Module 7.4 - Advance Heart Failure Flashcards
What is advanced heart failure?
Occurs when pts with known heart failure are treated for their symptoms, but they persist in spite of maximizing therapy. In patients with heart failure period adjustments in medications, particularly diuretic therapy, can provide relief from debilitating edema, fatigue and shortness of breath. In advance heart failure this no longer works
What are some subjective/objective physical exam findings associated with advanced heart failure?
- Extreme exercise intolerance
- Anorexia and unintended weight loss with cachexia-characterized by body wasting including loss of muscle and body fat
- Hypotension and evidence of poor perfusion
- Refractory volume overload with pulmonary congestion
- Lightheadedness
- Patients with HFrEF - On physical exam, systolic BP may be < 90 mmHg as a combination of medical therapy and poor cardiac output. If patients are asymptomatic and continue to have evidence of adequate perfusion, a SBP of 90 is acceptable. This should be based on careful examination of your patient and thorough ROS. Patients with HFpEF are often hypertensive. Uncontrolled HTN may lead to a worsening of HF.
- If patients show evidence of poor perfusion with cool extremities, worsening fatigue and AMS, decrease in therapy may be indicated. ACE inhibitor and BB may be needed.
- Congestive hepatopathy is an indication of right heart failure that can accompany severe heart failure. Patients may experience the feeling of bloating and describe early satiety with meals. Patients may describe episodes of “bendopea”, losing their breath, experiencing dizziness when bending forward. Volume overload increases pressure in the pulmonary system with evidence of high pulmonary capillary wedge pressures. Physical exam of a patient with extra volume with include peripheral edema and likely ascites and a positive hepato-jugular reflux.
- The persistent complaint of orthopnea and PND despite therapy and increase in diuretics may occur
- It is important to rule out worsening of comorbidities, especially lung disease, as a contributing factor of their symptoms and exam findings
- Compliance to medications, fluid and sodium restriction and exercise program should be assessed. Poor adherence may contribute to repetitive episodes of CHF decompensation that may appear to be progression of disease only.
What lab/diagnostic tests are associated with advanced heart failure?
- Lab work – Poor or worsening renal failure is an indication of advancing heart failure. Review of renal function must be trended and the results looked at comprehensively. A sudden worsening of BUN and/or creatinine may be related to therapy.
- Hyponatremia is often seen in advanced HF and is associated with worse outcomes.
- Hypoalbuminemia is common in advanced HF and is also associated with worse outcomes. It results from decreased liver synthesis, increased vascular permeability and increased renal and GI losses.
- Liver function studies will be abnormal in the presence of liver congestion. Most common is an elevated serum bilirubin. Some patients may also show an elevation in their AST and ALT along with an elevated Alk phos.
- BNP levels may be chronically elevated above the traditional normal value. While an acutely elevated BNP indicates a change in volume status, there is no BNP value that indicates or designates with the heart failure is considered “advanced”.
- CXR – Patients will have episodes of fluid retention characterized by pulmonary edema and/or pleural effusions seen on the study. In chronic HF, there may be no evidence of pulmonary congestion due to increased pulmonary lymphatic drainage
- EKG – common abnormalities in patients with advanced HF include the development of Q waves and ST and T wave abnormalities. These may, however, been present especially if the patient has ischemic cardiomyopathy. Atrial fibrillation, NSVT and VT may occur in patients with advanced HF.
- Echocardiogram may continue to show worsening of LV function, dilation of left ventricle and decreased cardiac output
- Right heart catheterization may be needed to document cardiac filling pressures (mean capillary wedge pressure > 20 mmHg and/or right atrial pressure > 12 indicates demonstrates severe cardiac dysfunction). Right heart catheterization (RHC) or placement of a pulmonary artery catheter to measure hemodynamics is an outpatient procedure frequently used in HF programs to monitor the status of their HF patients. It is most informative when the patient’s clinical status has been optimized. Measurements of the pulmonary pressures and cardiac output that remain severely compromised despite max medical treatment is concerning for and indicative of advanced heart failure.
- Six minute walk distance < 300 m shows severe functional impairment
- The inability to perform any type of exercise is another indication of severely advanced HF.
What are Angiotensin receptor neprilsyn inhibitors (ARNI) and how are they used?
- Drugs that combine an ARB (Valsartan) and a neprilsyn inhibitor (sacubitril).
- Together they block both the angiotensin receptor and the enzymatic breakdown of endogenous natriuretic and the peptides that are responsible for vasodilatation.
- The combination drug (Entresto) is proving to be more effective than an ACE in reducing hospitalizations and mortality.
How is Ultrafiltration used in advanced heart failure?
The ACC/AHA guidelines for the management of congestive heart failure state that the use of ultrafiltration can produce meaningful clinical benefits by reducing fluid overload in congestive heart failure patients.
What is cardiac resynchronization therapy and how is it used in advanced heart failure?
- Patients with advanced heart failure may develop dysynchrony with heart contractions with the right and left ventricles contracting at different times. If there is a large discrepancy or difference of these contractions, the cardiac output can be decreased leading to worsening heart failure.
- Resynchronization therapy also known as bi-ventricular pacing utilizes implanted leads that stimulate the RV and the LV simultaneously with the goal to improved cardiac function. These leads are incorporated into the AICD device that patients with severe systolic HF receive.
How is inotropic support used in advanced heart failure?
- It has been shown to relieve symptoms temporarily for patients with severe left heart failure.
- IV dopamine and dobutamine are commonly used sympathomimetic amines that can be used in advanced HF.
- Dopamine has a renal vasodilating action that promotes diuresis.
- Dobutamine stimulates cardiac output without a marked decrease in peripheral vascular resistance.
- Milrinone is a phosphodiesterase inhibitor that is better tolerated for long term use. It improves cardiac output and stroke volume but does have an effect on the blood pressure by increasing vasodilation which may not be well tolerated by some patients.
What are some common causes of acutely decompensated heart failure?
It is a common occurrence in patients with HF and can potentially be fatal due to respiratory distress. Etiologies include:
- Left ventricular heart failure (HFrEF)
- Diastolic dysfunction (HFpEF)
- Primary fluid overload (due to transfusion)
- Severe hypertension
- Severe renal disease
- Acute MI
How do you manage patients with acutely decompensated heart failure?
- Respiratory compromise should be rapidly assessed and stabilized. Adequate oxygenation and ventilation should be established. Supplemental oxygen and ventilator support (NIV) or intubation may be needed
- Vital sign monitoring, watch for trends in hypotension and hypertension
- Continuous cardiac monitoring
- IV accesses for prompt diuretic therapy
- Urine output monitoring
- If severe HTN is present, early vasodilator therapy should be implemented. The role is to decrease systemic vascular resistance
- Thromboembolism prophylaxis is indicated
- Sodium restriction, fluid restriction
- In patients with HFpEF, long term therapy is based on treating the underlying causes of heart failure.
How are diuretics used in advanced heart failure?
- Treat pts promptly w/ IV diuretics (IV form is prefered because of greater bioavailability)
Patients with normal renal function can receive initial doses as listed:
- Furosemide – 20 mg to 40 mg IV
- Bumetanide – 1 mg IV
If there is little or no response, the dose should be doubled and scheduled Q6 or q12 hours depending on the patient
How do you manage patients with acute decompensating heart failure (ADHF) with worsening renal function with diuretic use?
- Other potential causes of renal injury should be investigated
- Patients with severe signs of congestion, especially if there is severe pulmonary edema, require the continued fluid removal regardless of the changes in their GFR. Discontinuing ACE or ARB therapy can be considered.
- Ultrafiltration should be considered if adequate diuresis cannot be obtained with increasing doses of diuretics
- Inotropic support as discussed earlier may be needed
When is mechanical support indicated in patients with advanced heart failure?
Pts w/ severe hemodynamic compromise (cardiogenic shock), particularly if the cardiac index is less than 2.0 L/min and a SBP below 90 mmHg, the use of an intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO) or short term mechanical circulation assist may be implemented.
