Heart Failure Continuum of Care Flashcards
Co-morbidities with Heart Failure in WOMEN
HTN Valvular disease Thyroid function Less obstructive CAD DM LVH (increased mortality)
Define Heart Failure
Complex, heterogeneous & progressive syndrome characterized by structural and/or functional abnormalities in cardiac contraction, consequent adverse euro-hormonal adaptations & remodeling & co-morbidities that collectively alter myocardial function, fluid regulation, respiration, & perfusion & overall hemodynamic stability
Unusual Causes of Cardiomyopathy
Hypertrophic obstructive cardiomyopathy (HCM) AL amyloid cardiomyopathy Myocarditis Tachycardia-induced cardiomyopathy (TIC) Takotsubo cardiomyopathy (TTC) Peripartum cardiomyopathy (PPCM)
Co-Morbid Conditions in Heart Failure
Anemia: of chronic disease Gout: thiazides contribute HTN Renal dysfunction: murderous marriage with the heart Lung disease; sleep-disordered breathing Rapid or irregular dysrhythmias DM Thyroid disorders
Types of Remodeling in Heart Failure
Hypertrophy (preserved EF HF)
Dilation (reduced EF HF)
Clinical Features of Heart Failure with Preserved Ejection Fraction
Volume overload
Decreased activity tolerance
QOL similar to low EF patients
Heart failure with preserved ejection fraction is associated with what kind of dysfunction?
Diastolic dysfunction
Signs/Symptoms of Diastolic Dysfunction
Increased LV wall stiffness
Decreased compliance/impaired relaxation
Decreased cardiac output
3 Stages of Diastole
Isovolemic (active) relaxation & rapid early filling
Diastasis (passive) filling
Active filling during atrial contraction
Define Grade 1 Diastolic Heart Failure
Impaired relaxation
Define Grade 2 Diastolic Heart Failure
Pseudonormal
Concomitant LA enlargement, LV hypertrophy and/or decreased LV ejection fraction
Define Grade 3 Diastolic Heart Failure
Restrictive/constrictive Difference is reversibility Impaired LV relaxation Increased LV stiffness Increased LA pressures
Define Dilation
Compensate for poor cardiac output, ventricle dilates, becomes thinned & weakened
Heart failure with reduced ejection fraction is associated with what kind of dysfunction?
Systolic dysfunction
Clinical Features of Reduced Ejection Fraction Heart Failure
Impairment of LV contraction EF less than 40% Decreased stroke volume Decreased cardiac output Engorgement of systemic veins Decreased perfusion to vital organs
Atrial Fibrillation in Heart Failure
Lead to an acute decompensated state
Common Symptoms of A-fib in Heart Failure
Fatigue
Dyspnea
Especially in preserved HF
Factors that Contribute to HF
Cardiac chamber enlargement Conduction system & anatomical heart abnormalities Adaptations of SNS Adverse responses to medications Electrolyte abnormalities
Functional Classification of HF
Class 1 (Minimal): no limitations Class 2 (Mild): no strenuous activity Class 3 (Moderate): activity limited to ADLs Class 4 (Severe): symptoms with any physical activity
2 Parts of a Cardiovascular Assessment
Wet or dry: assessing fluid status & congestion
Warm or cold: assessing indicators of perfusion
No Low Perfusion or Congestion at Rest
Warm & dry
Congestion at Rest but No Low Perfusion at Rest
Warm & wet
Low Perfusion at Rest & No Congestion at Rest
Cold & dry
Lower Perfusion & Congestion at Rest
Cold & wet
Possible Evidence of Low Perfusion
Narrow pulse pressure Sleepy/obtunded Low serum sodium Cool extremities Hypotension with ACE inhibitor Renal dysfunction
Signs/Symptoms of Congestion
Orthopnea/PND JV distension Ascites Edema Rales (rare) S3 Hepato-jugular reflex
Follow Up Questions with SOB
Occurring at rest or with exertion
Awaken patient from sleep
Occur when walking on a flat surface; worse with stairs/carrying items
Increasing with daily activities now as opposed to 1 & 6 months ago
Ask family if patient looks more SOB than normal
Follow Up Questions with Cough
Productive, non-productive, blood tinged sputum
Worse with exertion or when lying down
Patient taking any new medication
Follow Up Questions with Chest Pain
Description Accompanied by diaphoresis, SOB, N/V Alleviating or aggravation factors With or without exertion Awaken patient from sleep
Follow Up Questions with Palpitations
Circumstances when symptoms occur
Duration & description
Accompanied by dizziness, loss of consciousness, shock from ICD
Follow Up Questions with Dizziness, Lightheadedness, Syncope
Occur with position changes, while bending over
Accompanied by palpitations
Loss of consciousness (alone or witnessed)
Follow Up Questions with Abdominal Fullness
Weight change in the past week, month
Presence of nausea, early satiety, abdominal bloating
Clothes feel tight (pants, belt)
Experiencing RUQ tenderness, feelings of pressure in abdomen
Follow Up Questions with Dietary Habits
Table salt added while cooking or eating
Consuming frozen processed meals, canned foods, eating in restaurants
Foods high in fat/cholesterol
Follow Up Questions with Edema
Presence in feet, ankles, calf, knees, back
Resolve overnight
Skin painful or seeping
Follow Up Questions with Sleep
Awaken during the night with SOB
Able to lay flat, sleep propped up in bed, on a sofa, recliner, or sit at the edge of the bed
Follow Up Questions with Mentation
Difficulty thinking, staying awake, concentrating or understanding written/verbal communication
Does family notice whether patient’s mind drifts or not paying attention
Falling asleep while talking to someone in person or on the phone
Follow Up Questions with Substance Abuse
Smoking
Illicit drugs
Alcohol
Follow Up Questions with Past Disease/Treatment
Recent infections Symptoms Treatment Rheumatic fever Chemo: type & year
Clues for Identifying Patients with Advanced HF
Repeated hospitalizations or ED visits for HF in past year
Progressive deterioration in renal function
Weight loss without other cause
Intolerance to ACE inhibitors due to hypotension and/or worsening renal function
Intolerance to beta blockers due to worsening HF or hypotension
Frequent systolic blood pressure
Diagnostic Testing for HF
CXR Lab: include biomarkers ECG ECHO, MUGA, MRI Risk stratification for CAD Risk stratification for HF
Non-invasive Imaging for Risk Stratification for CAD
Nuclear stress test
Stress echo
Invasive Imaging for Risk Stratification for CAD
Cardiac cath
Initial Lab Testing & as Indicated
CBC without diff CMP A1C BNP TSH Lipid panal UA: proteinuria, RBCs Uric acid CXR (new/suspected HF)
Diuretic Guidelines
Used in symptomatic patients to reduce fluid
Increase initial dose as necessary to relieve congestion
Torsemide & bumetanide can be effective in patients with poor absorption of oral meds or erratic diuretic effect, esp. RHF
IV diuretics may be pessary to relieve congestion
Avoid chlorthiadone or metolazone when high-dose loop diuretic therapy not effective
Education to adjust daily dose of diuretic in response to weight gain from fluid overload
Diuretic refractoriness may represent patient non-adherence
Observe for SE
SE of Diuretic Therapy
Electrolyte abnormalities
Symptomatic hypotension
Renal dysfunction
Worsening renal function
MOA of ACE Inhibitors
Inhibits conversion of angiotensin I to II
Dilates blood vessels
Decreases systemic vascular resistance & blood pressure
Effect of ACE Inhibitors
Reduces morbidity & mortality
Improves cardiac function, symptoms, & clinical status
Contraindications for ACE Inhibitors or ARBs
Hx of intolerance Pregnancy Serum K+ >5 mEq/L Symptomatic hypotension Caution: patients with Cr >3.0 mg/dL
Surveillance with ACE Inhibitors & ARBs
BP
Renal function
Potassium
ACE Inhibitors in HF
Captopril
Enalapril
Lisinopril
Ramipril
Beta-blockers in HF
Metoprolol XL
Carvedilol
Bisoprolol
When to start beta-blockers?
When patient is NOT significantly congested
Beta-Blocker Effects
Increased LVEF Global symptom improvement Decreased hospitalizations & mortality Decreased sympathetic stimulation Stable HF & LVEF less than 40% Beneficial in DM2 or CAD Ok with COPD, PAD
Managing Vasodilator SE of Beta-Blocker Up-Titration
Temporary
Separate dosing of Beta-blocker & ACEI
Persistent: reduce vasodilators
Managing Fluid Retention in Beta-Blocker Up-Titration
Increase diuretic to restore baseline weight
Delay up-titrating until weight is at baseline
Managing Bradycardia/AV Block in Beta-Blocker Up-Titration
Check digoxin level
Persistent: cardiac pacing
Patient Selection for Aldosterone Antagonists
On ACEI/ARB & beta-blocker therapy
K+ less than 5.0
Creatinine less than 2.5 in men & 2.0 in women
When is an aldosterone antagonist not recommended?
Absence of a concomitant loop diuretic
New HF Drugs
Entresto (Sacubitril/valsartan)
Corlanor (Ivabradine)
MOA of Entresto (Sacubitril/valsartan)
Sacubitril: inhibits breakdown of vasoactive peptides including BNP, bradykinin; results in natriuresis & diuresis
Valsartan: ARB, antagonizes angiotensin II at ATI receptor; decreases AT II dependent aldosterone release, increases vasodilation
Monitoring with Entresto (Sacubitril/valsartan)
BP Volume status BUN/Cr K+ BNP: may impact
SE of Entresto (Sacubitrli/valsartan)
Decreased BP Hyperkalemia Cough Dizziness Acute renal failure Angioedema
MOA of Corlanor (Ivabradine)
Reduces the slow diastolic depolarization phase
Indications for Corlanor (Ivabradine)
Reduce risk of hospitalization for worsening HFrEF
Slow releasing with HR resting >70 bp on maximum beta-blocker or contraindicated for beta-blocker use
Contraindications for Corlanor (Ivabradine)
Acute decompensated heart failure BP less than 90/50 Sick sinus syndrome SA block Complete heart block Resting heart rate less than 60 bpm Severe hepatic impairment Pacemaker dependent
Relative Contraindications for Corlanor (Ivabradine)
Negative chronotropes (amiodarone, digoxin) Increased bradycardia
SE of Corlanor (Ivabradine)
Bradycardia HTN Dizziness Fatigue Complete heart block A-fib
Interactions with Corlanor (Ivabradine)
Not for patients with a demand pacemaker set to a rate of >60 bpm
Delayed absorption with food
Increased plasma exposure
Monitoring Parameters
HR (50-60 bpm) Signs/symptoms of improvement in HF Cardiac rhythm BP HR
Other Medical Treatments for HF
Vasodilators: nesiritide, nitroglycerine, nipride) Inotrope infusion: dobutamine, dopamine Milrinone (Primacor) "inodilator) Anticoagulation Dysrhythmics Lipid management Screen for sleep disordered breathing
MOA of Dobutamine
Stimulates beta-adrenergic receptors
Can not be used with beta-blockers
MOA of Dopamine
Norepinephrine release
Promotes diuresis
MOA of Milrinone (Primacor) “inodilator”
Decreases systemic vascular resistance & peripheral vascular resistance
Increase cardiac output
Can be used with beta-blockers
Treatment Strategies for HF preserved EF`
Manage comorbidities: BP, a-fib, myocardial ischemia, DM
Block neuro-hormonal activation
Improve left ventricle relaxation
Screen for/treat sleep disordered breathing
Sodium restriction
Treatment Strategies for Right Sided HF
Oxygen therapy Inhalers, CPAP if indicated Digoxin: rhythm problems Diuretics Pulmonary HTN Accompanied with preserved LV HF
Medications that May Hurt a HF Patient
Most CCBs Amlodipine Felodipine Anti-arrhythmic drugs Megestrol acetate NSAIDs Corticosteroids
Surgeries & Medical Devices to Treat HF
CABG TAVR Cardiac tranplantation CRT: cardiac resynchronization therapy (bi-ventricular pacing) ICD LVAD
Indications for ICD Placement
LVEF less than 35%
QRS >120 ms
NYFC III-IV
Ventricular Assistive Devices (VADs)
Type of mechanical circulatory support device sufficient to replace/assist pumping function of the LV Durable Expensive: $75K-125K Narrowed/no pulse pressure No valves: constant flow
VADs & Emergencies
Do not interfere with ICD/pacemaker Can exercise like everyone else Patient responsive? LVAD pumping? Get LVAD running? CPR only if LVAD not running Defibrillation can be done
Complications of LVADs
Arrhythmias: stable vs. unstable Right heart failure Hypovolemia Bleeding Infection (drive line) Thrombus/stroke (embolic/hemorrhagic)
Non-Pharmacologic Recommendations for Heart Failure Patients
Sodium restrictions Fluids Sleep disordered breathing Weight Exercise Education/self-care
Risk Factors for OSA
Obesity Male Post-menopausal women Men neck >16" Women neck >15"
Risks with having OSA
Exacerbate myocardial ischemia Increased risk for arrhythmias Fatigue Excessive daytime sleepiness Mood disturbance Decrease QOL
Benefits of CPAP
Improve heart function & functional status in HF patients Decreased apnea-hypopnea index Increased nocturnal O2 Increased LVEF Decreased norepinephrine levels Increased 6 minute walk distance
Weight Management & HF
BMI: 18-30 ideal
Cachexia
Cachexia & HF
Predicts worse prognosis
Weight loss >5% in 12 months or BMI
Exercise & HF
Recommended as safe/effective for patients who are able to improve functional status
Cardiac rehab can improve functional capacity, exercise duration, QOL, & mortality
When should a HF patient stop exercise?
Rapid pulse CP/pressure Unusual SOB Irregular or slow HR Weakness Faintness or dizziness Extreme fatigue
Define Self-Care
Process whereby individuals and/or their caregivers perform the daily activities that serve to maintain health, well-being, prevent illness, manage chronic illness or restore health
Mechanisms Through Which HF Self-Care Influences Health outcomes
Neuro-hormonal deactivations
Limited inflammation
Avoidance of pharmacology
Limited myocardial hibernation
Self-Care Activities in HF
Medications: take as prescribed Follow a lower sodium diet Monitoring symptoms of worsening HF Daily weighing Physical activity Alcohol, smoking, fluid intake
Hospitalization Requirements for HF Patients
Worsened congestion without dyspnea
S/S of pulmonary or systemic congestion even in absence of weight gain
Major electrolyte disturbance
Associated co-morbid conditions
Symptoms suggestive of TIA or stroke
Repeated ICD firings
Previously undiagnosed HF with S/S of systemic or pulmonary congestion
Guiding the HF Patient out the Door
Near optimal volume Stable after transition from IV to oral diuretics for 24 hours Exacerbating factors addressed LV EF documented Near-optimal medical therapy Patient & family education initiated FU clinic visit scheduled within 7 days
Risk Factors for Highest Risk of Readmission
Advanced age
Co-morbidities: renal disease, DM2, COPD, HF severity, psychiatric disease, frailty
Low education/literacy levels
Prior admission for HF
Patient behaviors: lacking self-care skills, adherence issues, substance abuse
Not ready for discharge
Absence of family, friend, religious, social, & financial support & access to transportation
3 Phases of Progressive HF
Chronic disease management
Supportive & palliative care phase
Terminal care phase
Parts of Chronic Disease Management
Diagnosis
Focus on extended survival
Concurrent palliation of symptoms
Promoting self care
Parts of Supportive & Palliative Care Phase
Appropriate when patients require recurrent hospitalizations
Focus on promoting comfort & QOL
Palliation of symptoms & advanced care planning
Barriers to the Use of Palliative Care
Traditional model of medicine: cure & comfort are mutually exclusive
Proposed integrated model of palliative care
Define Hospice Care
A deploy of a team of doctors, nurses, chaplains, & social workers to help people with fatal illness to have the fullest possible lives now
