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www.cardionursing.com 1
Cynthia Webner DNP, RN, CCNS, CCRN-CMC, CHFN Karen Marzlin DNP, RN, CCNS, CCRN-CMC, CHFN Handouts at www.cardionursing.com
2
“I’m not telling you it
is going to be easy, I’m
telling you it is going
to be worth it.”
~ Art Williams
www.cardionursing.com 2
Definition
• Heart Failure is a complex clinical syndrome resulting from any structural or functional cardiac disorder impairing the ability of the ventricle to either fill or eject
Clinical Syndrome Resulting Clinical Manifestations
Dyspnea and fatigue May limit exercise
tolerance
Fluid overload
May lead to pulmonary
congestion and peripheral edema
AND / OR
Impaired functional capacity and quality of life
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Definitions
Definition of Heart Failure
Classification Ejection
Fraction Description
I. Heart Failure with
Reduced Ejection
Fraction (HFrEF)
≤40% Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these
patients that efficacious therapies have been demonstrated to
date.
II. Heart Failure
with Preserved
Ejection Fraction
(HFpEF)
≥50% Also referred to as diastolic HF. Several different criteria have
been used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF,
Borderline
41% - 49% These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF
Improved
>40% It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or
recovery in EF may be clinically distinct from those with
persistently preserved or reduced EF. Further research is needed
to better characterize these patients.
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HFrEF (Systolic Dysfunction) vs HFpEF (DiastolicDysfunction)
HFrEF - Systolic Dysfunction
• Impaired wall motion and ejection
• Dilated chamber
• 50% of HF Population
• Hallmark: Decreased LV Ejection Fraction < 40%
• Coronary artery disease is cause in 2/3 of patients
• Remainder – other causes of LV dysfunction
Cardiomyopathy not synonymous with HF
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• Filling impairment • Normal chamber size • 50% of patients with HF have
preserved LV function • Normal EF or elevated • Caused by Hypertension Restrictive myopathy (C) Ischemic heart disease Ventricular hypertrophy (D) Valve disease Idiopathic
HFpEF - Diastolic Dysfunction
Primarily disease of elderly women with HTN
• Diagnosis is made when rate of ventricular filling is
slow
• Elevated left ventricular filling pressures when volume and contractility are normal
In practice: the diagnosis is made when
a patient has typical signs and symptoms of heart failure and has a normal or elevated
ejection fraction with no valve disease.
HFpEF - Diastolic Dysfunction
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Left versus Right Sided Heart Failure
Two sides of the heart form a circuit, neither side can pump significantly more blood than the other for long
Signs/symptoms of failure reflect each respective ventricle
The Real Culprit: Neurohormonal Response
SNS Response
RAAS Response
Ventricular Remodeling
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Activation of SNS
First Responder Decreased CO → ↓ BP → activates baroreceptors and vasomotor
regulatory centers in medulla
Increase circulating catecholamines Stimulates alpha and beta receptors
Increase HR
Peripheral vasoconstriction
Contractility Positive effect: ↑ CO and BP
Negative effect: ↑ O2 demand → ischemia, arrhythmias, sudden death
Chronic Stimulation of SNS
Norepinephrine (circulating catecholamine) is Cardiotoxic Decreases heart’s ability to respond to sympathetic
stimulation
Down regulation of B1 receptor sites (less sensitive)
Contributes to decreased exercise tolerance
Can also lead to ventricular remodeling
Be aware of your patient’s heart rate response to activity.
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Activation of RAAS Kidney’s response to decreased perfusion due to
decreasing CO
Concentrations of angiotensin II, and aldosterone rise as end result
Potent vasoconstriction
Sodium/water absorption increases
Result
Increased preload and increased afterload
Increased myocardial oxygen demand
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Harmful Result of RAAS Activation
Enhanced preload increases end-diastolic volume dilating the LV
LV becomes overstretched
LV changes size and shape (ventricular remodeling)
Contractility decreases
Congestive symptoms develop
Ventricular Remodeling
• Process of pathological growth
• Can occur from prolonged activation of SNS/RAAS
• Involves Hypertrophy of myocytes Pressure – thicken (concentric)
Volume – elongate (eccentric)
Genetically abnormal – inefficient contraction
Increased ventricular muscle mass, change in ventricular shape
Collagen matrix becomes fibrotic
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Symptoms
Fluid Accumulates in Pulmonary Capillary Bed
Increased Pulmonary Pressure / Volume
Atrial Overload
Atrial Dilatation
Increased Atrial Pressure / Volume
Increased Ventricular Pressure / Volume
Decreased Ejection of Ventricular Contents
Decreased Ventricular Contractility
Ventricular Dilatation
Changes in Systolic Dysfunction
Mitral Regurgitation
Dilated Mitral Valve Annulus
Vasoconstriction / Fluid Retention
Activation of Neuro- hormonal Responses
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The Good Guys: Natriuretic Peptides
Cardiac hormones secreted by myocytes Atrial natriuretic peptide (ANP) Produced in atria
Brain natriuretic peptide (BNP) Produced in ventricles in response to increased
ventricular pressure/stretching Stronger release than ANP
Promote vasodilatation (preload/afterload reduction)
Reduce sodium/water retention (diuretic response)
Reduce production/action of vasoconstrictor peptides
Plasma concentrations elevated in patients in fluid overload
Neseritide (Natrecor) is the synthetic form of BNP
B-type natriuretic peptide (BNP) or N-terminal
pro-B-type natriuretic peptide (NT-proBNP)
Good to assess in patients with dyspnea being evaluated for HF
Should not be used as the sole tool to diagnose HF
Must be used in concert with signs and symptoms
Special consideration with renal insufficiency and obesity.
Low values have strong negative predictive value
Adds to prognostic information
Natriuretic Peptides
22 2014
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2014 23
Causes of Elevated Naturetic Peptide Levels
Cardiac
Heart failure, including RV syndromes
Acute coronary syndrome
Heart muscle disease, including LVH
Valvular heart disease
Pericardial disease
Atrial fibrillation
Myocarditis
Cardiac surgery
Noncardiac Advancing age Anemia Renal failure Pulmonary: obstructive sleep
apnea, severe pneumonia, pulmonary
hypertension Critical illness Bacterial sepsis Severe burns Toxic-metabolic insults,
including cancer chemotherapy and envenomation
Heart Failure Symptoms
Exercise intolerance (hallmark) Ability to perform ADLs
Fatigue
Dyspnea
Paroxysmal nocturnal dyspnea
Frequent night urination with less during the day
Peripheral edema/weight change
Chest pain
GI problems
Confusion/altered mental status
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Heart Failure Symptoms
Symptoms in the elderly
Many don’t experience exertional dyspnea because they are sedentary
More common:
Daytime oliguria/nocturia
Mental disturbances
Anorexia
GI disturbances
Classification of Heart Failure New York Heart Association
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Physical Exam Findings General Appearance (resting dyspnea, cyanosis, cachexia)
Weight gain
BP/HR
Include orthostatic pressures
JVD
Hepatojugular reflux
Edema
Displaced apical impulse
S3/S4
Lung sounds
www.cardionursing.com 2014
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Treatment Strategies
STAGE AAt high risk for HF but
without structural heart
disease or symptoms of HF
STAGE BStructural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Prevent hospitalization
· Prevent mortality
Strategies
· Identification of comorbidities
Treatment
· Diuresis to relieve symptoms
of congestion
· Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
· Revascularization or valvular
surgery as appropriate
STAGE CStructural heart disease
with prior or current
symptoms of HF
THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality
Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists
Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin
In selected patients· CRT· ICD· Revascularization or valvular
surgery as appropriate
STAGE DRefractory HF
THERAPY
Goals
· Prevent HF symptoms
· Prevent further cardiac
remodeling
Drugs
· ACEI or ARB as
appropriate
· Beta blockers as
appropriate
In selected patients
· ICD
· Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital
readmissions· Establish patient’s end-
of-life goals
Options· Advanced care
measures· Heart transplant· Chronic inotropes· Temporary or permanent
MCS· Experimental surgery or
drugs· Palliative care and
hospice· ICD deactivation
Refractory symptoms of HF at rest, despite GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Development of
symptoms of HFStructural heart
disease
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HFpEF
No evidence based medical therapy
ARBs, aldosterone antagonists, and sildenafil have all been tested
ARBs and aldosterone antagonists may reduce hospitalizations but not mortality
Focus on co-morbid conditions:
HTN
Sleep apnea
Atrial Fibrillation
Stages, Phenotypes and Treatment of HF
STAGE AAt high risk for HF but
without structural heart
disease or symptoms of HF
STAGE BStructural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Prevent hospitalization
· Prevent mortality
Strategies
· Identification of comorbidities
Treatment
· Diuresis to relieve symptoms
of congestion
· Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
· Revascularization or valvular
surgery as appropriate
STAGE CStructural heart disease
with prior or current
symptoms of HF
THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality
Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists
Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin
In selected patients· CRT· ICD· Revascularization or valvular
surgery as appropriate
STAGE DRefractory HF
THERAPY
Goals
· Prevent HF symptoms
· Prevent further cardiac
remodeling
Drugs
· ACEI or ARB as
appropriate
· Beta blockers as
appropriate
In selected patients
· ICD
· Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital
readmissions· Establish patient’s end-
of-life goals
Options· Advanced care
measures· Heart transplant· Chronic inotropes· Temporary or permanent
MCS· Experimental surgery or
drugs· Palliative care and
hospice· ICD deactivation
Refractory symptoms of HF at rest, despite GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Development of
symptoms of HFStructural heart
disease
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Details for HF pharmacology were
discussed during yesterday’s CV
pharmacology session.
Cardiac Resynchronization Therapy
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Cardiac Resynchronization Therapy (CRT)
Treatment modality for heart failure not just pacing
Treatment modality in conjunction with drug therapy
Goals: Improve hemodynamics by restoring synchrony of
ventricular contraction
Improve quality of life
Decrease mortality and morbidity
CRT
Goal: Force biventricular pacing
Goal: Ventricular Pacing 90% of time or greater
Causes of Loss of Bi V pacing: Long AV Delays
Prolonged PVARP
ST with 1 degree AV Block
Lead dislodgement
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Normal Ventricular Depolarization
Ventricular Depolarization with LBBB
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Indications for CRT Therapy Patient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or
with implantation of pacing or defibrillation device for special indications
LVEF <35%
Evaluate general health status
Comorbidities and/or frailty
limit survival with good
functional capacity to <1 y
Continue GDMT without
implanted device
Acceptable noncardiac health
Evaluate NYHA clinical status
NYHA class I
· LVEF ≤30%
· QRS ≥150 ms
· LBBB pattern
· Ischemic
cardiomyopathy
· QRS ≤150 ms
· Non-LBBB pattern
NYHA class II
· LVEF ≤35%
· QRS 120-149 ms
· LBBB pattern
· Sinus rhythm
· QRS ≤150 ms
· Non-LBBB pattern
· LVEF ≤35%
· QRS ≥150 ms
· LBBB pattern
· Sinus rhythm
· LVEF ≤35%
· QRS ≥150 ms
· Non-LBBB pattern
· Sinus rhythm
Colors correspond to the class of recommendations in the ACCF/AHA Table 1.
Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along
with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D
unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and
personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival.
NYHA class III &
Ambulatory class IV
· LVEF ≤35%
· QRS 120-149 ms
· LBBB pattern
· Sinus rhythm
· LVEF ≤35%
· QRS 120-149 ms
· Non-LBBB pattern
· Sinus rhythm
· LVEF ≤35%
· QRS ≥150 ms
· LBBB pattern
· Sinus rhythm
· LVEF≤35%
· QRS ≥150 ms
· Non-LBBB pattern
· Sinus rhythm
· Anticipated to require
frequent ventricular
pacing (>40%)
· Atrial fibrillation, if
ventricular pacing is
required and rate
control will result in
near 100%
ventricular pacing
with CRT
Special CRT
Indications
Internal Monitoring with CRT
Heart rate variability
Patient activity
Night heart rate
Impedance
Routine re-evaluation of pacing burden is important in the treatment of HF. If HF
worsens assess CRT function.
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Automatic Implantable Cardioverter Defibrillators
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ICD Device
Pulse Generator Single chamber, dual chamber, or biventricular pacing
Back up pacing
Antitachycardia pacing
Implanted subcutaneously – same as pacemaker
Defibrillator lead Detects arrhythmias
Delivers therapy
Defibrillator lead capable of pacing and defibrillating
Placed in right ventricle
ICD Functions
ATP-Anti tachycardia Pacing Tiered Antiarrhythmic Therapies
44 2014 www.cardionursing.com
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ICD Functions
Cardioversion Shock Delivers shocks from 0.1 to 30 joules synchronized on the
R wave
45 2014 www.cardionursing.com
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ICD Functions
Defibrillating Shock Delivers high energy (20-34 joules) unsynchronized shock
for VF
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Acute Decompensated Heart Failure
47
Common Precipitating Factors of ADHF
Non adherence with
Medications
Dietary sodium intake
Fluid intake
Excessive alcohol or drug use
ACS
Arrhythmias
Persistent hypertension
Valvular heart disease
Recent addition of negative inotrope
Nonsteroidal anti-inflammatory drugs
Worsening renal function
Endocrine abnormality
Concurrent infection
New anemia
Pulmonary embolism
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Evidence of severe ADHF, including:
Hypotension
Worsening renal function
Altered mentation
Dyspnea at rest
Typically reflected by resting tachypnea
Less commonly reflected by oxygen saturation <90%
Hemodynamically significant arrhythmia - including new onset of rapid atrial fibrillation
Acute coronary syndromes
Hospitalization Recommended
Worsened congestion: Even without dyspnea Signs and symptoms of pulmonary or systemic congestion Even in the absence of weight gain Major electrolyte disturbance Associated comorbid conditions Pneumonia Pulmonary embolus Diabetic ketoacidosis Symptoms suggestive of transient ischemic accident or
stroke Repeated ICD firings Previously undiagnosed HF with signs and symptoms of systemic or pulmonary congestion
Hospitalization Should be Considered
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Improve symptoms, especially congestion and low-output symptoms
Optimize volume status
Identify etiology
Identify and address precipitating factors
Optimize chronic oral therapy
Minimize side effects
Identify patients who might benefit from revascularization
Identify patients who might benefit from device therapy
Identify risk of thromboembolism and need for anticoagulant therapy
Educate patients concerning medications and self management of HF
Consider and, where possible, initiate a disease management program
Treatment Goals
Patient 1: Volume overload (Backwards Failure)
Patient 2: Profound depression of cardiac output –hypoperfusion (Forwards Failure)
Patient 3: Signs and symptoms of both fluid overload and hypoperfusion (cardiogenic shock)
3 Clinical Presentations
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Determine
Volume Status
Perfusion Status
Role of / or presence of precipitating factors and/or comorbidities
Ejection fraction HFpEF
HFrEF
Evaluation Guides Treatment Decisions
Hypoperfusion vs. Volume Overload
Intravascular Volume Overload Elevated jugular
venous pressure
Hepatojugular reflex
Orthopnea
Dyspnea
Crackles
Weight gain
Peripheral edema
Hypoperfusion Narrow pulse pressure
Resting tachycardia
Cool Skin
Altered mentation
Decreased urine output
Increased BUN/Creatinine
Cheyne Stokes Respirations
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0
1
4
3
2
5
20 18 16 14 12 10 8 6 4 2 32 30 28 26 24 22 34 36
Preload: Pulmonary artery occlusive
pressure
Fo
rwa
rds
Flo
w:
CI,
Sk
in t
em
p (
wa
rm o
r c
old
)
Normal Hemodynamics (I) No pulmonary congestion:
• PAOP < 18; Dry lungs
No hypoperfusion:
• CI > 2.2; Warm skin
Backwards Failure (II) Pulmonary congestion
• PAOP > 18; Wet lungs
No hypoperfusion
• CI > 2.2; Warm skin
Forwards Failure (III) No pulmonary congestion
• PAOP < 18; Dry lungs
Hypoperfusion
• CI < 2.2; Cold skin
The Shock Box (IV) Pulmonary congestion
• PAOP > 18; Wet lungs
Hypoperfusion
• CI < 2.2; Cold skin
55
Hemodynamic and Clinical Subsets
2014
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Treatment for Acute Decompensated Heart Failure
Congestion with Adequate Perfusion
Subset II
Reduce Preload
Hypoperfusion with No Congestion
Subset III Increase contractility Assure adequate preload
Hypoperfusion with Congestion
Subset IV
Reduce Afterload
0
1
4
3
2
5
20 18 16 14 12 10 8 6 4 2 32 30 28 26 24 22 34 36
Preload
Forw
ard
s Fl
ow
: C
ard
iac
Ind
ex
Skin
te
mp
(w
arm
or
cold
)
Preload changes: move patient along the current curve
58
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0
1
4
3
2
5
20 18 16 14 12 10 8 6 4 2 32 30 28 26 24 22 34 36
Changing Contractility: moves patient to a higher curve
Preload
Fo
rward
s F
low
:
CI,
Sk
in t
em
p (
warm
or
cold
)
0
1
4
3
2
5
20 18 16 14 12 10 8 6 4 2 32 30 28 26 24 22 34 36
Changing Afterload:: moves patient up and to the left
(improves forwards flow and reduces preload)
Fo
rward
s F
low
:
CI,
Sk
in t
em
p (
warm
or
cold
)
Preload
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Acute Decompensated Heart Failure
Reduce Afterload Arterial vasodilators High dose Nitroglycerin Nitroprusside Neseritide
Intra aortic balloon pump
Increase Contractility Positive Inotropes
Dobutamine
Milronone
Dopamine
Reduce Preload Diuretics Venous Vasodilators Low dose NTG Neseritide
Ultrafiltration
Ultrafiltration
UNLOAD Trial Veno-venus ultrafiltration
(UF) vs standard IV diuretic therapy for hypervolemic HF
200 patients randomized UF with statistical
significance for: greater weight loss (48 hours), greater fluid loss (48 hours), less 90-day resource utilization for HF.
No statistically significant difference in dyspnea scores or creatinine levels (safety endpoint)
CARESS-HF Trial Treatment of ADHF,
worsening renal function, persistent congestion with stepped pharmacologic approach vs ultrafiltration
188 patients randomized
UF: inferior to pharmacologic therapy and associated with adverse events.
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Additional Care Issues
Routine use not recommended
When to consider: Refractory to initial therapy
Volume status and cardiac filling pressures are unclear
Pulmonary and systemic pressures unclear
Clinically significant hypotension (SBP < 80 mm Hg)
Worsening renal function
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Foley Catheter
Not recommended routinely in heart failure
If need to closely monitor hourly urine output
Possible outlet obstruction
High risk patients include those with BPH and or right sided volume overload
Dietary Sodium Restriction Water follows sodium
If hyponatremic Serum sodium < 130 mEq/L
2 liters per day
Serum Sodium < 125 mEq/L
Stricter fluid restriction may be considered
If persistent fluid overload Assure sodium restriction in conjunction with fluid
restriction
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Oxygen therapy is recommended if the patient exhibits hypoxemia
If not hypoxemic no need for oxygen therapy
Use of non-invasive positive pressure ventilation may be considered for severely dyspneic patients with clinical evidence of pulmonary edema.
Criteria for Discharge
Exacerbating factors addressed
Near optimal volume status achieved
Transition from intravenous to oral diuretic successfully completed
Patient and family education completed, including clear discharge instruction
LVEF documented
Smoking cessation counseling initiated
Near optimal pharmacologic therapy achieved, including ACE inhibitor and beta-blocker (for patients with reduced LVEF), or intolerance documented
Follow-up clinic visit scheduled, usually for 7 to 10 d
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Criteria for Discharge
Advanced HF Patient or recurrent admission Oral medication regimen stable for 24 h
No intravenous vasodilator or inotropic agent for 24 h
Ambulation before discharge to assess functional capacity after therapy
Plans for post discharge management (scale present in home, visiting nurse or telephone follow up generally no longer than 3 d after discharge)
Referral for disease management, if available
Advanced HF
Decision Making
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Severe symptoms of HF with dyspnea and/or fatigue at rest
or with minimal exertion (NYHA class IIIb or IV) on optimal medical therapy
Repeated episodes of fluid retention (pulmonary and/or systemic congestion, peripheral edema) and/or reduced cardiac output at rest (peripheral hypoperfusion) on optimal medical therapy
Objective evidence of severe cardiac dysfunction shown by at least 1 of the following on optimal medical therapy: LVEF <30% Mean PCWP >16 mmHg and/or RAP >12 mmHg by PA
catheterization High BNP or NT-proBNP plasma levels in the absence of
non-cardiac causes
Indicators for Advanced Heart Failure
Severe impairment of functional capacity while on optimal medical therapy shown by 1
of the following:
Inability to exercise
6-Minute walk distance < 300 m
Peak Vo2 <12 to 14 mL/kg/min
Repeated (≥2) hospitalizations or ED visits for HF in the past year or > 1 hospitalization for heart failure
Progressive deterioration in renal function
Progressive decline in serum sodium, usually to <133 mEq/L
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 <90 mm Hg
High diuretic requirements to maintain volume status (i.e. furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapy)
Frequent ICD shocks
Indicators for Advanced Heart Failure
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Heart Failure Survival Score All cause mortality
Seattle Heart Failure Model All cause mortality, urgent transplantation or LVAD implant
EVEREST Risk Model Combined endpoint of mortality or persistently poor quality of life
over the 6 months after discharge EFFECT 30-day and 1-year mortality
ADHERE In-hospital mortality
ESCAPE Discharge Score 6 month mortality
Prognostic Models
>2 Prompt Referral for Advanced Rx
Hospitalization for HF on oral HF therapy
Inability to take ACEI/ARB/BB
BUN> 45, Creat>2.5, CrCl< 45 cc/min
BNP >4 x’s upper limit of normal
Na+ < 136
Malnutrition/Cachexia
VO2 <55% predicted
LVEDD >7.0 cm
Risk Factors for Mortality > 2 Referral for Advanced Treatment
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Palliative Care versus Hospice
When should they be involved
Making an assessment
Having the discussion
End of Life Decision Making
Establishing trust
Identifying patient values, preferences, and goals for care early in the course of treatment
Using the framework “Ask-Tell-Ask” to determine both what patients know and what they want to know
Understanding the reasons why there are conflicts regarding decisions of care
Using numeric data in a clear and understandable way as a decision aid
Respecting that patient’s may change their goals as the disease progresses
Components of effective shared decision making include:
Allen, 2012.
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Bridge to transplant (BBT) for those who are
transplant eligible
Destination therapy (DT) for those who are not transplant eligible.
Bridge to Decision (BTD)
Careful consideration for all therapies Some patients may be too ill with multisystem issues
to benefit from MCS
Some decisions are best made in the hands of the most experienced centers
Absolute and Relative Contraindications for Durable MCS
Absolute Contraindications
Relative Contraindications
· Irreversible hepatic disease
· Irreversible renal disease · Irreversible neurological
disease · Major coagulopathy · Right sided heart failure
(unless candidate for biventricular support)
· Medical non-adherence · Severe psychosocial
limitations
· * Hypertrophic, infiltrative, or restrictive cardiomyopathy
· Uncorrectable moderate or greater aortic insufficiency
· Age _80 y(for destination therapy) · Obesity or malnutrition · MS disease that impairs rehabilitation · Active systemic infection · Prolonged intubation · Untreated malignancy · Severe PVD · Active substance abuse · Impaired cognitive function · Unmanaged psychiatric disorder · Lack of social support
Source: Peura et al., 2012; Slaughter et al., 2010. * May be a relative contraindication
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Temporary Assist Devices in Acute Shock / Bridge to Decision or
Recovery
IABP
ECMO
Percutaneously implanted MCS
Impella
Tandem Heart
Surgically implanted extracorporeal MCS
CentriMag
Thoratec pVAD II
Abiomed BVS 5000
Abiomed AB 5000
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Cardiac arrest with ongoing CPR
Cardiogenic shock, IABP-dependent on inotropes and vasopressors
Intra-operative failure to wean from cardiopulmonary bypass
Bridge to a decision: indeterminate neurologic status or other significant co-morbidity (i.e., possible incurable malignancy) with critical clinical deterioration
Who Gets a Device Acutely
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Long Term Therapy
Bridge to Transplant
Extracorporeal MCS Thoratec pVAD II
Implantable MCS Heart Mate II
HeartWare HVAD
Total Artificial Heart CardioWest
Abiomed: Abiocor II
Destination Therapy
Heart Mate II
HeartWare HVAD
Investigational Devices
Heart Mate II
2014 86
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HeartWare HVAD
2014 87
EDUCATION
EDUCATION
EDUCATION
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I sure hope my wife is
getting this?
Are we going to be able to afford these
medications?
BLAH, BLAH, BLAH, BLAH!
ANY QUESTIONS? No, I think
we’ve got it.
Discharge Focus 1. Diet and Nutrition
2. Discharge Medications
3. Activity Level
4. Follow up appointments
5. Daily Weight
6. Response to symptoms
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ACC / AHA Guidelines
“the addition of a 1-hour, nurse educator– delivered teaching session
at the time of hospital discharge using standardized instructions
resulted in improved clinical outcomes, increased self-care
measure adherence, and reduced cost of care”
Education and Counseling • Individualized education and counseling to focus on self care
• Should be delivered by providers using a team approach in which nurses with expertise in HF management provide the majority of education and counseling (HFSA 2010).
• Patients’ literacy, cognitive status, psychological state, culture, and access to social and financial resources should be taken into account for optimal education and counseling.
• Treat depression and anxiety to improve education comprehension
• Repeat, repeat, repeat
• Use “teach back” method
• Hospital education should be limited to “essential” education
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Who should be involved?
93
Identify primary care giver / support person
and include in ALL education.
The Best Treatment Patient Education & Self-Care Maintenance and Self-Care Management
• Self-care maintenance following the rules and instructions related to the
disease process
• Self-care management decision-making process and critical thinking to make
decisions in response to changes in the client’s current health status
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Self-Care Behaviors
Rationale for self-care behaviors: smoking cessation; daily weight monitoring; avoidance of heavy alcohol intake; avoidance of nonsteroidal antiinflammatory drugs and other over-the-counter herbal therapies and drugs, especially decongestants and sodium-based antacids
Monitoring for changes in HF signs and symptoms; what to do if symptoms worsen (first person to call for all issues or when to call which member on the team)
Rationale for activity and exercise; easy warm up/cool down exercises; getting started; when to stop or slow down
95
Barriers to Self-Care Management
96
Lack of knowledge
Literacy
Multiple medications
Fear of medication side effects
Living alone (lack of social support)
Memory problems
Higher acuity
Multiple needs
Co-morbidities
Shorter LOS
Noncompliance
Transportation issues
Financial concerns
Depression / anxiety
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Education Content
The Big Picture
What HF is, its causes and symptoms, timeline (chronic), consequences (poor prognosis; premature death; greater risk for hospitalization) and measures to control it (self-care actions and monitoring)
Why drugs are used in HF; how they improve survival or reduce symptoms; common side effects and what to do when they occur; how to take medications for greatest effectiveness
98
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Medications
Don’t wait until discharge!
Include the person who will assist with medication What is the plan for filling prescriptions? What is the system for medication administration
used at home?
Need to know trade/generic names Issue of medication reconciliation Use of instruction sheets versus labeled pill bottles
Don’t use term “meds as at home”
99
Medications Alternatives for routine schedule Diuretics after errands Flexible diuretic dosing ACE inhibitor at night
Discussion regarding medications to avoid
Non-steroidals
Adherence history Financial concerns Need to understand the progress made with HF management Need to understand the importance of not running out of their medication Regular follow-up with provider to monitor labs, etc.
100
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Fluid Volume Status
Causes of intravascular volume overload; can occur silently (without symptoms)
Role of excess sodium in fluid retention
How diuretics work
Rationale for BID dosing if CKD
Role of additional thiazide diuretic
Need to know when NOT to take diuretics 101
Daily Weights
• Use same scale, same amount of clothing
• Empty bladder and before breakfast
• Record on calendar
• Report 2 pounds in one day or 3 to 4 pounds in a week
• Many patients don’t call because they feel “OK
• Barriers due to confusing fluid gain from fat gain
• Telephone based weight recordings or device data
• Do you weight all patients with heart failure daily while hospitalized even when admitted for non cardiac reasons?
• Special considerations with ECF
102
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Response to Symptoms
Focus on changes! Is there a change in their activity tolerance?
Impact on their ADL’s?
Pants are becoming tight?
Unable to sleep lying flat?
103
Diet and Nutrition
Moderate sodium restriction Exact amount is not known
2 to 3 gram reasonable?
Most have moderate restriction when attempting to diurese
May liberalize when nutrition or orthostatic hypotension is a concern
Nutritional support for cardiac cachexia Caloric supplementation
Limit alcohol
104
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Low Sodium Tips
“Low” sodium considered to be <4 grams / day
2-3 grams / day recommended for patient with clinical syndrome of heart failure < 2 grams with moderate to severe heart failure
Discuss how sodium impacts fluid retention
Salt = sodium
Focus on what they can eat
High sodium foods Approximately 70% of sodium
intake comes from processed and pre-packaged foods.
Some never or hardly every foods
105
Low Sodium Tips
Dining at restaurants or in another person’s home
Reading labels
Salt used in cooking
Sodium alternatives
Be realistic – there must be joy in life
AHA: Eat Less Salt resource book
Teach people how to do rather than tell them what to do!! 106
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Fluid Limitation
In the outpatient fluid restrictions reserved for patients with advanced heart failure refractory to high dose oral diuretics
Indicated in the hospital setting in the presence of severe hyponatremia Sodium level < 130 mEq/L
Explain the thirst mechanism
107
Activity
Screen for depression
Evaluate anxiety levels
Exercise training should be considered for all stable outpatients with chronic HF who are able to participate in protocols needed to produce physical conditioning. Get them in Cardiac Rehab if possible
30 minutes moderate activity / exercise 5 days per week
Work if able 108
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Follow Up
• Contact within 48-72 hours
• Appointment within on week from discharge
• Will need to have actual date, time and location included in discharge instructions
• Allows for up titration of medications
• Continues evaluation for progression of disease Need for ICD
Need for CRT
109
IS THERE ONE CORRECT ANSWER?
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Nearly 2 million Medicare patients readmitted
within 30 day of discharge
Cost of those readmissions = $17.5 BILLION
National average for readmission 19%
Readmissions a symptom of an overly expensive and uncoordinated healthcare system Limited connection from inpatient to outpatient
HF readmissions rate 20-25% at 30 days > 50% at 6 months
35% of 30 day readmissions due to HF
Readmission Data
Readmissions are prevalent and costly Adverse events associated with hospital discharge are common And about ¼ of them are readmissions
Patients are not taking ideal medication regimens No f/u on meds, tests and workups is common Real room for improving hospital-receiver communication But value of PCP f/u unclear – probably varies Might not be as powerful as hospitalist f/u
Creating the perfect in-house discharge process probably won’t make enough difference
SES is probably related to readmission risk But the CMS measures do not adjust for it
Ideal risk identification strategies are unavailable.. Clinicians often have a different perspective on what led to the readmission
than patients do
What We Know
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Multidimensional Nursing Roles
Coordinate care with interdisciplinary team members who can target coexisting medical, social, and financial issues
Facilitate behavioral strategies that ease patient and caregiver burdens related to adherence to the treatment plan
Educate on advance directive planning and community services that meet learning needs
Promote continuity of care between home, HF clinic, or palliative care services Foster collaborative relationships Coach collaborators to use evidence-based therapies Ensure open communication Position patients and caregivers to proactively assess and manage signs and symptoms of
worsening condition
Assess goal progression Recognize and target unresolved HF issues
113
Systematic review 47 trails
At 30 days a high intensity home-visiting program reduced all cause readmissions
At 3-6 months home-visiting programs and multidisciplinary heart failure clinic (MDS-HF) interventions reduced all cause readmissions
Structured telephone support (STS) reduced HF specific readmissions but not all cause readmissions
Mortality benefit with MDS-HF clinic, Home-visiting programs, and STS
Based on current evidence, telemonitoring interventions and primarily educational interventions are not efficacious for reducing readmissions or mortality
Transitional Care Interventions Feltner, C., Jones, C. D., Cené, C. W., Zheng, Z. J., Middleton, J. C., & Jonas, D. E. (2014). Transitional Care Interventions to Prevent Readmissions for Persons With Heart Failure. Ann Intern Med, 160, 774-784.
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Final Thought They may forget your
name, but they will never
forget how you made
them feel.
-Maya Angelou
116
BE THE BEST THAT YOU CAN BE
EVERY DAY. YOUR PATIENTS ARE
COUNTING ON IT!