5/1/2020

Heart Failure 101

out of the lab, into the clinic 1 1

Objectives today

Provide an overview of clinical aspects of heart failure    diagnosis assessment management  Interacting with a HF patient 5/1/2020 1 2

Definition of heart failure

 state in which the heart cannot pump a sufficient supply of blood to meet the physiological requirements of the body,

or requires elevated filling pressures to do so

 a pathological condition leading to a debilitating illness characterized by poor exercise tolerance, chronic fatigue, along with high morbidity and mortality 1 3 3

Some truths about HF



HF is a chronic, progressive that is life limiting condition



HF is a terminal condition —eventually it leads to the patient ’s death



There is no “cure”



HF is common



HF prevalence is on the rise

1 4 4

Implications for the patient

 HF symptoms range from none to an inability to complete basic ADLs  HF patients may not appear ill, but have profound symptoms; unable to function in the way family members feel they should  HF clinical progression is cyclical , and unpredictable — patients have no control over what they can and cannot do on any given day 5/1/2020 1 5

What is your risk?

1 in 5 will develop heart failure

5/1/2020 1

Circulation

2002; 106: 3068 - 3072.

Heart failure: not going away

5/1/2020 1

Arnold Can J Cardiol 2007

7

The cost of heart failure

Hospitalization $15.4

52% Total Cost $40 billion

$3-4

13% Nursing Home $3.9

7% Lost Productivity/ Mortality* $2.8

Home Healthcare $2.4

10% Physicians/Other Professionals $2.0

Drugs/Other Medical Durables $3.1

5/1/2020 1 8

AHA. 2006 Heart and Stroke Statistical Update

Heart failure: the numbers

    Prevalence Incidence Hospitalization Average stay 600,000 Canadians 50,000 / year #1 cause 7 days 

1.4 million days

Death  in hospital  30 days post discharge 2-22%

10%

 1 year

30%

5 year

50%



J. Ezekowitz CMAJ 2009, EJHF 2008

1 9 9

Modes of death in HF

 50% of HF patients “

DROP

” 

sudden cardiac death

 40% of HF patients “

DROWN

” 

progressive HF

1

HF etiology

 ISCHEMIC (50% HF)  CAD-ischemia+/-MI   HTN (diastolic and systolic HF) (25%) NON ISCHEMIC (25 % HF)  Dilated  Hypertrophic  Restrictive  Valvular 1

Mechanisms of heart failure

myocardial injury

mechanical abnormalities

electrical disorders left ventricular dysfunction loss of pump

Rosa Gutierrez 2006

12 5/1/2020 1

Chemical mediators of HF

Angiotensin I / II Aldosterone ADH-antidiuretic hormone Epinephrine / Norepinephrine Endothelins Natiuretic peptides Atrial NP B-type NP C-type NP

5/1/2020 1 13

Modes of heart failure

 Systolic (pumping dysfunction) vs

Diastolic (filling dysfunction)

   Compensated vs Decompensated Right sided HF vs Left sided HF Forward HF vs Backward HF

A HF patient can have one or several of these

Types of heart failure

compensated



if the force of the contraction is moderately decreased the heart can meet the metabolic demands

 temporary improvement CO

decompensated



occurs when the force of the contraction is decreased further resulting in the

appearance of clinical signs & symptoms

Rosa Guterriez 2006

1

Forward flow HF symptoms

 “

Out of gas

”

—

related to O2 delivery

 fatigue  weakness/lack of energy  cognitive dysfunction  decreased exercise tolerance 1

Backword flow HF symptoms

 “

Plumbing

”

—

related to congestion

 shortness of breath  orthopnea  paroxysmal nocturnal dyspnea (PND)  edema  fluid retention / weight gain  decreased exercise tolerance 1

Diagnostic accuracy of traditional HF work-up 5/1/2020 1

Dao Q et al J Am Coll Cardiol 2001;37:379-85

18

Diagnosis of HF-CCS 2006

1

Disease progression

5/1/2020 1 20

Echocardiogram

 WHY in HF:

useful for



assessing chamber size



volume of cavity



thickness of walls, valves



assessing pumping function (systolic)



assessing filling function (diastolic)

 determining

LVEFx within 10%

5/1/2020 1 21

Additional testing in HF



BNP

(and other biochemistry eg. TSH, Cr)  MIBI/Thallium (viability scan)  Coronary Angiogram  24/48 hr Holter monitor; Event Monitors  VO2 Max 5/1/2020 1 22

BNP -CCS 2007



BNP / NT-proBNP

… should be measured to confirm or rule out a diagnosis of heart failure the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt in (class I, level A) 

currently the most practical use of this test

 

under cut-off point —HF unlikely above cut-off point —HF very likely

5/1/2020 5/1/2020 1 1 23 23

BNP (CCS 2007)

BNP

Age (years) All Heart failure is unlikely

< 100 pg/ml

Heart failure possible but other diagnoses must be considered

100-500 pg/ml

Heart failure is very likely

> 500 pg/ml

NT-proBNP < 50 5/1/2020 5/1/2020 50 - 75 > 75

< 300 pg/ml < 300 pg/ml < 300 pg/ml 300-450 pg/ml > 450 pg/ml 450-900 pg/ml > 900 pg/ml

1 1

900 - 1800 pg/ml > 1800 pg/ml

24 24

5/1/2020

HF Management

1 25

HF treatment goals (quality and quantity) 

Slow progression of syndrome



Control symptoms



Prolong Life

5/1/2020 1 26

CCS on HFPSF ( Diastolic HF )



Guideline based medications should be considered in HF with preserved EF** (

diastolic HF

) for:

 

relief of

HF symptoms  

Pulmonary congestion Peripheral edema

treatment of

HF risk factors  

HR, atrial fibrillation BP (as per HTN guidelines)

**overall lower level of evidence associated with HFPSF

5/1/2020 1 27

CCS on Systolic Heart Failure

 Medical Therapy  ACE inhibitors  Beta-blockers  Spironolactone  Diuretics  Digoxin  Nitrates  Statins  ASA, Warfarin  Device Therapy  ICD  CRT  Other Therapy  Multidisciplinary clinics  Exercise rehab  Dietary referral  Review of co-morbidity  Review of other drugs 

LIFESTYLE!

www.hfcc.ccs.ca

1

HF treatment is guided by…

 EFx-ejection fraction 

ventricular systolic function

 NYHA functional class 

symptom status



Patient/Family Perspectives !!

1

Ejection Fraction



EFx

—its all about the LV ( and RV !)  how much blood is ejected per ventricular contraction is measured by percentage and is indicative of pump

efficiency

  the -- normal heart

never 100%

will pump out 60-70% of the blood that enters the left ventricular chamber the LV ’s normal shape is the

perfect pump

1

New York Heart Association Functional Classification-NYHA

NYHA I

: no physical activity limitation

NYHA II

: slight limitation of physical activity

NYHA III

: marked limitation of physical activity

NYHA IV

: unable to carry out any physical activity or HF symptoms at rest 1

“

You are not your EFx

”  Patients who have an EFx of 10% may have NYHA FC I symptoms 

an asymptomatic patient may be at risk for a sudden cardiac death, or arrhythmic event if their EFx is low



HF diagnosis may be missed if patient asymptomatic

 Patients with a normal or near normal EFx may have NYHA FC II-III symptoms 

a patient can have HF with a normal EFx (preserved LV function)

1 1

ICD-internal cardiac defibrillator     many HF patients at risk for sudden cardiac death primary / secondary prevention

quantity of life

selection criteria:

 EFx    NYHA functional class prognosis

medications maximized

5/1/2020 1 33

CRT-cardiac resynchronization

    mechanical dys-synchrony impacts pump function third lead attempts to improve synchrony

quality (and quantity) of life

selection criteria:

 EF (  30%)    QRS width on ECG (120 ms) NYHA functional class (II-IV)

medications maximized

5/1/2020 1 34

Nutrition management of HF

 Limit Sodium Intake  Avoid Excessive Fluids 5/1/2020  Daily Morning Weights 1

Liz Woo MHI HFC 2009

35 35

Salt / Sodium restriction: Less than 3 gm Na/day most HF patients Less than 2 gm Na/day severe edema      do not add salt remove the salt shaker from the table avoid pickles, luncheon meats, can soup, can tomatoes read labels for “ hidden salt ” less than 5% of total

Rosa Gutierrez 2006

1

Fluid restriction:

2 liters / day if clinically stable 1-1.5 liters / day with severe edema Fluid is: “ anything wet ”  tea, juice, coffee, milk, water, watermelon, ice  keep a diary  adjust for hot weather, illness

Rosa Gutierrez 2006

1

Weight

  accuracy   same scale shoes / no shoes compare home / prior clinic weight   does this number make sense?

what is the ideal, “ dry weight ” ?



**NEW PTs

: record discharge wt on chart if admission if

within 2-3 months

of initial clinic visit 5/1/2020 1 38

HF co-morbidity  Diabetes  COPD  Renal disease  HTN  Thyroid disorder  Cancer

HF rarely exists in a vacuum

1

Self care in HF

 “ YOU have the most power over your condition ”  “ AVOID worse ” behaviors that make heart failure  “ PAY ATTENTION , act EARLY ” “

you can’t ignore your heart failure…

” 5/1/2020 1 40

HF assessment

 Thorough patient history & physical exam  Establish baseline data and monitor trends  Appropriate surveillance ongoing 5/1/2020 1 41

Patient history

 Symptom status / most limiting factor: 

SOB



Fatigue



NYHA FC

  We use patient specific activities to measure —link to frequently done tasks ie. vacuuming, stairs Patient may avoid activities that provoke symptoms — helpful to ask “ what are you not doing now that you would like to, or could do before?

” 5/1/2020 1 42

history cont…

New or changed:

 Palpitations  Dizziness  Lightheadedness  Syncope  Angina  Depression  GI / appetite 5/1/2020 1 43

HF de-compensation triggers

       Dietary indiscretion #1

(with a bullet)

 salt / fluid lapse Medications  new / dose stopped / changed / forgotten / skipped OTC / PRN Infection Co-morbidity interplay Ischemia Arrhythmia Disease progression 1 1

Physical exam

 Weight  Edema  JVP  Heart rate / rhythm  Blood pressure  HS auscultation  Lung auscultation 5/1/2020 1 45

Fluid balance assessment

         Weight increase Edema Orthopnea / PND (Paroxysmal nocturnal dyspnea) HS cough JVP elevation + Hepatojugular reflex Respiratory auscultation-crackles, rales CXR Heart auscultation-S3 5/1/2020 1 46

5/1/2020

Edema

“

where do you keep your water?

” 1 47

5/1/2020 1 48

Edema

 swelling in legs, feet, ankles?

 bloating in abdomen —ascites?

 swelling anywhere else?

pitting / non-pitting?

5/1/2020 1 49

Jugular Venous Pressure  JVP reflects pressure and volume in the right atrium changes  most proximal location to view 

9-10 cm column of blood supported to clavicle from right atrium when upright

 observe at 90 degrees, 30-45 degrees  measured in cm ASA 5/1/2020 1 50

5/1/2020 1 51

Lung auscultation

 crackles throughout  expiratory wheezes  decreased AE bases  quiet breath sounds 

who is wet?



who is euvolemic?

5/1/2020 1 52

What

’

s the plan?

 Self care teaching / reinforcement 

What has or could de-stabilize this patient

’

s HF?

 Guideline based treatment options  Medications  ICD / CRT  Interventions ie. Angiogram, Sx  Follow up 

What surveillance level does this patient require?

5/1/2020 1 53

MHI Heart Function Clinic

 Clinic #s:    700 active patients 25 new referrals/month 120 patient visits/month    83000 minutes on the telephone 66000 minutes in clinic 45000 minutes reviewing test results 

support for this clinic is backed by extensive local data collection, clinical trials and ongoing quality improvement

5/1/2020 1 54