACE and BB started
  • Tolerated, titrated
  • Clinical improvement over 12-14 weeks

59
Peripartum CardiomyopathyIncidence
  • Varies widely geographically, ranging
  • United States 1/2289-1/4000 live births,
  • to 1/300 live births in Haiti99.

? We are seeing a lot more cases like Mrs. Doe,
than true incidences of peripartum cardiomyopathy
due to more non-Caucasians, more obesity, and
increased hypertension in pregnancy
60
How soon should I see HF patients?
Triage category Access target Clinical scenarios
Emergent lt 24 hours Acute severe myocarditis Cardiogenic shock Transplant and device evaluation of unstable patients  New-onset acute pulmonary edema
Urgent lt 2 weeks Progressive HF / decompensated HF New diagnosis of HF, unstable, decompensated New progression to NYHA IV, AHA/ACC stage D Post myocardial infarction HF Post hospitalization or ER visit for HF HF with severe valvular heart disease
Semi urgent lt 4 weeks New diagnosis of HF, stable, compensated NYHA III, AHA/ACC stage C
Scheduled lt6weeks lt12 weeks Chronic HF disease management, NYHA II NYHA I, AHA/ACC stage B
61
How often should my HF patient be seen?
Risk group Features defining risk of group Suggested frequency of follow-up
Low risk NYHA Class I or II No hospitalizations in past year No recent changes in medications On all optimal medical HF therapies At least yearly (90 suggested within 12 months, 50 within 6 months) In certain cases, may consider discharge of patient from clinic to specialist office (in addition to primary care).
Intermediate No clear features of high or low risk. 1-6 months
High risk NYHA IIIb or IV symptoms, frequent symptomatic hypotension, more than 1 HF admission (or need for outpatient intravenous therapy) in past year, recent  HF hospitalization esp. in past month, rising creatinine, especially eGFR lt 30 ml/min, Non-adherence to therapy for any reason During titration of HF medications (ACEi/BB/ARB/MRA) New onset heart failure Complication of HF therapy Need to downtitrate or discontinue beta-blockers or ACE/ARB Concomitant and active illness (i.e. high grade angina, severe COPD, frailty) frequent ICD firings (1 month) Minimum 1-2 visit per month In some cases, there may be weekly assessments or even more frequent- especially if patient willing to undergo multiple visits to potentially avoid a hospitalization.
62
When should I get another EF Measurement?
Clinical Scenario Timing of measurement Modality of Measurement Comments
New Onset Heart Failure Immediately or within 2 weeks for baseline assessment ECHO (preferred when available) or MUGA or CMRI 70 request ECHO and 30 MUGA, report should include numeric EF or small range of EF as well as diastolic function evaluation
Following titration of triple therapy for HFrEF, or consideration of ICD/CRT implantation 3 months after completion of titration ECHO or MUGA or CMR (preferably the same modality and lab as initial test) LVEF following optimal medical therapy may obviate device therapy.
Stable Heart Failure Approximately every 2-3 years, especially if EF is above 40 ECHO or MUGA or CMRI Rationale is to screen for those who may cross from HFrEF to HFpEF and vice versa, which may change therapeutic goals
Following significant clinical event (i.e. hospitalization for HF) Within 30 days, during hospitalization if possible. ECHO or MUGA or CMRI, cardiac catheterization in context of ACS Frequently helpful information such as EF, degree of valvular dysfunction and RVSP.
63
? Ejection fractions do not remain the same
forever-they will change over time, thus should
be checked periodically (or at least thought
about) as there is no predefined schedule for EF
measurement
Circ Heart Fail. 20125720-726
64
Mrs. Doe Follow Up
  • Now asymptomatic
  • Diuretic stopped due to hypovolemia
  • Repeat ECHO EF 54
  • LV EDD 48 mm
  • No MR
  • Normal RVSP est but only trivial TR

? Because she is asymptomatic, she starts
playing with her drugs, and questions whether
she could go off them completely.
65
Now she wants to stop her HF meds
  • Yes or no?
  • If so, which ones?
  • ? If EF goes above 40, good prognosis. Thus, for
    certain conditions you may be able to
    stop/discontinue medications if EF returns to
    normal, or above 40 (refer to following 2
    slides).

66
Maternal Complications Associated With
Subsequent Pregnancy

44

31

25
21
21
19

14

0

A B HF Symptoms
A B gt20 Decreased LVEF at F/U
A B Maternal Mortality
A B gt20 Decreased LVEF
including aborted pregnancies
67
Contractile Reserve in Patients With Peripartum
Cardiomyopathy and Recovered Left Ventricular
Function
Lampert et al. AM J Ob Gyn 1997 176189
68
Who can I discharge from my HF clinic?
  • Stable NYHA I or II for 6-12 months
  • On optimal devices and pharmacological therapies
  • Stable adherence to optimal HF therapy
  • No hospitalizations for gt 1 year
  • LVEF gt 35 (consistently shown if more than one
    recent EF measurement)
  • Reversible causes of HF

69
Case
  • 74 yo male with 10 year hx DCM (normal
    coronaries), followed in HF clinic
  • ICD inserted 6 years ago
  • Has done very well since you have seen him

70
Case
  • Perindopril 8 mg OD
  • Digoxin 0.125 mg OD
  • Carvedilol 25 mg BID
  • Spironolactone 25 mg OD
  • Lasix 40 mg OD- patient has not been taking it

71
Case
  • BP 120/70, HR 60 reg
  • JVP ASA, - AJR
  • HS S1, S2, no murmurs, no rub
  • 1 pretibial edema bilaterally
  • No palpable organomegaly
  • Chest clear
  • NT-proBNP 810, reasonably well controlled

72
Case
  • Hb 128, WBC 6.5 (n diff)
  • Na 139, K 4.7, creat 100
  • LVEF 54 and LVID 55 mm
  • Had been 23 and 64 mm 3 years ago

73
Would you stop his medications?
  • Yes
  • No
  • It depends

74
Would you replace his ICD?
  • Yes
  • No
  • Leave it to EP
  • Depends

75
Can HF Meds be stopped?
Clinical Presentation Conditions to justify withdrawal of TT after 6-12 months of therapy Comments
Tachycardia related cardiomyopathy Normal EF NYHA FC I Underlying tachycardia controlled Usually due to atrial fibrillation/flutter with increase HR, may rarely occur due to PVCs. May need BB for rate control
Alcoholic Cardiomyopathy Normal EF NYHA FC I Abstinence ETOH Nutritional deficiency may coexist. May need control of obesity and obstructive sleep apnea
Chemotherapy related CM Normal EF NYHA FC I No further drug exposure Certain types of chemo (trastuzamab - high rate of improvement one it is stopped) are more likely to reverse than others (anthracyclines for which therapy should be continued). Long-term surveillance strongly recommended
Peripartum Cardiomyopathy Normal EF NYHA FC I   Repeat pregnancy may be possible for some(REF 2009) (silversides). Consultation at high-risk maternal centre should be undertaken.
Valve replacement surgery Normalization of EF NYHA FC I Normally functioning valve Less consensus on regurgitant lesions with ongoing dilation of LV
76
What is the evidence for drug withdrawal in HF?
  • Almost nil for ACE (however symptoms may return
    in majority of cases)
  • Few studies of BB (show development of symptoms,
    and recurrence of phenotypic HF syndrome)
  • Several case series of up to 60 patients
  • No controls
  • No denominator
  • Largest Trial Waagstein 24pts withdrawal
  • 66 deteriorated, 4 died
  • Morimoto- Japan- 13 patients
  • 7 deteriorated, 4 died
  • Swedberg, initial paper in 15 DCM
  • 40 worsened
  • When deterioration occurred, it did so within a
    few months

77
Consort Diagram
78
Withdrawal of agents
  • ACE inhibitors
  • Clinical worsening in 70
  • Minor change in EF
  • Exception seems to be in renal dysfunction
  • Beta Blockers
  • In both NICM and ICM
  • Odds ratio of return of HF 26 in one study if BB
    stopped
  • About 70 chance of lower EF, often with symptoms
  • MRA
  • No real data
  • Diuretics
  • Increased likelihood of return of symptoms
  • PPCM
  • Low incidence of HF if EF returned to normal

79
39 year old male
  • Seen last year with A Flutter and LVEF 22
  • Was drinking heavily at time and was hypertensive
  • Cardioverted and in NSR since then
  • Now LVEF on ACE and BB and OAC is 60
  • Asymptomatic

80
Do you stop his medications?
  • Yes
  • No
  • Depends

81
Tachycardia-Induced Cardiomyopathy
  • Caused by persistent supraventricular or
    ventricular arrhythmias, especially atrial
    fibrillation, atrial flutter, atrial tachycardia,
    junctional tachycardia, ventricular tachycardia
  • May occur at any age
  • Should be suspected when LV dysfunction (with or
    without typical HF signs/symptoms) occurs with a
    persistent, inappropriate tachycardia or
    tachyarrhythmia, without another identified cause
  • Important to exclude inadequately treated HF and
    other conditions that may produce a persistent
    tachycardia

Arnold JMO, Howlett JG, Ducharme A et al. Can J
Cardiol 200824(1)21-40.
82
Follow up
  • Patient still drinking 2 drinks per day (what he
    admits to)
  • Patient has gained 30 lbs (salesman, travel) and
    BP is elevated 150/94
  • Patients has developed diabetes during the past
    year

83
Alcohol-Induced Cardiomyopathy
  • Alcohol consumption is a major risk factor for
    dilated cardiomyopathy
  • Recommendation
  • Permanent abstention from alcohol must be
    recommended and reinforced (refer to a
    counselling program if necessary) in patients
    diagnosed with an alcohol-related cardiomyopathy
  • (Class I, Level C)

Arnold JMO, Howlett JG, Ducharme A et al. Can J
Cardiol 200824(1)21-40.
84
Mrs. PP
  • 60 year old female presented 1 year ago with
    breat cancer, HER
  • Underwent FAC and Trastuzamab therapy for 6
    months
  • 9 month EF showed EF 60 to 44
  • Trastuzamab stopped
  • Progressive heart failure 3 months later
  • Placed on Ace and BB and diuretic and Trastuzamab
    stopped

85
Questions (Y or N)
  • Would you stop trastuzamab for good?
  • When would you re-check LVEF?

86
Further Follow-up
  • 3 months later LVEF is 55 on therapy
  • Do you stop therapy?
  • Why or why not?
  • How long would you follow if EF stayed normal?

87
Chemotherapy-Induced Cardiomyopathy
  • Most common and severe with anthracyclines and
    herceptin
  • Recommendations
  • Patients receiving known cardiotoxic agents for
    cancer should be carefully monitored during and
    after therapy. If LV function deteriorates, they
    should be aggressively treated with beta-blockers
    and other standard therapies for HF
  • (Class IIa, Level B)
  • In patients with a history of chemotherapy-induced
    cardiomyopathy or HF, other cancer treatment
    options should be considered
  • (Class IIa, Level B)

Arnold JMO, Howlett JG, Ducharme A et al. Can J
Cardiol 200824(1)21-40.
88
Additional Case
89
Case study Mr. CC
  • 62 year old man- presents to ER 4 week history
    of increasing SOB, 3 pillow orthopnea, PND.
  • PMHx- viral cardiomyopathy (8 years ago).
  • EF 35, NYHA class I symptoms (until recently)
  • Hypertension, family history CAD, non-smoker,
    rare ETOH, no diabetes, lipids normal.
  • Normal coronaries coronary angiogram 8 years
    ago
  • Medications Ramipril 12.5 mg daily, metoprolol
    25 mg BID (not taking these for a few months-
    they make him itchy and give him a cough)

90
Mr. CC findings
  • Weight 103.7 Kg
  • bp 159/96 mm Hg
  • ECG Sinus rhythm- 80 bpm (narrow QRS)
  • Lab Creatinine 110umol/L, urea 9.2mmol/L, K4.3
    mmol/L, Na140mmol/L
  • CXR mild pulmonary edema
  • Echo global hypokinesis, EF 15, no significant
    valvular abnormalities, RVSP 54 mm Hg. Dilated
    LA, RA, LV.
  1. How would you optimize the pharmacological
    management for this patient?
  2. Does he need to be followed in a heart function
    clinic?
  3. How do you work through adherence issues?
  4. Does he need an ICD?

91
Mr. CC 2 years later
  • Progress over next 2 years
  • Followed in HFC- optimization
  • No hospitalizations
  • NYHA Class I within 6 months
  • Optimized medications
  • Working through challenges with adherence
    trust, negotiation
  • Sleep clinic assessment
  • Developed atrial fibrillation
  • No ICD

Medications Atacand 32 mg OD Coreg 37.5 mg
BID Lasix 40 mg prn- rarely uses Norvasc 2.5 mg
OD Pradaxa 110 mg BID
Weight 100 Kg. BP 124/82 mm Hg, ECG- Afib 72bpm
.
Echo global HK- EF 35-40. No valvular
abnormalities, RVSP lt35mmHg RNA- EF 34
92
Case Summary
  • 78 year old lady with a history of mildly
    obstructive cardiomyopathy for the past 30 years
  • Very stable on diltiazem 180 mg daily
  • Lives with husband and used to walk everyday
  • No history of CAD
  • Over  the past 2 years, developed shortness of
    breath on exertion and palpitations, also
    presents occasional dizziness
  • Referred for  evaluation at CHF clinic
  • PEx JVP 15, irregular HR 80/ min, loud systolic
    murmur of aortic stenosis, no S3, mild
    hepatomegaly and no pedal edema.
  • ECG Afib and LVH
  • Echo  small LV with asymmetric hypertrophy and
    normal LVEF
  • Severe calcified aortic stenosis Grad 80/45 with
    very small LVOT, very calcified mitral annulus
    with 20/10 gradients and severe LA dilatation
  • No significant MR
  • Moderate TR with PA pressure 50 mmHg JVP

93
What is your plan?
  • Anticoagulation and cardioversion
  • Diuretics
  • Change cardizem for B blocker
  • Cardiac cath with intended surgery
  • Keep in CHF clinic

94
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