Management of Acute Decompensated Heart Failure

Transcription

Management of Heart Failure
Across the Continuum
Objectives:
At the end of this course, you will be able to:
1. Describe the different types of Heart Failure (Systolic versus Diastolic )
2. Describe both, the ACC stages and NYHA classes of Heart Failure
3. Identify recommended therapies for treatment of Heart Failure
4. Explain the different medication classes and their uses for the treatment of
Heart Failure
5. Identify differences between ambulatory, inpatient and transitional Heart Failure
patient treatment goals
6. Explain the differences between ambulatory, inpatient and transitional
monitoring
7. Describe potential causes for readmission of a heart failure patient
2012 Trinity Health - Novi, Michigan - INTERNAL
2
Heart Failure Across the Continuum – Table of Contents
1.
¾
¾
¾
¾
¾
¾
2.
¾
14 – 20
History and Physical
Recommended Therapies: Considering ACC Stage
Medications overview
• ACE / ARB / B-Blocker
• Diuretics
• Others
Transition to inpatient care
21 – 32
33 – 54
Hospitalized Patient (Inpatient Care)
¾
¾
¾
¾
¾
¾
¾
4.
Types of Heart Failure
Systolic vs. Diastolic
ACC Stages
NYHA Classes
Ventricular Remodeling
Pathophysiology
HF in Ambulatory Care
¾
¾
¾
3.
4 – 13
What is Heart Failure
Goals of ED and IP Care Treatment / acute presentation
Clinical features / causes of acute clinical change
Special concerns and Key tests (BNP, ECHO, ECG, CXR)
Principles of treatment
Indications for Invasive Therapy
Documentation for improved coding
Transition to ambulatory care
55 – 59
Transitional Care
¾
¾
¾
¾
Transition support
Causes of readmission for HF
Remote Monitoring and Readmission Risk Assessment
Palliative Care
5. Conclusions
60
6. Appendix and References
61 – 70
Post test with answers
71 – 72
3
What is Heart Failure?
• A clinical syndrome resulting from any structural or functional cardiac defect
limiting ventricular filling, a syndrome is described by specific symptoms and signs
• Around 5.8 million people in the United States have heart failure.
• About one in five people who have heart failure die within one year from diagnosis.
• HF ranks as the most frequent cause of hospitalization and re-hospitalization
among older Americans.1,2
• In 2010, heart failure will cost the United States $39.2 billion.3 This total includes
the cost of health care services, medications, and lost productivity.
• The most common causes of heart failure are coronary artery disease, high blood
pressure, and diabetes.
• HF is diagnosed on the presence of characteristic signs and symptoms and not on
the basis of any diagnostic tests
– Tests such as echocardiograms and cardiac stress testing establish the
pathophysiologic cause but do not define whether heart failure is present or not
1 Wier LM, Levit K, Stranges E, et al. HCUP Facts and Figures: statistics on hospital-based care in the United States, 2008: exhibit 2.3, most frequent principal diagnoses by
age. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports.jsp.
2 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):
1418-1428.
3 Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics—2010 Update. A Report from the American Heart Association Statistics Committee and
Stroke Statistics Subcommittee . Circulation. 2010;121:e1-e170.
4
Types of Heart Failure
•
There are several ways to clinically classify heart failure:
– By type
• Systolic versus diastolic
– By stages or classes
• American College of Cardiology (ACC)/American Heart
Association (AHA), Stages A, B, C and D
• New York Heart Association classes I - IV
– By underlying cause
• Ischemic, due to radiation therapy, etc.
– By anatomical location
• Right versus left
•
Coding classifications and definitions focus primarily on systolic versus
diastolic (or both) and acute versus chronic (or both). Specific
documentation is necessary to help coding accurately reflect severity of
illness and risk of mortality
5
Systolic Versus Diastolic Heart Failure
• In 1994, the Agency for Healthcare Research and Quality
(AHRQ) in association with the American Heart Association
and the American College of Cardiology, developed
guidelines to distinguish systolic and diastolic dysfunction.
• It is important to distinguish between the two as their longterm treatments are different.
• Patients may also have combined systolic and diastolic heart
failure.
6
Systolic Versus Diastolic Heart Failure (continued)
• Systolic heart failure is characterized by
inability of heart muscle to contract
vigorously
– Results in inadequate amount of blood
and oxygen to body
– Failure to contract adequately causes
fluid backup into the lungs causing
pulmonary congestion
• Evidenced by:
– Ejection Fraction usually less than
40%
– Confusion
– Shortness of breath
– Diaphoresis
– Fatigue
– Pulmonary edema
• Common patient populations include:
– Men aged 50-70; patients with CAD,
Hx MI, or certain cardiomyopathies
• Diastolic heart failure occurs when the
heart has a problem relaxing between
contractions (diastole) to allow enough
blood to enter the ventricles.
– Results in systemic fluid accumulation
– Some patients may also have pulmonary
congestion
• Evidenced by:
– Ejection fraction >50%
– Jugular vein distension (JVD)
– Peripheral edema (especially in legs,
ankles and feet)
– Ascites/Anasarca
– Hepatomegaly
– Pulmonary Hypertension
• Common populations include:
– Older women; patients with obesity,
hypertension and chronic lung conditions
7
ACC/AHA Stages for Heart Failure (cont.)
At Risk for Heart Failure:
STAGE A
High risk for developing HF
STAGE B
•
Asymptomatic LV dysfunction
Designed to emphasize preventability of HF
Heart Failure:
STAGE C
Past or current symptoms of HF
STAGE D
•
End-stage HF
Designed to recognize the progressive nature of LV
dysfunction
8
ACC/AHA Stages for Heart Failure (cont.)
Complement, but do not replace NYHA classes
•
NYHA Classes - shift back/forth in individual patient
(in response to Rx and/or progression of disease)
•
ACC Stages - progress in one direction due to
cardiac remodeling
9
NYHA Classes for Heart Failure
10
ACC/AHA Stages for Heart Failure
At Risk for Heart Failure
Stage A
Stage B
At high risk for HF but without structural heart disease or symptoms of HF
Structural heart disease but without symptoms of HF
Patients with:
─Hypertension
─Atherosclerosis
disease
─Diabetes
─Metabolic syndrome
Heart Failure
Stage D
Structural heart disease with prior or current symptoms of HF
Refractory HF requiring specialized interventions
Patients with:
Known structural heart disease
Patients with:
─Previous MI
─LV remodeling including LVH and Low EF
─Asymptomatic valvular disease
And
Shortness of breath and fatigue, reduced exercise tolerance
Or Patients
─Using cardiotoxins
─With HFx CM
Stage C
11
Patients:
Who have marked symptoms at rest despite maximal medical therapy (e.g. those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions
Ventricular Remodeling - Illustration
a
b
c
RV LV RV LV RV
LV
Ventricular remodeling ‐ Cross‐sectional view of left and right ventricles:
a, normal; b, concentric hypertrophy; and c, eccentric hypertrophy.
Abbreviations: LV, left ventricle; RV, right ventricle. Produced and printed with permission from The Cleveland Clinic Foundation; Cleveland, Ohio.
Consequences of Ventricular Remodeling:
High Pressure (wall stress) heightens myocardial oxygen consumption, which promotes further hypertrophy and activates
neurohormonal systems –
resulting in reduction of ejection fraction, ventricular performance, morbidity and mortality.
Goals for Understanding Ventricular Remodeling: Promote regression and prevent progression of LV enlargement to decrease disease progression and improve survival
Source: CRITICALCARENURSE Vol 24, No. 6, DECEMBER 2004 , pg 18
12
Pathophysiology of Acute HF
↑ MVO2
↑Wall stress
↑Heart Rate
↑Ischemia
Afterload mismatch
↓Cardiac
output
Hypoperfusion/
Hypotension
End organ
dysfunction
↓ LV contractility
↑Vasoconstriction
↑Diastolic
dysfunction
↑Wall stress
↑Left atrial and
Pulmonary
Venous pressure
Inflammatory/
Neurohormonal
activation
Renal dysfunction
(fluid and salt retention)
Blood volume
expansion
13
Pulmonary
edema
Inflammatory
Neurohormonal
activation
Volume
redistribution
AlveolarCapillary leak
Hypoxia
Heart Failure in
AMBULATORY CARE
14
Heart Failure in Ambulatory Care
Patient History & Physical for identification of potential HF
Presenting
Symptoms
• Cough/sputum
production
• Dyspnea on exertion
• Paroxysmal nocturnal
dyspnea
• Orthopnea
• Chest pain
• Palpitations
• Edema
• Fever or viral illness
• Fatigue
• Recent weight gain
• Decrease exercise
intolerance
• Blood loss
•
•
•
•
•
•
•
•
•
•
Past Medical
History
Family, Social and
Dietary History
Physical Exam
History of HF
History of MI
Cardiac risk factors
HTN/smoking/DM/^lip
ids
RF/Endocarditis
Thyroid dysfunction
Thromboembolic
disease
Postpartum
Blunt chest trauma
HIV
• Ischemic heart disease
• HF
• Congenital heart
disease
• Risk factors for ASCAD
• Salt and fluid intake
• Tobacco use / abuse
• Alcohol use / abuse
• Drug abuse
• Other Toxins
(Chemotherapy,
Stimulants, TCA, COX1 and COX-2 inhibitors,
Glitazones,
glucocorticoids)
• Vital signs (including height
and weight)
• Cyanosis, pallor, jaundice
• Diaphoresis
• Labored breathing, rales >
25%, lung sound that do not
clear with cough
• Tachycardia, bradycardia,
arrhythmias
• Left lateral displacement of
point of maximal impulse
• S3, S4, or murmur
• Elevated jugular venous
pressure, + hepato-jugular
reflux
• ABD, large, pulseatile, or
tender liver
• Decreased peripheral pulses
• LE edema
15
Recommended Therapies; Reduce Risk: Patients in Stage A
• Treating known risk factors (hypertension, diabetes, etc.)
with therapy consistent with contemporary guidelines
• Avoiding behaviors increasing risk (i.e., smoking, excessive
consumption of alcohol, illicit drug use)
• Periodic evaluation for signs and symptoms of HF
• Ventricular rate control or sinus rhythm restoration
• Noninvasive evaluation of LV function
• Drug therapy
– Angiotensin Converting Enzyme Inhibitors (ACEI)
– Angiotensin Receptor Blockers (ARBs)
16
Recommended Therapies: Patients in Stage B
• General Measures as advised for Stage A
• Drug therapy for all patients
– ACEI or ARBs
– Beta-Blockers
• ICDs in appropriate patients
• Coronary revascularization in appropriate patients
• Valve replacement or repair in appropriate patients
17
Patients in Stage C with Reduced LVEF with Symptoms
•
General measures as advised for Stages A and B
•
Drug therapy for all patients
–
–
–
–
•
Diuretics to reduce fluid retention
ACEi
Beta-blockers (reduces mortality)
Avoid NSAIDS, most anti-arrhythmics and most Ca2+ channel blockers
Drug therapy for selected patients
–
–
–
–
Aldosterone Antagonists (moderately severe symptoms, and easy to monitor)
ARBs (for those ACEi intolerant)
Digitalis (reduces hospitalizations)
Hydralazine/nitrates (ACEi / ARB intolerance; hypotension or renal
insufficiency
•
ICDs in appropriate patients (primary prevention of SCD and secondary
prevention prolong survival)
•
Cardiac resynchronization in appropriate patients
•
Exercise Testing and Training
18
Patients in Stage C with Normal LVEF with Symptoms
• Treating known risk factor (hypertension) with therapy consistent
with contemporary guidelines
• Ventricular rate and sinus rhythm control for all patients
• Restoration/maintenance of sinus rhythm in appropriate patients
• Drugs for all patients
– Diuretics (control pulmonary congestion and peripheral edema)
• Drugs for appropriate patients
– ACEI
– ARBs
– Beta-Blockers
Might be effective in
symptom control, with
controlled hypertension
• Coronary revascularization in patients with CAD in whom
symptomatic or demonstrable myocardial ischemia is judged to
be having an adverse effect on cardiac function
19
Patients in Stage D (Refractory Heart Failure)
• Patients are now symptomatic at rest despite optimal
medical therapy – requiring close monitoring:
– Close management of fluid retention and other symptoms
– Refer for transplant if potentially eligible
– Refer to a HF program with expertise in refractory HF
– Discuss End of Life care
• May include AICD deactivation
• For selected patients consider the following:
– LVAD (Left Ventricular Assist Device)
– PA (Pulmonary Artery) catheter placement
– Continuous IV infusion of a positive inotrope (palliation)
20
Heart Failure
MEDICATIONS
21
Medication Overview:
• ACEi if
• Aldosterone Antagonists
– Current/prior symptoms of HF • Hydralazine and long
– Reduced LVEF
acting nitrites
• ARB’s
• Digoxin
• Β-Blockers
• Diuretics and Salt
Restriction if
• Rx to avoid
– Current/prior sx of HF
– NSAIDs
– Reduced LVEF
– Most anti-arrhythmics
– Fluid Retention
– Most Ca2+ channel blockers
22
ACE Inhibitors
Selection
Exclusions
Monitoring
• SBP> 85 mmHg
• Minimal volume
overload
• Dose increased at
intervals determined
by BP and renal
function
• Patients with
borderline renal
titration should be
slower
• ACE allergy
• Moderate severe AS
• Cardiogenic shock
• BP <80 mmHg
• Hyperkalemia
• Serum Creatinine>3
• Bilateral Renal artery
stenosis
• Pregnancy
• Any in patient
requiring IV pressors
• Cough
• Increase fatigue
• Dizziness
• SBP <80
• Renal function
• Lowest diuretic
possible
• Stagger ACE and BBlockers
• Avoid NSAID’s
23
ACE Agents
Agent
Initiation
Steps
Target
Captopril
6.25mg tid
12.5-25mg tid
50mg tid
Enalapril
2.5mg bid
5mg bid
2.5-20mg bid
Lisinopril
5mg daily
5, 10mg daily
5-40mg daily
Ramipril
2.5mg bid
2.5mg bid
5mg bid
Quinapril
5mg bid
10mg bid
10-20mg bid
Fosinopril
10 mg daily
5-10-20mg daily
20-40mg daily
ACC Guidelines:
•ACEIs and Beta-blockers should be used in all patients with a recent or remote history of
MI regardless of EF or presence of HF.
•ACEI should be used in patients with a reduced EF and no symptoms of HF, even if they
have not experienced MI.
•ACEI or ARBs can be beneficial in patients with hypertension and LVH and no symptoms
of HF.
24
ARB’s
Selection
Exclusions
Monitoring
• May be used if ACE’s
cannot be tolerated
• SBP > 85 mmHG
• Minimal fluid overload
• Dose increase
determined by BP and
renal function
• Patients with border line
renal function should be
titrated slower
• Only Valsartan and
Candesartan are
approved for use in
patients with HF
• Allergy
• Increase fatigue
• Dizziness
• Hypoperfusion
• SBP < 80 mmHg
• SBP<80 mmHg
• Renal function
• Pregnancy
• Not be used with
ACE and B-Blocker
• Any patient on IV
pressors
• Severe renal artery
stenosis
• Potassium > 5.5
25
• Avoid NSAID’s
ARB Agents
Agent
Initiation
Titration
Target
Candesartan
4mg daily
8-16-32mg
daily
32mg daily
Losartan
25mg daily
50-100mg daily 100mg daily
Valsartan
40mg bid
80mg bid
160mg bid
ACC Guideline:
• For older patients – “start low and go slow”
•An ARB should be administered to post-MI patients without HF who are intolerant
of ACEIs and have a low LVEF.
•ACEIs or ARBs can be beneficial in patients with hypertension and LVH and no
symptoms of HF.
•ARBs can be beneficial in patients with low EF and no symptoms of HF who are
intolerant of ACEIs.
26
B-Blockers
Selection
Exclusions
Monitoring
• SBP >85 mmHg
•Cardiogenic shock
• Not requiring IV
pressors
•Hypoperfusion
• No longer
significantly volume
overload
•Symptomatic
bradycardia
• Hold if SBP<80 mmHg
• Hold HR < 55 bpm
• Monitor daily weights
• May cause increase
fatigue, weight gain,
dizziness, and or heart
block
• Prescribe lowest diuretic
possible
• Stagger B-blocker and
ACE dosing
• Avoid NSAID’s
• An ARB should NOT be
given with ACE and Bblocker
• Used with ACE
inhibitors
•SBP<80 mmHG
•Significant volume
overload
• When only one drug
can be initiated for
HF, B-Blockers are
preferred
27
B-Blockers Agents
Agent
Initiation
Titration
Target
Carvedilol
3.125mg bid
6.25-12.5mg bid
6.25-25mg bid
Metoprolol
6.25-25mg QD
25, 50 100mg daily 200 mg daily
Bisoprolol
1.25mg daily
2.5-5mg daily
10mg daily
Titration Recommendations:
• Start while in hospital and D/C on that dose if tolerating
• Increase at 2-4 week intervals until target dose is reached or patient becomes
symptomatic
ACC Guidelines:
• Beta-blockers and ACEIs should be used in all patients with a recent or remote history
of MI regardless of EF or presence of HF.
• Beta-blockers are indicated in all patients without a history of MI who have a reduced
LVEF with no HF symptoms.
• Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol,
and sustained release metoprolol succinate) are recommended for all stable patients
with current or prior symptoms of HF and reduced LVEF, unless contraindicated.
28
Diuretic Agents
Agent
Initiation
Titration
Target
Furosemide
40mg daily
80-160mg daily
160-200mg daily
Bumetanide
1 mg daily
2,4 mg daily
8 mg daily
Torsemide
10mg daily
25,50, 100mg daily 200mg daily
HCTZ
25mg daily
25-50mg daily
50 mg daily
ACC Guidelines:
•Diuretics and salt restriction are indicated in patients with current or
prior symptoms of HF and reduced LVEF who have evidence of fluid
retention.
•Monitoring - Smallest dose possible: avoid: hypokalemia;
hypomagnesemia; prerenal azotemia; orthostatic hypotension
29
Aldosterone Antagonists
Agent
Initiation
Target
Spironolactone
12.5mg daily
25 mg daily
Eplerenone
50 mg daily
50 mg daily
ACC Guidelines:
• Addition of an aldosterone antagonist is recommended in selected patients
with moderately severe to severe symptoms of HF and reduced LVEF who
can be carefully monitored for preserved renal function and normal
potassium concentration. Creatinine should be less than or equal to 2.5
mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium
should be less than 5.0 mEq/L. Under circumstances where monitoring for
hyperkalemia or renal dysfunction is not anticipated to be feasible, the risks
may outweigh the benefits of aldosterone antagonists.
• Routine combined use of an ACEI, ARB, and aldosterone antagonist is not
recommended for patients with current or prior symptoms of HF and reduced
LVEF.
30
Long Acting Nitrates
Agent
Initiation
Target
Hydralazine
25mg 4 X/d
50mg 4 X /day
Isosorbide dinitrate
30 mg tid
40 mg tid
• Selection
– Use with African-Americans who may be
ACE/ARB intolerant, or may not respond to
optimal management
31
Digoxin
32
Heart Failure
TRANSITIONS TO INPATIENT
33
Heart Failure Care Transitions Ambulatory to Hospital
Goals: Primary Care in the ambulatory setting must coordinate patients
returning to the hospital
– Ensure patient history and care plan is available for emergency and
or hospital physicians (as necessary or appropriate)
– Help patient understand the reasons they will need hospitalization
and what they can do to help avoid these circumstances
•
Primary care is integral to coordination of patient care; Key concepts: well
coordinated care between providers, across settings and equal coordination of
care across providers and settings
•
Evidence based care1 means better care for the individual, better health for the
population and reduced costs for the health system
•
Patient experience should be at the forefront of care
– leverage the latest clinical advances and health information technology to ensure
patients receive the most timely, efficient and safest care possible.
– latest evidence-based clinical data helps clinicians make the most informed
decisions, when and where they need it.
1 - ACC/AHA Task Force on Practice Guidelines. Manual for ACC/AHA Guideline Writing Committees: Methodologies and Policies from the ACC/AHA
Task Force on Practice Guidelines. 2006. Available at: http://www.acc.org/qualityandscience/clinical/manual/pdfs/methodology.pdf and
http://circ.ahajournals.org/manual/ . Accessed January 30, 2008.
34
Goals of Emergency / Inpatient Treatment
•
Treat life-threatening conditions
•
Establish the diagnosis
•
•
Review signs and symptoms
•
Adequacy of systemic perfusion
•
Volume status
•
Get input from PCP or other physicians treating the patient
Contribution from precipitant or co-morbid factors
•
Assess and treat any other cardiac and non-cardiac conditions
•
Evaluate the Cardiac Status
•
Evaluate the stage/class; systolic/diastolic
•
Identify and treat precipitant(s)
•
Monitor and reassess frequently
35
Acute Decompensated Heart Failure Presentation
1.
Volume overload
Pulmonary and/or systemic congestion frequently
precipitated by acute increase in chronic hypertension.
2.
Profound depression of cardiac output
Hypotension, renal insufficiency, and/or a shock
syndrome.
3.
Combination of 1 and 2
36
Heart Failure - Clinical Features
Cardiac
Fluid/Electrolytes
• Hypotension/Hypertension
• Tachycardia (heart rate >100 bmp)
• New arrhythmias or uncontrolled chronic arrhythmias
• Elevated BNP levels • Ejection fraction may be impaired or normal depending on type of failure
• Weight gain of 2‐3 or more pounds in 1 day
• Jugular vein distention (JVD)
• Edema
• Low Sodium and Chloride levels
Respiratory
• SOB/ Dyspnea/Orthopnea
• Coughing clear, white or pink sputum
• Tachypnea (respirations >24)
• Altered lung sounds: crackles
• Hypoxia/ABG’s with PO2 <70 • Oxygen requirement or need for increasing amounts including BiPap
• CXR noting: “CHF”/Pulmonary edema/Pleural effusion
• Acute respiratory failure
37
The Hospitalized Patient
Common causes for the acute clinical change:
–
–
–
–
–
–
–
–
–
Non-compliance with Drug therapy or diet
AMI – Acute Myocardial Infarction
Uncorrected high blood pressure
Atrial fibrillation or other arrhythmia
Recent addition of negative inotropic drugs (verapamil, nifedipine,
diltiazem, beta blockers)
Pulmonary Embolism
NSAID, EtOH, or illicit drug use
Endocrine abnormalities (Diabetes, thyroid disease)
Concurrent infection (Pneumonia, viral illnesses)
38
The Hospitalized Patient
• Special concerns during the H&P
– Establish the diagnosis (symptoms and signs of HF)
• Class/Stage
– Adequacy of systemic perfusion
– Volume status
– Contribution from precipitant or co-morbid factors
• Key tests:
–
–
–
–
Electrocardiogram (ECG)
Chest radiography (CXR)
B-type natriuretic peptide; N-terminal pro b-type natriuretic
Echocardiography
39
Electrocardiogram: Common Abnormalities in Heart Failure
Abnormality
Causes
Clinical implications
Sinus tachycardia
Decompensated HF; anemia; fever; hyperthyroidism
Clinical assessment; Laboratory investigation
Sinus bradycardia
b-Blockade; Digoxin; Anti-arrhythmics;
Hypothyroidism; Sick sinus syndrome
Evaluate drug therapy; Laboratory investigation
Atrial
Hyperthyroidism; infection; mitral valve diseases;
tachycardia/flutter/fibrillati
Decompensated HF; myocardial infarction
on
Slow AV conduction; medical conversion;
electroversion; catheter ablation;
anticoagulation
Ventricular arrhythmias
Ischemia; infarction; cardiomyopathy; myocarditis;
hypokalemia, hypomagnesaemia; Digitalis overdose
Laboratory investigation; Exercise test;
perfusion studies; coronary angiography,
electrophysiology testing; ICD
Ischemia/Infarction
Coronary artery disease
Echo; troponins; coronary angiography;
revascularization
Q waves
Infarction; hypertrophic cardiomyopathy; LBBB, preexcitation
Echo; coronary angiography
LV hypertrophy
Hypertension; aortic valve disease; hypertrophic
cardiomyopathy
Echo/Doppler
AV block
Infarction; drug toxicity; myocarditis; sarcoidosis;
Lyme disease
Evaluate drug therapy; pacemaker; systemic
disease
Microvoltage
Obesity; emphysema; pericardial effusion;
amyloidosis
Echo; chest X-ray
QRS length > 120 ms of
LBBB morphology
Electrical and mechanical dysynchrony
Echo; CRT-P; CRT-D
Source: European Journal of Heart Failure (2008), 933-989 doi:10.1016/j.ejheart.2008.08.005
40
Chest Radiography: Common Abnormalities in Heart Failure
Abnormality
Causes
Clinical Implications
Cardiomegaly
Dilated LV, RV, atria; Pericardial effusion
Echo/Doppler
Ventricular
hypertrophy
Hypertension, aortic stenosis, hypertrophic
cardiomyopathy
Echo/Doppler
Normal pulmonary
findings
Pulmonary congestion unlikely
Reconsider diagnosis (if untreated);
Serious lung disease unlikely
Pulmonary venous
congestion
Elevated LV filling pressure
Left heart failure confirmed
Interstitial edema
Elevated LV filling pressure
Left heart failure confirmed
Pleural effusions
Elevated filling pressures; HF likely if
bilateral; Pulmonary infection, surgery, or
malignant effusion
Consider non-cardiac etiology if
abundant; If abundant, consider
diagnostic or therapeutic centers
Kerley B lines
Increased lymphatic pressures
Mitral stenosis or chronic HF
Hyperlucent lung
fields
Emphysema or pulmonary embolism
Spiral CT, spirometry, Echo
Pulmonary infection
Pneumonia may be secondary to pulmonary
congestion
Treat both infection and HF
Pulmonary infiltration Systemic disease
Diagnostic work-up
41
B-Type Natriuretic Peptide (BNP)
Pro-BNP, BNP and NT-pro-BNP
When the heart is stressed, it produces a precursor, pro-BNP, which
is separated to release the active hormone BNP and an inactive
fragment, NT-proBNP
Both BNP and NT-proBNP are produced mainly in the heart’s left
ventricle, and released as a natural response to heart failure,
hypotension, angina, hypertrophy (when the left ventricle has been
“stretched” too much from the accumulation of blood and fluid), or
when overworked (i.e. rapid heart rate)
Elevations of BNP are dependent on overall patient condition
(including presence and type of co-morbid conditions) and the stage
and type of heart failure.
BNP levels should be correlated with other clinical indicators
42
Conditions that Influence BNP Concentrations
BNP Values*:
• <100 pg/ml = no systolic or diastolic heart failure
• 100-200 pg/ml = normal or chronic CHF
• 200-400 pg/ml = could be indicative of LV or RV CHF, PE, LVH, ESRD, AMI
• >400 pg/ml = overt CHF
*Normal levels and clinical significance of values vary between hospitals and physicians
Increased BNP:
Decreased BNP:
•
Age (older)
•
Obesity
•
Sex (female)
•
•
Ethnicity (black)
Early acute heart failure (less than 1
hour)
•
Renal dysfunction
•
Acute mitral regurgitation
•
Myocardial infarction/acute coronary
syndromes
•
Mitral stenosis (in the absence of
right ventricular failure)
•
Right-sided heart failure (cor
pulmonale, acute pulmonary embolus)
•
•
High output failure (cirrhosis, septic
shock)
Stable NYHA Class I patients with
decreased LV ejection fraction
43
Echocardiography – Helps Identify the Etiology of Heart Failure
Measurement
Abnormality
Clinical implications
LV ejection fraction
Reduced (45 - 50%)
Systolic dysfunction
LV function; global and focal
Myocardial infarction/ischemia; Cardiomyopathy; myocarditis
End-diastolic diameter
Akinesis; hypokinesis; dyskinesis
Increased (.55 - 60 mm)
Volume overload; HF likely
End-systolic diameter
Increased (.45 mm)
Volume overload; HF likely
Fractional shortening
Reduced (25%)
Systolic dysfunction
Left ventricular thickness
Hypertrophy (.11 - 12 mm)
Hypertension; aortic stenosis; hypertrophic cardiomyopathy
Left atrial size
Increased (.40 mm)
Increased filling pressures; Mitral valve dysfunction; Atrial
fibrillation
Valvular structure and
function
Valvular stenosis or regurgitation
(especially aortic stenosis and mitral
insufficiency)
May be primary cause of HF or complicating factor; Assess
gradients and regurgitant fraction; Assess hemodynamic
consequences; Consider surgery
Mitral diastolic flow profile
Abnormalities of the early and late
diastolic filling patterns
Indicates diastolic dysfunction and suggests mechanism
Tricuspid regurgitation peak
velocity
Increased (.3 m/s)
Increased right ventricular systolic pressure Suspect
pulmonary hypertension
Aortic outflow velocity time
integral
Reduced (15 cm)
Reduced low stroke volume
Inferior vena cava
Dilated Retrograde flow
Increased right atrial pressures; Right ventricular dysfunction
Hepatic congestion
Pericardium
Effusion; hemopericardium;
thickening
Consider tamponade; uremia; malignancy; systemic
disease; acute or chronic pericarditis; constrictive
pericarditis
44
The Hospitalized Patient – Principles of Treatment
• Stabilize systemic perfusion if necessary
• If fluid overloaded, IV loop diuretics
– Initially equal or greater than oral outpatient dose
– Later guide by urine output and signs / symptoms
• Increase dose?
• Continuous IV diuretic infusion
• Add 2nd medication (metolazone, spironolactone)
– While on IV diuretics or changing HF meds, daily basic metabolic
panels
• Monitor I/Os, vital signs, body weight daily
• Check signs and symptoms of perfusion and congestion
both supine and standing
45
The Hospitalized Patient – Principles of Drug Therapy
• Continue home meds as appropriate
• If not on a BB, start while inpatient
– Start at a low dose
– If not on a BB during admission:
• Start at low dose
• Monitor for orthostatic hypotension
• Vasodilators only if
– Severely symptomatic volume overload
– Inadequate response to diuretics after escalation
– No systemic hypotension
46
The Hospitalized Patient – Other Therapy Options
• Progressive deterioration of renal function BUN >80 mg/dl and Cr
>3 mg/dl or hyperkalemia may necessitate discontinuation of
ACE inhibitors and spironolactone
• Use of further vasodilators, either oral or intravenous, should be
considered
• Intravenous inotropic therapy can improve renal function and
allow effective diuresis
• Invasive hemodynamic monitoring
– For refractory symptoms and signs
• Ultrafiltration or hemodialysis may be necessary
47
Initial Management of Acute Heart Failure
Target
Therapeutic
example
Mechanism of action
Side effects
Alleviate
congestion
IV furosemide
Water and sodium
excretion
Electrolyte
abnormalities
Reduce
elevated LV
filling
pressures
IV nitrates
Direct relaxation of
vascular smooth
muscle cells through
various mechanisms
Hypotension,
decreased
coronary
perfusion
pressure
48
Initial Management of Acute Heart Failure (cont.)
Target
Therapeutic
example
Mechanism of action
Side-effects
Poor cardiac
function
Inotropes
Activate Cyclic adenosine
monophosphate (cAMP)
or calcium sensitization,
resulting in improved
contractility and
vasodilation (with
increased sympathetic
tone)
Hypotension,
arrhythmias,
myocardial
damage,
association with
increased morbid
events
Tachycardia
and increased
systemic
blood
pressure
Beta-blockers:
IV esmolol may
be used when
HF is related to
AF with RVR
and/or severe
hypertension
Blockade of beta-1 and
beta-2 receptors
Bradycardia,
hypotension,
negative inotropy;
however given
short half-life
esmolol, these
side-effects should
be short-lived
(i.e. in cases of
excessive
sympathetic tone)
49
Use of Diuretics
Appropriate
•
Adverse Effects
Helpful in relieving
congestion and decreasing
volume overload: consider
loop diuretics as first choice
•
Multiple divided doses
versus continuous infusion
•
High-dose versus low-dose
loop diuretics
•
Consider combination of
diuretics.
50
•
Precipitation of metabolic
abnormalities
•
May predispose to
arrhythmias
•
Worsening of renal function
•
Lower the dose as tolerated
once euvolemic state is
achieved.
Additional Medication Considerations
•
Diuretics are useful in relieving the symptoms of congestion and
correcting the volume overload, but excessive diuresis can cause
metabolic abnormalities and adversely effect the neurohormonal
balance.
•
Vasodilator therapy should be aggressively pursued for controlling the
hemodynamic abnormalities and relief of symptoms in acute
decompensated heart failure.
•
Beta blockers should be continued through hospitalization when
admitted with ADHF unless contraindicated. Beta blockers should be
part of discharge medication regimen unless contraindicated.
•
ACEi/ARB should be continued through hospitalization in spite of
modest deterioration in renal function and should be optimized prior to
discharge, unless contraindicated.
•
Aldosterone antagonists should be considered for patients in Class III
and Class IV CHF, unless contraindicated.
51
Indications for Invasive Therapy
Implantable Cardioverter Defibrillator
•
Nonischemic cardiomyopathy or ischemic heart disease at least 40
days post MI with ejection fraction of <35% with NYHA Class II or III
symptoms on maximum chronic optimal medical therapy and
reasonable expectation of survival of more than 1 year with good
functional status.
Indications for Cardiac Resynchronization Therapy
•
Sinus rhythm
•
QRS duration >0.12 msec
•
LVEF <35%
•
Typically NYHA functional Class II or III, but any patient regardless of
NHYA class can be considered (new addition to ACC in 2009)
52
Major Scenarios for Consideration of
Implantable Cardiac Defibrillators in HF
Scenario 1
•
•
Current/prior symptoms of HF
Reduced LVEF with history of cardiac arrest, ventricular
fibrillation, or hemodynamically destablizing ventricular
tachycardia
Scenario 2
•
•
•
Nonischemic Cardiomyopathy or Ischemic disease, 40
days post myocardial infarction and a LVEF < 35%
NYHA Class II or III on optimal therapy
Expected survival > 1yr
Scenario 3
•
•
•
•
LVEF < 35%
Sinus rhythm or Atrial fibrillation
NYHA Class III or Class IV on optimal therapy
Cardiac dyssynchrony (QRS >= 0.12 seconds)
53
Secondary
prevention to
prolong survival
Primary prevention
of sudden cardiac
death
Consider for that are
severely symptomatic –
also consider AICD with
Resynchronization
Therapy
Heart Failure Documentation Improvement Key Concepts
For acute care, documentation should indicate severity of the patients
illness or condition, key terms that indicate severity and / or specify the
patient's condition:
•
Document the etiology of the cardiomyopathy – such as hypertensive heart
disease, ischemic heart disease, valvular and which valve(s), viral, alcoholic,
etc.). This documentation reflects a higher level of evaluation.
•
Document the known results of cardiac function studies and state whether
they reflect failure due to left ventricular systolic dysfunction, left ventricular
diastolic function or both.
•
Clarify the patient’s heart failure status (due to chronic left ventricular systolic
or diastolic dysfunction) and whether the current episode reflects acute
decompensation.
•
Document whether the patient had an acute MI within eight weeks of this
episode and whether the acute MI was the cause of this episode of
decompensation.
•
Name/document the relationship if this is a CKD patient and volume overload or
non-cardiac pulmonary edema led to the decompensation.
54
Heart Failure
TRANSITIONS TO AMBULATORY
55
Heart Failure Care Transitions Hospital to Ambulatory
Goals: Coordination with Primary Care
•
Help patients understand the importance of avoiding readmission by
reinforcing the following:
– Take medication as prescribed (understanding purpose of meds)
– Keep appointments with your doctors (primary care and other providers)
– Keep track of daily weights and nutrition (especially salt and fluids restriction)
and bring health records to doctor visits
– Get daily physical activity
– Know the warning signs and what do to for increasing symptoms of HF
– Maintain a healthy lifestyle to improve overall well being
•
Primary care providers should understand readmission risk scores and
how their patients would benefit from remote monitoring
56
Heart Failure Care Transitions
Causes of Hospital Readmission for CHF
HFSA Research 2000
57
Remote Monitoring and Readmission Risk
Remote Monitoring (Tele-health) – Studies have shown that
monitoring HF patients through telephone or other device
monitoring can reduce HF Readmissions
Readmission Risk – Several tools are publically available and
include LACE; Modified LACE; Yale New Haven Readmission
Risk Tool
Risk Assessment can help clinicians understand a HF patient’s
individual needs for management across care settings
(Transitions or Health Coach; Home Care; Remote Monitoring
i.e. Tele-monitoring; or Palliative Care)
58
Palliative Care Integrative Model
Newer
Figure 1. Palliative Care Integrative Model
Figure 2. Disease-Directed Palliative Care Model
• Initiate Palliative Care at the diagnosis
• Intended for people with serious illnesses
• Focus is on providing patients with relief from their symptoms and the stress of
a having a serious illness and improving quality of life — no matter the diagnosis
• Appropriate at any age and at any stage of an illness, and it can be provided
along with treatments that are meant to cure.
59
Conclusions
•
Manage HF better by using evidence-based guidelines more
consistently
– Early recognition of HF and prompt action in outpatient and inpatient
settings
– Careful, anticipatory, collaborative care especially at transitions
ambulatory ↔ acute care
– Patient and caregiver education
•
Prevent readmissions
– Ambulatory monitoring
– Discharge planning
– Invasive, restorative or palliative care
•
Learn from best practices
– From peers
– From Trinity organizations
60
Appendix
•
ACC Guideline Drug Tables
pgs 62 – 64
•
ACC Stages and Treatments Options
pgs 65 – 66
•
Clinical Profiles of Acute Heart Failure
pg 67
•
Heart Failure ICD-9 Codes
pg 68
•
Ventricular Remodeling Definition
pg 69
61
Cardiovascular Medications Useful for Treatment of
Various Stages of Heart Failure
Drug
Stage A
Stage B
Stage C
CV Risk –
Reduction in future
cardio-vascular risk
Ace Inhibitors
Benazepril (Lotensin)
H
Capropril (Capoten)
H, DN
Post MI
HF
Enalapril (Vasotec, Renitec)
H, DN
Asymptomatic LVSD
HF
Fosinopril (Monopril)
H
Lisinopril (Prinivil, Zestril)
H, DN
Moexipril (Univasc)
H
Perindopril (Aceon)
H, CV Risk
Quinapril (Accupril)
H
Ramipril (Altace)
HF
Post MI
HF
H – Hypertension
HF - Heart Failure
HF
H, CV Risk
Post MI
Post MI
H
Post MI
Post MI
Trandolspril (Mavek)
DN –Diabetic
Nephropathy
LVSD – Left
ventricular systolic
dysfunction
Angiotensin Receptor Blockers
Candesartan (Atacand)
H
Eprosartan (Teveten)
H
Irbesartan (Avapro)
H, DN
Losatan (Cozaar)
H, DN
Olmesartan (Benicar)
H
Telmisartan (Micardis)
H
Valsartan (Diovan)
HF
2005 ACC / AHA
Guidelines for
Diagnosis and
Management of Heart
Failure in Adults
CV Risk
H, DN
Post MI
62
Post MI, HF
Cardiovascular Medications Useful for Treatment of
Various Stages of Heart Failure
Drug
Stage A
Stage B
Stage C
Aldosterone Blockers
Eplerenone (Inspra)
H
Spironolactone (Aldactone)
H
Post MI
Post MI
HF
DN –Diabetic
Nephropathy
Beta-Blockers
Acebutolol (Sectral)
H
Atenolol (Senormin, Tenormin)
H
Betaxolol (Kerlone)
H
Bisoprolol (Zebeta)
H
Carteolol (Cartrol)
H
Carvedilol (Coreg)
H
Labetalol (Trandate, Normodyne)
H
Metoprolol succinate (Toprol XL)
H
Metroprolol tartrate (Lopressor)
H
Nadolol (Cargard)
H
Penbutolol (Levatol)
H
Pindolol (Visken)
H
Propranolol (Inderal)
H
Post MI
H – Hypertension
HF
Post MI
HF, Post MI
HF - Heart Failure
LVSD – Left
ventricular systolic
dysfunction
HF
Post MI
2005 ACC / AHA
Guidelines for
Diagnosis and
Management of Heart
Failure in Adults
Post MI
Timolol (Betimol, Istalol)
Post MI
Digoxin
CV Risk –
Reduction in future
cardio-vascular risk
HF
63
Oral Diuretics Recommended for Use in the Treatment of
Fluid Retention in Chronic HF
Drug
Initial Daily Dose (s)
Max Total Daily Dose
Duration of Actions
Bumetanide (Bumex)
0.5 to 1.0 mg once or twice
10 mg
4 to 6 hours
Furosemide (Lasix)
20 to 40 mg once or twice
600 mg
6 to 8 hours
10 to 20 mg once
200mg
12 to 16 hours
250 to 500 mg once or twice
1000 mg
6 to 12 hours
Chlorthalidones (Thalitone)
12.5 to 25 mg once
100 mg
24 to 72 hours
Hydrochlorothiazide (HydroDIURIL)
25 mg once or twice
200 mg
6 to 12 hours
Indapamide (Lozol)
2.5 mg once
5 mg
36 hours
Metolazone (Mykrox, Zaroxolyn)
2.5 mg once
20 mg
12 to 24 hours
5 mg
20 mg
24 hours
12.5 to 25 mg once
50 mg
2 to 3 days
50 to 75 mg twice
200 mg
7 to 9 hours
Loop Diuretics
Torsemide (Demadex)
Thiazide Diuretics
Chlorothiazide (Chlotride, Diuril)
Potassium-Sparing Diuretics
Amiloride (Midamor)
Spironolactone (Aldactone)
Triamterene (Dyrenium)
Sequential Nephron Blockade
Metolazone (Mykrox, Zaroxolyn)
2.5 to 10 mg once plus loop diuretic
Hydrochlorothiazide (HydroDIURIL)
25 to 100 mg once or twice plus loop diuretic
Chlorothiazide (Chlotride, Diuril) (IV)
500 to 1000 mg once plus loop diuretic
2005 ACC / AHA Guidelines for Diagnosis and Management of Heart Failure in Adults
64
Jessup M. and Brozena S. N Engl J Med 2003;348:2007-2018
65
ACC/AHA Stages and Treatment for Heart Failure
66
Clinical Profiles of Acute Heart Failure
(Dickstein et al)
Hypertensive AHF
Pulmonary
Edema
Acutely
Decompensated
Chronic HF
ACS and
HF
Cardiogenic
Shock
67
Right HF
Heart Failure ICD-9 CM Codes
ICD-CM-9 Codes for Heart Failure
428 Heart failure – heart failure due to hypertension list first a hypertension code, using the
following (402.0-402.9, with fifth-digit 1 or 404.0-404.9 with fifth-digit 1 or 3) as appropriate;
Excludes: rheumatic (398.91)
428.0 Congestive heart failure,
unspecified; Congestive heart disease;
Right heart failure (secondary to left
heart failure)
Excludes: fluid overload NOS (276.6)
428.2x
Systolic heart
failure (see
specific 5th
digit below)
428.3x
Diastolic heart
failure (see
specific 5th digit
below)
428.4x Combined
Systolic/Diastolic
heart failure (see
specific 5th digit
below)
428.1 Left heart failure - Acute edema
of lung with heart disease NOS or heart
failure; Acute pulmonary edema with
heart disease NOS or heart failure;
Cardiac asthma; Left ventricular failure
428.20
Unspecified
428.30
Unspecified
428.40
Unspecified
428.9 Heart failure, unspecified
Cardiac failure NOS; Heart failure NOS;
Myocardial failure NOS; Weak heart
428.21 Acute
428.31 Acute
428.41 Acute
428.22
Chronic
428.32 Chronic
428.42 Chronic
428.23 Acute
on chronic
428.33 Acute on 428.43 Acute on
chronic
chronic
68
Ventricular Remodeling - Definition
Table 1: Ventricular remodeling: definition and consequences
Definition: A cascade of changes in genome expression, cells, molecules, and interstitium
that alters the size, shape, and function of the left ventricle after injury. Alterations in heart
size and shape (volume) that are not associated with preload-mediated increase in myocyte
length.
Hallmarks leading to change in shape of left ventricle from a V to a U include a Combination
of:
• Dilatation (myocyte lengthening and cell slippage)
• Cell loss/death (apoptosis)
• Interstitial fibrosis
• Heart failure after myocardial infarction: formation of a discrete collagen scar
• Nonischemic heart failure: isolated fibrosis
• Hypertrophy (see Figure 1b and c) Initially concentric (thickening of myocytes); Then
becomes eccentric (thinning of the left ventricular walls)
Consequences:
• High pressure (wall stress) in the ventricle during systole and diastole heightens
myocardial oxygen consumption, a situation that promotes further hypertrophy and
activates neurohormonal systems
• Reduction in ejection fraction; Reduced ventricular performance Morbidity and
mortality
Source: CRITICALCARENURSE Vol 24, No. 6, DECEMBER 2004 , pg 18
69
References
1.
2005 / 2009 ACC / AHA Guidelines For Diagnosis And Management Of Heart Failure In Adults
2.
Wier LM, Levit K, Stranges E, et al. HCUP Facts and Figures: statistics on hospital-based care in the
United States, 2008: exhibit 2.3, most frequent principal diagnoses by age. Agency for Healthcare
Research and Quality. http://www.hcup-us.ahrq.gov/reports.jsp.
3.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service
program. N Engl J Med. 2009;360(14):1418-1428.
4.
Lloyd-Jones D, Adams RJ, Brown TM, Et Al. Heart Disease And Stroke Statistics—2010 Update. A Report
From The American Heart Association Statistics Committee And Stroke Statistics Subcommittee .
Circulation. 2010;121:e1-e170.
5.
Heart Failure Society Of America 2010 Guideline Executive Summary. Journal Of Cardiac Failure
2010;16:476-506.
6.
Dickstein et al. European Journal Of Heart Failure (2008), 933-989 Doi:10.1016/J.Ejheart.2008.08.005
7.
Eric D. Adler, MD; Judith Z. Goldfinger, MD; Jill Kalman, MD; Michelle E. Park, BA; Diane E. Meier, MD,
Palliative Care In The Treatment Of Advanced Heart Failure
Http://Circ.Ahajournals.Org/Content/120/25/2597
8.
CRITICALCARENURSE Vol 24, No. 6, December 2004 , Pg 18
9.
Jessup M. And Brozena S. N Engl J Med 2003;348:2007-2018
10. HFSA Research 2000
70
Post Test:
Questions and Answers
1. True or False: Heart Failure is diagnosed on the basis of diagnostic tests
False: HF is diagnosed on the presence of characteristic signs and symptoms and not on the basis of any diagnostic
tests
2. ______ heart failure is characterized by: an inability of heart muscle to contract vigorously;
results in inadequate amount of blood and oxygen to body; and is evidenced by Ejection
Fraction usually less than 40%
a.
b.
c.
d.
Systolic Heart Failure
Diastolic Heart Failure
Both Systolic and Diastolic Heart Failure
Neither Systolic or Diastolic heart Failure
3. What stage and class is a person in end stage Heart Failure?
a.
b.
c.
d.
Stage A/Class I
Stage D/Class IV
Stage B/Class II
Stage C/Class III
4. True or False: When treating older patients with ARBs, one should: “start low and go slow”
True
5. These are goals for what setting of Heart Failure treatment: Establish the diagnosis;
Review signs and symptoms; Identify adequacy of systemic perfusion and volume status
a.
b.
c.
d.
Ambulatory goals
Transitional goals
Emergency and Inpatient goals
These are not goals for any setting of Heart Failure treatment
71
Post Test Cont.:
Questions and Answers
6. Which of the tests listed below if not a key test for hospital management of Heat Failure:
a.
b.
c.
d.
ECG
Chest radiography
ProBNP or NT-proBNP
These are all key tests
7. True or False: Excessive diuresis will not cause metabolic abnormalities or adversely
effect the neurohormonal balance
False: Diuretics are useful in relieving the symptoms of congestion and correcting the volume overload, but excessive
diuresis can cause metabolic abnormalities and adversely effect the neurohormonal balance
8. What is Acute Decompensated Heart Failure Presentation?
a.
b.
c.
d.
Volume overload
Profound depression of cardiac output
Combination of A and B
All of the above
9. True or False: Patient and caregiver education will assist in the patient’s Heart Failure
management
True
10. What of the below options are potential causes for readmission:
a.
b.
c.
d.
Failure to see care
Prescription non-adherence
Diet non-adherence
All of the above
72

Management of Acute Decompensated Heart Failure

Transcription

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