September 29,2010
Karen Harkness RN CCNC PhD
Definition
 Not a clinical diagnosis
 Heart failure is a complex syndrome in which
abnormal heart function results in, or increases
the subsequent risk of, clinical symptoms and
signs of low cardiac output and/or pulmonary or
systemic congestion. (CCC guidelines, 2006)
Epidemiology
Incidence: 10-23% Age > 80 years
Ontario: 9943 patients hospitalized between 1999-2001 ( F/up 6 yrs)
Mean age: 76 years (SD 11.5) (60% >75 yrs of age)
Female: 50%
1 yr mortality: 33%
5 yrs mortality: 69%
Median survival: 2.4 yrs
Age 70-75 male: median life expectancy 3.5 yrs. ( US population 12 yrs)
Age 70-75 female: median life expectancy 2.9 yrs (US population 14.6 yrs)
Most common diagnosis for patients admitted to hospital (Age >65 yrs)
Most of the costs due to hospitalization
Ko et al., Am Heart J 2008
Pathophysiology of HF
Cardioregulatory centres
Sympathetic nervous system
Baroreceptors
AVP
Aldosterone
Peripheral
Vasconstriction
Angiotensin II
release
Renal SNS
activation
Salt and water retention
Heart Failure- Terminology
LV Ejection Fraction (< 35%, <40%)
• Heart failure with reduced ejection fraction
• Systolic dysfunction
Normal LV Ejection Fraction (> 40%)
• Heart failure with preserved ejection fraction (HF/PEP)
• Diastolic Dysfunction
Heart Failure- Terminology
Stages
A- No cardiac structural abnormalities, presence of risk
factors (Hypertension, diabetes, obesity, smoking,
CAD, excessive ETOH intake)
B- No symptoms, cardiac structural changes
C- Symptoms, structural changes
D- Refractory symptoms, despite optimal management
…… more terminology
New York Heart Association Classification
I- No symptoms
II- Symptoms with moderate activity
III- Symptoms with regular activity
IV- Symptoms at rest
Terminology… last slide……
Grade LV Systolic Dysfunction
Grade I- Ejection Fraction >50%
Grade II- Ejection Fraction 35-50%
Grade III- Ejection Fraction 20-34%
Grade IV- Ejection Fraction <20%
Predictors of Heart Failure
LVEF ≤ 25%
LVEF ≥ 55%
68 yrs
74 yrs
Women*
34%
69%
Diabetes
39%
44%
Hypertension*
63%
80%
Atrial fibrillation*
28%
32%
Chronic Renal Impairment
27%
31%
Age
Based on ADHERE registry
* Based on Framingham Criteria
Coronary Artery Disease – most common reason for HF
Aging and Heart Failure
Cardiovascular Changes
Ability to respond to stress - physiological- exercise or
pathological -hypertension, ischemia
1.
responsiveness to Beta stimulation
2.
vascular stiffness (isolated systolic hypertension)
3.
Heart muscle stiffer- impaired relaxation – major filling occurs
in late diastole (atrial kick really important for CO)
4. Altered myocardial energy metabolism in mitochondria
Aging and Heart Failure
Other system changes
Kidneys GFR (8 cc/min/ decade)
 Capacity to respond to intravascular volume changes
- More likely to get electrolyte imbalances with diuretics
- Less responsive to diuretics
Lungs
- Respiratory reserve (increased sense of SOB secondary to CO)
- V/Q mismatch
- Sleep disordered breathing
Nervous System
- Impaired thirst mechanisms (watch get ‘too dry’)
- Impaired auto regulation (cerebral changes)
- Impaired reflex responses (orthostatic hypotension)
Common Clinical Presentations
of Heart Failure
 Dyspnea
 Orthopnea
 PND
 Fatigue
 Abdominal distension
 Cough
 Edema
 Weight gain
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Uncommon Clinical Presentations
of Heart Failure
 Cognitive impairment*
 Delirium*
 Nausea*
 Abdominal discomfort
 Nocturia
 Oliguria
 Anorexia
 Cyanosis
* May be more common
presentation in elderly patients.
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Physical exam
 JVP elevated
 Enlarged apical impulse
 S3
 Murmur of mitral
regurgitation
 Peripheral edema
 Other:
 HJR
 Ascites
Diagnosis of Heart Failure
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Management of ADHF
AHF diagnosed, treatment based on symptoms and signs
Volume overload
Mild overload
Volume overload + low cardiac output
Mod. –severe
overload
Mild- Mod
low output
• Inadequate response
to IV diuretics
• Increase oxygen req
• CPAP and BIPAP req
•fatigue
IV diuretics
IV lasix bolus
IV diuretics
+ IV vasodilators
• Cr < 200 umol/L
40 mg
•Cr > 200 umol/L
80 mg
• consider lasix
infusion
•Add IV nitrates
Very low output
• consider PA line
•Add vasodilator
after BP stabilized
SBP > 90 mmHg
SBP < 90 mmHg
• Milrinone
•Dobutamine
•Dobutamine
•Vasopressors
Howlett Can J Cardiology, July 2008
Lab Tests- Decompensation
 Electrolytes, Urea, Creatinine

Creatinine can be elevated due to AHF (improves with Rx)

Decreased renal perfusion, renal venous congestion

Hyponatremia - dilutional from increased ADH

Potassium
 CBC- Anemia, WBC
 Liver Function

Hepatic congestion: increased bilirubin, ALP, INR
 Other : TSH, Glucose
 BNP
Brain Naturetic Peptide (BNP)
• Hormone synthesized in the heart- response to wall distension
• Oppose vasoconstriction, sodium retention and anti-diuretic effects of RAAS
•“Natural” vasodilator and diuretic
BNP and NT-pro BNP
BNP < 100pg/ml
NT-proBNP < 400 pg/ml
HF unlikely
BNP 100-400 pg/ml
NT-proBNP 400-2000 pg/ml
HF uncertain
Need echo evaluation
BNP > 400pg/ml
NT-proBNP > 2000 pg/ml
High HF probability
Other causes of BNP- Acute PE, Pulmonary hypertension, Anemia, Cor pulmonale, Renal
insufficiency, Septic Shock, Hyperthyroidism
Palazzuoli et al., Intern Emerg Med Sept 2010
Why Decompensation?
Cardiac in Origin
 Atrial fibrillation or flutter (new, uncontrolled)
 Sinus Tachycardia
 Ischemia/infarction (HF usually stubborn and/or acute onset)
 Hypertension
 Suboptimal pharmacological regimen for HF
Non-cardiac
 Infections (urinary, resipratory)
 Anemia/ Blood loss
 Medication interaction (pharmacological, non-pharmacological)
Behavioral
 Medication non-compliance (unintentional ?)
 Excessive salt or fluid intake (unintentional ?)
Goals of Therapy
1.
Relieve symptoms / congestion (find and address
‘trigger’)
2.
Stabilize condition and lower risk for (re)
hospitalization
1.
Initiate treatments that will slow disease
progression and improve long-term survival
2.
Limit significant adverse effects (arrhythmia, renal
failure, over-diuresis )
Management HF with
Preserved LV Systolic Function
 Control blood pressure
 Control heart rate
 Diuresis if congestion
 Revascularize if reversible ischemia
Management of HF (EF<40%)
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Pharmacological management
NYHA I
ACE (Ramipril, Enalapril),
Betablocker (Bisoprolol, Carvedilol)
ARB (ACE intolerant. Candesartan)
NYHA II Diuretics
(furosemide)
ARB (hypertension)
NYHA III Spirolonlactone (right sided HF)
DIGOXIN (atrial fib, K+ too high for other choices)
Nitrates (orthopnea, CAD)
NYHA IV Combination of diuretics (metolazone, Hcthz)
IV diuretics
Clinical tips
ACE inhibitor e.g. Ramipril
 Start low 1.25 mg daily
 Try BID dosing if concerned of low bp
ARB- Candesartan
 Start low ( 4 mg daily)
Beta Blockers
 Coreg- renal excreted, more effect on bp than other BB
Lowest dose 3.125 mg BID
 Bisoprolol- daily, start 2.5 mg OD (1.25 mg really tiny),
Beta 1 selective
Clinical tips
Lasix
 Try alternate days if a nuisance to patient
 If BID, second dose before 4 pm
 If IV, try infusion if concerned about low bp or not
responding to bolus dosing
Bumetanide
 Better GI absorption in gut edema
 1 mg = 40 mg lasix
Metolazone
 Be very careful with over diuresis
 Tiny dose- 1.25 mg OD prn
 Maintenance- 1-2 times a week vs. daily
Clinical tips
Aldactone
 Tiny dose– 12.5 mg alternate days
 Do not add if already taking ACE and ARB
 Helpful with right sided HF
 Breast tenderness in men, especially if taking Digoxin
Eplerenone
 Like aldactone, haven’t tried yet (no breast tenderness)
Nitrates
 Apply when they are most symptomatic with SOB
Digoxin- keep level 0.5-1.0
 Start tiny – 0.625 mg OD to alternate days
Clinical tips
Hydralazine and nitrates
 Start low ( Hydralazine 5 mg q 8h)
( Isordil 10 mg q8h)
Calcium Channel Blockers
 Avoid Diltiazem unless you know normal LV systolic
function
 Prefer Amlodipine for ongoing hypertension