Heart Failure

Diagnosis and Treatment

Paul Peacock CNS Heart

Function

Heart Failure

• Heart failure is a complex clinical

syndrome that results from any structural

or functional impairment of ventricular

filling or ejection of blood. (Yancy et al,. 2013)

• Prevalence 10 % > 65 years

– >65 age group to double in the next 25 years

– Poor 5 year survival at 50-75% (National Heart Foundation NZ, 2009)

(National Heart Foundation NZ, 2009)

Predicting the unpredictable

• Patients with severe heart failure may die at

any point along the trajectory

• Mechanisms vary (MADIT 1)

• NYHA 1- SCD

• NYHA 3-4 HF death

Heart Failure Causes– CVD – Myocardial Infarctions

– Hypertension

– Cardiomyopathy (heart muscle enlargement)

• Idiopathic

• Non Ischemic dilated

• Inflammatory- myocarditis

• Toxic

• Virus

– Valvular

– Thyroid Dysfunction

– Infiltrative disease –Amyloidosis - Sarcoidosis

– Arrhythmias (National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand 2011)

Clinical History for Symptoms

(FACES)– Fatigue

– Activity Limitations

– Congestion

– Edema

– Shortness of Breath

(Harvard)

Heart Failure Signs

• Heart Rate & Rhythm

• Blood Pressure

• S3 Gallop (99% specific)

• Increased JVP

• Hepatojugular reflux (96 % specific)

• Pitting Oedema

• Abdominal ascites

• Rales / Crackles

Figure 2

Heart, Lung and Circulation 2018 27, 1123-1208DOI: (10.1016/j.hlc.2018.06.1042)

Copyright © 2018 National Heart Foundation of Australia Terms and Conditions

Ejection Fraction

Terminology of Heart Failure

Heart Failure Reduced Ejection Fraction (HF-R-EF)

Occurs when the heart muscle does not contract with enough force. An

ejection fraction less than 40 percent indicates systolic heart failure

(Systolic HF)

– Associated with progressive chamber dilation and eccentric remodelling indicates

systolic heart failure

• Unable to get OUT – Unable to get IN

Heart Failure Preserved Ejection Fraction (HF-P-EF)

Occurs when the heart contracts normally (a normal ejection fraction)

but the ventricle does not relax is stiff or fill properly (Diastolic H F)

– Associated with abnormal diastolic function, usually with concentric remodelling or

hypertrophy

– Unable to get IN - Unable to get OUT

HF R EF ( OUT / IN)

• ¼ bucket out

• VS.

• 1 bucket In

• Pressure builds

back from where

It came from

HF N EF (IN / OUT)

FASTER SQUEEZE

VOLUME / FLUID in wrong place

HF preserved EF

(HFnEF/ HFpEF)

Treatment timelines• 1-3 Months

– Up Titration

• “ What can I Titrate Up” – Renal/BP/Hr

• 3-6 Months– What Progress- ECHO

• 6-9 Months– Other Therapies

• ARNI

• ICD

• CRT

• LVAD - Transplant

Health Pathways

Medication Therapy

• Diuretics (FLUID OFF)– Furosemide / Bumetanide

• ACE inhibitors or ARB (STOP the SQUEEZE)– Perindopril / Enalapril / Cilazapril or Losartan

• Beta Blockers (SLOW DOWN)– Bisoprolol / Carvedilol

• Aldosterone antagonists– Spironolactone

Mechanical Therapy

• Cardiac Resynchronisation Therapy

(CRT)– Improves function (Don’t stop beta blockers)

• Implanted Cardioverter Defibrillator

(ICD)– Termination not Prevention of arrhythmias

• Left Ventricular Assist Device– Bridge to transplant

• Transplant

Figure 3

Heart, Lung and Circulation 2018 27, 1123-1208DOI: (10.1016/j.hlc.2018.06.1042)

Copyright © 2018 National Heart Foundation of Australia Terms and Conditions

In Hospital nurse Role

• Daily weight

– All patients actively receiving management

for HF should have daily weights while in

hospital

• Assessment of Fluid status

– Input and Output first 24hr-48hr

– No evidence for fluid restriction.

Teaching SELF MANAGEMENT

– resources – Staying Well with Heart Failure

Heart Failure Diuretic • Loop Diuretics

– Frusemide

• variable bio availability 10-100%

• Peak effect IV-30-60min oral 1-2hr (4-5 hr duration)

– Bumetanide

• Bio availability 80-100%

• Peak effect IV- 15-30min oral 1-2hr (5-6 hr duration)

RAAS inhibition• Start Low – go slow Perindopril vs. Cilazapril / Inhibace +/ Enalipril

• Helps LV remodelling

• Improves Morbidity & Mortality (NNT 22)

• Titrate to highest tolerated dose every 2-3

weeks

• Check renal function before starting and at

each increase– Rise in Urea, Creatinine and K is expected- small pt

asymptomatic no action

– Creatinine >30% above baseline or 200 umol/L acceptable

– K up to 5.5mmol/L acceptable

Add an ACE

• Perindopirl– 2mg OD (nocte) Target 8mg OD

• Enalapril– 2.5mg OD Target 10-20mg BD

• Quinapril– 2.5mg OD Target 20-40mg OD

• Cilazapril– 0.5mg OD Target 1-2.5mg OD

• Captopril– 6.25 -12.5mg OD Target 50mg TID

Don’t like ACE- Try ARB• Angiotensin 2 Receptor Antagonist

• Losartan 12.5mg OD titrate 50mg OD (GOUT)

• Candesartan 4mg OD titrate 32mg OD

• Monitor:

– Hypotension

– Hyperkalaemia (especially if charted Spirolactone)

– Renal Function

Add in a Beta Blocker

• Start low – titrate slow -2 weekly

• Improved survival but

– 25% chance condition could worsen at first

• Titrate max dose

– unless hypotension or HR<60

• Never stop suddenly

– rebound hypertension & arrhythmias

Beta Blocker

• Bisoprolol –

• Bisoprolol is cardioselective and therefore should be the preferred agent if beta-blockers are used in patients with respiratory problems.

• Carvedilol –

• Carvedilol may be more effective at reducing hypertension. Note: Carvedilol should be prescribed twice daily for heart failure.

EF < 40% add MRA

• Mineralocorticoid Receptor Antagonist

– Spriolactone12.5mg aim 25mg Eplerenone

Renal 1/4/8 and 12 weekly renal function

– Side Effects

• Upset Stomach Diarrhoea

• Leg gramps at night

• Headache

• Confusion

• Breast Tenderness

– Eplerenone 25mg-50mg

Change to ARNIs? (Angiotensin receptor and neprilysin inhibitor)

Triple Whammy

• Dabigatran

http://www.heartfoundation.org.nz/know-the-facts/conditions/heart-failure

75 % of patients with chronic illness use internet for decision making(Gilmore et al., 2013)

25% of the PHC nurses did not use any educational material

35% of the medical ward nurses did not use any educational

material (Gilmore et al., 2014)

40% of patients diagnosed with heart failure were not aware or

unable to describe it or had little information from health

professionals. (Buetow & Coster, 2001)

Daily Self Management

(National Heart Foundation NZ, 2009)

(Gilmour J., 2013)

Aggressive Fluid and Sodium Restriction

in Acute Decompensated Heart Failure, RCT:

• Conclusions and Relevance:– Aggressive fluid and sodium restriction has no effect on weight loss or

clinical stability at 3 days and is associated with a significant increase in

perceived thirst. We conclude that sodium and water restriction in patients

admitted for ADHF are unnecessary.

Fluid restriction of 1.5–2 L/day may be considered in

patients with severe HF to relieve symptoms and

congestion. 2016 ESC Guidelines for the diagnosis

and treatment of acute and chronic heart failure

Aliti et al (2013), Travers et al. (2007)

Li, Y., Fu, B., Qian, X. (2015)

Self Management Principles

• Knowledge

– “What is the name of the water pill?”

– “What is the weight gain to report to your

practice?”

– “What are the signs you should be thinking

about?”

– “What foods should you limit”(Peter et al., 2015)

Self Management Principles

• Attitudes

– “Why is it important to weigh your self daily ?”

– “Why is it important to check for swelling ?”

– “Why is it important to take your tablets?”

(Peter et al., 2015)

Self Management Principles

• Behaviours– “How will you remember to take your pills every

day ?”

– “How will you remember to weigh your self every day?”

– “How do you plan to reduce salt in your diet ?”

– “How do you plan to check for signs and symptoms every day?”

(Peter et al., 2015)

But this is not the end….

ACP in the Cardiology• More than end of life

• Review at 3 months with

ACP discussion

• Balance of therapeutic

options

– Angioplasty/PAMI

– ICD

– TAVI

– LVAD

– Transplant

Diagnosing Death

• Previous admissions with worsening heart

failure

• Weight Loss (5-10% ) over past 3-6 mths

• No identifiable reversible cause

• Receiving the optimum amount of heart

failure drugs

• Failure to respond within 2 to 3 days to

necessary changes in diuretics

• Deteriorating renal function

Practical things

• Share advice

• Trial addition Metolazone

• Sub Cut Frusemide

• Midazolam

• Opiates

• Home Oxygen

• Cardiopulmonary Rehab

• Advance Care Planning

ACP in the Cardiology

Partnership with patient

• Internal Cardiac

Defibrillator (ICD)• when to turn off.

• Surgery in Octogenarian

•Research required for End of

Life Care in Heart Failure

patients

References• Aliti et al. (2013). Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure,

RCT. JAMA Intern Med. 2013;173(12):1058-1064

• Albert, N. (2002) fluid Management Strategies in Heart Failure. Critical Care Nurse 32:20-32. doi: 10.4037/ccn2012877

• Auer, J (2013). What does the liver tell us about the failing heart? European Heart Journal 34, 711-714 doi:10.1093/eurheartj/ehs440

• Buetow, S., Coster, G. (2001) Do general practice patients what heart failure understand its nature and seriousness, and want improved information? Patient education and counselling, 45, 181-185. doi:10.1016/S0738-3991(01)00118-5

• Fletcher, P. (2000) Beta Blockers in Heart Failure. Australian Prescriber, 23 (6),120-123.

• Heinzel et al (2015) Myocardial hypertrophy and its role in heart failure with preserved ejection

fraction. J Appl Physiol 119: 1233–1242, 2015. doi:10.1152/japplphysiol.00374.2015

• Khatib, R. (2008) Diuretics in heart failure part 1. pharmacology and mechanisms. British journal of

Cardiac Nursing. (3) 7 310-314.

• Khatib, R. (2008) Diuretics in heart failure part 2. considerations in practice . British journal of

Cardiac Nursing. (3) 8 350-357.

• Khatib, R. (2011) Prescribing diuretics in the management of heart failure. Nurse Prescribing. 9.9

435-441

• Li, Y., Fu, B., Qian, X. Liberal versus restricted fluid administration in heart failure patients, a

systematic review and meta analysis of randomised trials. Int heart Journal.56(2) 129-5

• Lourenco et al (2018) An integrative translational approach to study heart failure with preserved

ejection fraction: a position paper from Working Group on Myocardial Function of the European

Society of Cardiology. European journal of Heart failure, 20, 216-227. doi:10.1002/ejhf.1059

Reference

• McMurray et al (2005) Practical recommendations for the use of ACE inhibitors, beta-blockers,

aldosterone antagonists and angiotensin receptor blockers in heart failure: Putting guidelines into

practice. The European Journal of Heart Failure, 7, 710-721

• National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (2011). Guidelines for Prevention, Detection and Management of Chronic Heart Failure in Australia. Author Retrieved from http://www.heartfoundation.org.au.

• National Heart Foundation of New Zealand. (2009). New Zealand Guideline for the Management of Chronic Heart failure. Auckland, New Zealand: Author Retrieved from http://www.heartfoundation.org.nz

• Pellicori,P., Kaur,K., Clark,A. (2015) Fluid Management in Patients with Chronic Heart Failure. Cardiac Failure Review, 2015;1(2):90–5

• Oktay, A,A., Rich, J,D., Shah, S,J. (2013) The Emerging Epidemic of Heart Failure with Preserved Ejection Curr Heart Fail Rep. 2013 December ; 10(4): . doi:10.1007/s11897-013-0155-7.

• Ouwerkerk et al (2017) Determinants and clinical outcome of uptitration of ACE-inhibitors and beta-blockers in patients with heart failure: a prospective European study. European Heart Journal. 00. 0-10. doi:10.1093/eurheartj/ehx026.

• Ross, S., Walker, T., Woods, D. (2006) ACE Poems patient orientated evidence that matters. BPAC 15.

• Stewart et al. (2016) Establishing a pragmatic framework to optimise health outcomes in heart failure and multimorbidity (ARISE-HF): A multidisciplinary position statement. International Journal of Cardiology, 212, 1-10. doi:10.1016/j.ijcard.2016.03.001

• South London cardiovascular and Stroke Network (2014) Prescribing Beta-blocker for patients with

heart failure due to left ventricular systolic dysfunction. Downloaded 07/03/16

• Travers et al. (2007) Fluid restriction in the management of decompensated heart failure: No impact on time to clinical stability. Journal of cardiac failure, Vol 13 No 2. doi:10.1016/j.cardfail.2006.10.012

Reference

• Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., . . . Wilkoff, B. L. (2013). 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 128(16), e240-e327. doi: 10.1161/CIR.0b013e31829e8776

• Walker, H,K., Hall, W,D., Hurst, J,W. (2009) The history, physical, and laboratory Examinations. 3rd

ed. Boston.

• Vaduganathan et al. (2017) Mode of Death in Heart Failure With Preserved Ejection Fraction. Journal of the American College of Cardiology Volume 69, (5) February 2017 DOI: 10.1016/j.jacc.2016.10.078

• Vazir,A., Cowie, M. (2016) Decongestion: Diuretics and other therapies for hospitalized heart failure. Indian heart Journal, 68, 61-68. doi:10.1016/j.ihj.2015.10.386

Reference• Congestive heart failure the basics https://www.youtube.com/watch?v=JHz_JivtNLc

• Listen to Physiological & pathological breath sounds

https://www.youtube.com/watch?v=O8OC7EiqBKQ

• Heart Sounds http://mediconet.blogspot.co.nz/2013/09/heart-sounds-murmurs-free-download.html

• CXR - How to read the chest x ray - Part I: Concepts and Quality

https://www.youtube.com/watch?v=qAjEJZ-mQvQ

• Diagnosis video https://www.youtube.com/watch?v=JHz_JivtNLc

• X-Rays -Case courtesy of A.Prof Frank Gaillard, <a href=

“http://radiopaedia.org/">Radiopaedia.org</a>. From the case <a

href="http://radiopaedia.org/cases/12334">rID: 12334</a>

• NMDHB Intranet / Clinical guidelines / Heart Failure

http://nnintranet/home/DocumentManager/NMDHBDocuments/ClinicalGuidelines/

• NMDHB intranet / Health Pathways http://nm.healthpathways.org.nz/index.htm

• www.medsafe.govt.nz datasheets

– Perindopril

– Bosovate

– Burinex

– Candesarten

– Metolozone

– Spitolactone