Heart Failure Flashcards
what are the modifiable risk factors of CVD
Modifiable:
▪ Smoking
▪ ETOH
▪ Overweight/Obesity
▪ Diabetes Mellitus
▪ HTN
▪ Hyperlipidaemia
▪ Sedentary lifestyle
what is cardiomyopathy?
▪ Cardio (heart), Myo (muscle), Pathy (disease)
▪ Precursor to Heart failure
Three main types
▪ Dilated
▪ Restrictive
▪ Hypertrophic
All cardiomyopathies have the same end result:
▪ Diminished capacity to pump blood around the body and other organs
because of structural +/- electrical changes in the heart.
Cardiomyopathy affects 1 in 500 people
▪ High chance you will see this on during your clinical placement!
symptoms of cardiomyopathy?
▪ Early satiety
▪ Delayed gastric emptying
▪ Anorexia
▪ Nausea
▪ Abdominal pain
▪ Rapid weight gain
▪ Shortness of breath
▪ Fatigue
▪ Chest pain
▪ Dizziness or lightheadedness
▪ Fluid retention: Patients don’t always hold fluid in the same place!, Ascites (Fluid retention in the peritoneal cavity), Pedal Oedema (Fluid retention in the extravascular compartments of the lower limbs), Pulmonary Oedema (Fluid retention inside the lungs), Intestinal Oedema (Fluid retention of the GIT)
Describe the treatment of cardiomyopathy. (lifestyle and dietary modifications)
Lifestyle modification
▪ Modifiable risk factor reduction
▪ Smoking, ETOH, Sedentary lifestyle etc.
Dietary Modification
Sodium Restriction
▪ Heart foundation suggests less than 2000mg/day (~5g)
▪ Current research which suggest more restrictive sodium intake leads to improved markers of heart failure and QOL (SODIUM-HF 1500mg/day)
Fluid Restriction
▪ As guided by the medical team
▪ Range from 1L – 2L, Most common restriction in 1.5L
Prevention of Malnutrition
▪ 50% of patients with heart failure experience some form of dry weight loss
what is the rationale behind recommending a low-sodium diet for cardiomyopathy?
High dietary Na+ intake causes increased blood volume and increased blood pressure which causes an increased workload on the heart which results in decompensation and development of peripheral fluid reetention
what is cardiac cachexia?
ESPEN
▪ Definition: >6% LOW in the past 6 months
▪ Incidence of weight loss >6% in patients with NYHA class III/IV is
approximately 10% per year
▪ Mortality is 2-3x greater than non-cachectic patients
▪ Multifactorial process
▪ Muscle wasting
▪ Reduced food intake
▪ Diminished capacity to regenerate muscle
▪ Hypermetabolic condition which almost always requires aggressive nutrition
support
describe the mechanism of cardiac cachexia?
Congestive heart failure causees an increase in angiotensin II this impacts the hypothalamus (reduced food intake) and skeletal muscle (muscle wasting) and skeletal muscle regeneration (suppressed muscle regeneration)
what is ejection fraction?
▪ Ejection Fraction – Measure of cardiac output
▪ 50% - 70% Normal output
▪ 41% - 49% Borderline output
▪ <40% Reduced Ejection fraction
what are the two main treatment pathways for advanced heart failure?
1) Transplant Pathway
Thorough MDT workup for VAD - > Transplant
Prioritise extension of life through invasive medical and MDT management
2) Conservative medical management
Optimise medications and lifestyle changes to prioritise comfort and QOL
what is a VAD?
Ventricular Assist Device
Patients can have one or both ventricles supported LVAD or BiVAD
VAD’s are continuously improving and getting smaller
Significant surgery and requires extensive rehabilitation to recover
key considerations of VADs?
QLD Health legislated to provide VAD as bridge to transplant, not destination therapy
Goal is to prepare patient for not only a VAD but also cardiac transplant.
Important to consider if patient is going to be appropriate for heart transplant when a viable organ is available
Length of time on the waiting list ranges from hours to years.
Not everyone who is assessed for a VAD/Transplant is deemed suitable
Patients can be delisted for transplant rapidly for many reasons
Small percentage of patients listed don’t make it to transplant
Nutrition assessment athro for VAD
Weight, Height, BMI
VAD – Reduced survival rates in BMI <22.9kg/m2, best survival in BMI >29.4kg/m2
Most likely due to increased physical reserves post surgery leading to better
recovery
TX – ISHLT guidelines max BMI = 35kg/m2, however have not defined min
BMI
Anaesthetics guidelines suggest avoiding transplant BMI <18.5kg/m2
Practical advice = Aim for BMI >22.9 for best outcomes for VAD and heart transplant.
Be cautious in patients who are approaching BMI 30-35
▪ Always consider dry weight!
Nutrition Assessment - Biochemistry for VAD
electrolytes – as part of the usual practice
▪ Na+, K+, Mg, Po4
▪ Na+
▪ High when dehydrated, low when fluid overloaded (under diuresis)
K+ important for heart muscle contractions
▪ Specifically want to avoid hyperkalaemia and hypokalaemia
▪ Generally like to keep K+ at 4.0mmol/L
▪ What diuretics is the patient on?
BNP - Brain natriuretic peptide
▪ Produced in the left ventricle when working harder than usual or is
stretched beyond normal ranges
▪ Used as a marker of heart failure and to monitor severity
Albumin (Alb)
▪ Poor marker of nutrition in most acute scenarios
▪ Consider LFT and CRP when evaluating the validity of Alb
▪ Protein synthesized in the liver
▪ Heart failure is an inflammatory condition
▪ Increased inflammation leads to increase CRP
▪ Increased inflammation effects liver protein synthesis
▪ Raised LFT + Raised CRP = Non reliable Alb level.
▪ Practical advice: Consider if the patient is in a state of inflammation
through medical history and biochemical markers and interpret
albumin level accordingly.
HbA1C
▪ Marker of Diabetes
▪ ISHLT Guidelines for Tx listing = <7.5%
Thiamine
▪ Deficiency can be related to diuretic use therefore should be checked
and replaced as needed.
Fat soluble vitamins
▪ Relevant when intestinal oedema coupled with steatorrhea is present
▪ Reduced uptake from diet, needs to be replaced through supplementation.
Micronutrients
▪ Raised CRP effects validity of micronutrient screen
Nutrition Assessment - Clinical for VAD
Nutrition impact symptoms
▪ Nausea, Vomiting, Diarrhoea, Constipation
▪ Check fat malabsorption
▪ Early Satiety
▪ Reduced appetite
▪ Abdominal pain
▪ Shortness of breath
BMD – Bone mineral density scan
▪ Check for osteoporosis and ax bone health status
▪ Rationale: Post transplant medications can lead to further deterioration of bone
structure
Medications – diuretics, antiemetics, electrolyte replacement, IVT
▪ Previous medical history: EF%, related co morbidities (DM, HTN, Dyslipidaemia
etc)
Nutrition Assessment - Diet for VAD
▪ Dietary intake
▪ Energy and protein (EEI, EPI)
▪ Fluid intake vs restriction
▪ Balance of saturated: unsaturated fats and other macronutrients
▪ ETOH – abuse is considered contraindication to Tx
Dietary requirements hypermetabolic pre VAD/Tx patient
(Non obese patient)
▪ Energy: 126-147kj/kg
▪ Protein: 1-1.5g/kg – Note this can be as high as 2g/kg
▪ Sodium: <2g Na+/day
▪ Above is a guide only, nutrition requirements are guided by constant monitoring of dry
weight compared to dietary intake.
Practical advice = Start with the above requirements and adjust as required,
always remember that equations are only an estimate, gold standard for
identifying energy requirements is through indirect calorimetry
Consider oral nutrition support (ONS)
▪ If ONS is being provided, is the type and amount being prescribed appropriate
for the patient?
▪ 1.5L Fluid restriction
▪ 2x Resource plus/day
▪ 2x 237mls = 474mls 32% of total fluid restriction
▪ 3000kj, 26g pro
▪ Resource 2.0 120mls TDS
▪ 3x 120mls = 360mls 24% of total fluid restriction
▪ 3000kj, 30g pro
▪ Practical advice = opt for low volume, high energy/protein supplements
when prescribing ONS to patients with a fluid restriction.
▪ This will help with compliance and overall QOL.
