Congestive Heart Failure Flashcards
Mortality rate/prognostication/role of palliative care in heart failure
- Worsen than many metastatic cancers
- Prognostication can be difficult as patients can decline and recover repeatedly
- Integrated palliative care can result in a survival benefit for advanced heart failure patients
Pathophysiology of Heart Failure symptoms
- Dyspnea/Fatigue/Limited Exercise tolerance
- Fluid overload and pump failure
- Hormonal and cytokine alterations resulting in sarcopenia in skeletal, respiratory, and cardiac muscles
- Sleep disordered breathing and desats - Anorexia/Nausea/Constipation/Cachexia
- Catabolic state secondary to neurohormonal activation - Pain
- May be anginal or due to muscle weakness with pain in legs and joints
- Procedures (implants/cardiac surgery)
- Comorbidities (e.g. peripheral neuropathy etc.) - Cognitive impairment/Dep/Anxiety
- Sleep disordered breathing and desats
- Depression is commonly comorbid
NYHA Heart Failure Classification
Stage I
- No limitations
Stage II
- Slight limitation of physical activity
- Comfortable at rest, but symptoms with ordinary physical activity (palps, fatigue, dyspnea)
Stage II
- Marked limitation of physical activity
- Comfortable at rest, but symptoms with less than ordinary physical activity
Stage IV
- Dyspnea at rest
- Unable to participate in any physical activity without discomfort
Natural history of CHF
Stage I
- After diagnosis and treatment with life style modifications, most patients have a period of being relatively asymptomatic
Stage II
- Eventually, patients become symptomatic (NYHA II-III) and are at risk of sudden death due to arrhythmias and may benefit from an ICD
Stage III
- Increasing loss of function with exacerbations that may require hospitalization (NYHA III-IV)
- Response to ‘rescue’ treatment)
- Opioids may be helpful
Stage IV
- Refractory heart failure with severe symptoms (NYHA IV)
- Prognosis may still be challenging
- Palliative Care involvement is most helpful
ICDs for CHF
- Secondary prevention
- Hemodynamically significant or sustained ventricular arrhythmia - Primary prevention
- Ischemic or non-ischemic cardiomyopathy, NYHA class II-III AND EF ≤ 35%
- Ischemic cardiomyopathy, NYHA Class I and EF ≤ 30%
- EF should be measured at least 1 month post MI, and at least 3 months post coronary revascularization procedure - Recommend AGAINST ICD implantation in patients with NYHA IV without anticipated improvement with further therapy and are not candidates for transplant or LVAD
As per CBD:
- Life expectancy > 1 year and reasonable quality of life
- EF < 30% with or without symptoms
Note that they do not improve QOL and sudden death may be a preferable mode of death for those with comorbidities or progressive HF
Deactivation of an ICD
- By patient request
- Discussed in the context of functional decline or deteriorating cardiac function requiring several shocks of ICD
- Avoid painful shocks during active phase of dying
- Simple and quick to do (magnet placed over the device to deactivate)
Prognostication in Heart Failure
- Should be a discussion early in the illness trajectory and there should be discussion of code status and SDM
- Prognostic models estimate death risk at 1, 2, and 3 years from measurement
- Seattle Heart Failure Model is well validated in a variety of patients
Predictive factors of death in CHF
- Frequent hospital admissions
- Poor function
- Weight loss > 10%
- Low albumin
- High BNP
- Renal function (ESRD)
- EF < 20%
- Symptoms at risk
- Previous embolic stroke
- Previous cardiac arrest
HFrEF treatment - Foundational
EF < 40%
- ARNI or ACE
- ARNI favoured over ACEi/ARB
- reduces CV death and hospitalizations
- Renal function may limit use - BB
- Reduction in mortality and hospitalizations
- Start low and go slow with more severe symptoms - Mineralocorticoid antagonist
- EF <40% and DM or MI with symptoms
- Reduces mortality and hospitalizations
- Avoid for GFR < 30% - SGLT2 inhibitor (empagiflozins, canagiflozin)
- Benefit regardless of DM status
- Improves QOL, Symptoms, and reduces hospitalizations and CV mortality
Acceptable increase in Cr after initiating an ACEi
- Up to 30% if no oliguria
- May stabilise at 30%
Additional treatments for HFrEF
Additional interventions:
- HR >70bpm despite BB and sinus, consider ivabradine (sinus node inhibitor)
- Recent HF hospitalization and worsening HF, consider vericiguat (guanylate cyclase inhibitor - lowers BP, avoid if SBP < 100 or on nitrates)
- Black patients on optimal GDMT or unable to tolerate ARNI/ACEi/ARB, consider hydralazine-nitrates
- Suboptimal rate control for AF or symptoms despite optimised GDMT, consider Dig (avoid in renal impairment, sinus node dysfunction)
Treatment of Dyspnea in CHF
- Opioids
- Small RCTs for opioids for dyspnea in heart failure (more evidence for COPD)
- May also be useful for refractory angina
- Preference for longer acting opioids (rather than PRN) for better compliance and fewer adverse events - Oxygen
- Very poor evidence, use only if the patient is on opioids, hypoxic, and feels relief with oxygen - Benzos
- May be used for dyspnea, but evidence is lacking and are risky in frail older aldults - Antipsychotics for dyspnea
- More evidence than benzos - Thoracentesis
- Likely to reaccumulate rapidly - SL Nitro
- If dyspnea is an anginal symptom - Diuresis
Treatment of Depression in CHF
- Occurs in 20% of patients with CHF and increases mortality rate
- TCAs
- Avoid, due to QT prolongation/arrhythmias and anticholinergic effects - SSRIs
- Generally well tolerated - SNRIs
- Useful if the patient also has neuropathic pain - Psychosocial care
- Honest communication, adequate plan of care following hospital discharge, and communication with family
- Reduction of emotional/physical burden on family
- Exercise
- Behavioural Activation
Treatment of Refractory angina or pain in CHF
Opioids
- Small RCTs for opioids for dyspnea in heart failure (more evidence for COPD)
- May also be useful for refractory angina
- Preference for longer acting opioids for better compliance and fewer adverse events
- Preferred to PRN dosing
NSAIDs
- Avoid in CHF due to sodium retention/HF exacerbation
Caution with QT prolonging meds
- Methadone
- Venlafaxine
- TCAs
Spinal cord stimulators, stellate ganglion blocks, spinal opioids
- Can be used for refractory angina (opioids generally preferred)
Indications for CRT
- Pacing system used to resynchronise ventricles
- May improve QOL and prolong life in patients with LV systolic dysfunction and dyssynchrony
- Can improve EF and symptoms
Candidates
- Ensure tx is optimised first (eg. ivabradine, ARNI)
- Patients in sinus rhythm with EF < 35% and QRS >130msec with LBBB with ambulatory symptomatic HF despite optimal medical therapy
Consider CRT:
- As above, but with QRS >150msec with NON-LBBB
- Permanent AF expected to have close to 100% pacing
Eligibility for heart transplant
Criteria
- Advanced HF, 70 years old or younger
Considerations for better outcomes:
- Frailty
- Obesity
- Psychosocial assessment
- Evaluation for medical adherence and substance use (including EtOH, smoking, cannabis, etc.)
Contraindications
- Pulmonary hypertension (risk of post transplant RV failure) - May go on an LVAD to reduce pulmonary pressures and undergo re-evaluation at 3-6 months post
Inotropes for heart failure
Dobutamine
- Increases cardiac output
- Decreases systemic vascular resistance
Milrinone
- Decreases systemic vascular resistance (vasodilation)
- Decreases pulm htn
Intermittent infusions may improve quality of life (improve energy, edema, and dyspnea), especially in younger patients with few comorbidities. However, increases risk of mortality with longer term use due to arrhythmias
Validated tools to assess QOL in HF
ESAS (Edmonton Symptom assessment scale)
Caregiver Burden Inventory
Minnesota living with heart failure questionnaire
Treatment of HFpEF
- Minimum effective diuretic dose to maintain euvolemia (usually loop diuretics )
- Treat hypertension
- Treat any underlying valvular disease
- In most causes, there will be some indication for an ACEi, ARB, or BB
- Consider an MRA if K < 5 and GFR > 30
Symptoms of CHF
- Same for HFrEF vs HFpEF
- Dyspnea, PND, orthopnea
- Elevated JVP
- Pulmonary rales
- Peripheral edema
Mechanism of action: BB
- Block sympathetic stimulation of the heart and improve EF
- Reduce hospitalizations and mortality
- Only start when patient is stable as may acutely worsen cardiac function
- Benefit for patients with even severe symptoms
- Patients may become intolerant toward end of life with hypotension, bradycardia, or hypoperfusion
Mechanism of Action: ACEis/ARBs/Hydralazine-ISDN
- Enhance forward blood flow by allowing blood vessels to dilate and slow ventricular remodelling and thus progression of disease
- Can improve symptoms
- Reduce hospitalizations and mortality
Mechanism of action: MRAs
- Block effects of aldosterone - reduce RAAS mediated ventricular re modelling
- Reduce mortality, hospitalization, and improve functional class
- Must monitor for hyperkalemia (may limit use in late stage CHF where renal insufficiency is more common)
- Epleronone causes less gynecomastia
Mechanism of action: Dig
- Does not prolong survival, but can be used for patients to improve symptoms if they are struggling with hypotension
- BB is generally preferred
- Avoid in renal insufficiency and use at low dose
Meds to avoid in CHF
- NSAIDs (fluid retention, volume overload,CHF exacerbation)
- TZDs in diabetes (fluid retention)
- QTc prolonging agents (methadone, TCAs, venlafaxine)
- Venlafaxine (HTN)
Mechanism of action in CHF: Diuretics
- Reduce overall volume load to reduce dyspnea and pulmonary edema
Non-pharm management of CHF
- Moderate sodium restriction (<2-3g/day) to reduce volume overload and allow for lower diuretic doses
- Limited fluid intake if prone to hyponatremia (<1.5-2 L/day)
- Exercise training
VAD
- Pump implanted into the chest and connected to the heart
- Control line connects through the skin to battery and control device
- Can be right or left VAD, but usually LVAD
- Can be used as a bridge to transplant or as ‘destination therapy’ (eg not eligible)
- Can be withdrawn if quality of life becomes too poor or if a new comorbidity arises
- Survival is 80% at 1 year, 70% at 2 years
Adverse events associated with VADs
- Bleeding
- Drive line infection
- Thombosis
- Thromboembolism
- Device failure
- Death
Withdrawal of LVAD
- Death typically occurs within 20 minutes
- Ensure subcut meds and access available for dyspnea (opioids) and anxiety (benzos)
Management of edema in CHF
- Limit fluid and salt intake
- Adjusting diuretics
- Elevation of legs (preferably above level of the heart)
- Bandages and wraps for weeping lesions and blisters
- Supports for testicular edema
Management of Fatigue in CHF
- Energy conservation techniques (pacing)
- Rehab
- Special equipment (e.g. shower chair)
- Therapeutic exercise
- Stimulant meds likely too risky, but coffee may be helpful
- Ensure other issues treated (e.g. OSA)
