HEART FAILURE:
Putting It All Together
South Carolina Association Clinical Documentation Specialists
Spring Meeting
March 23, 2012
Joan M. Lacey, ACNP, ANP, AACC
Carolina Cardiology
Greenville, SC
Heart failure is a common clinical
syndrome resulting from any
structural or functional cardiac
disorder that impairs the ventricles
ability to fill and eject blood and the
bodies neurohormonal adaptation to
this process
What Exactly is Heart
Failure?
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A syndrome with many causes and manifestations!
Pump failure and altered hemodynamics
Altered cell biochemistry (Ca++ cycling)
A Perfusion disorder: revascularization and mechanical
assistance
A rhythm disorder
An endocrinopathy, neuropathy, and vasoregulatory
dysfunction
Abnormal proliferative signaling and gene expression
Irreversible premature cell death
Less than 50% 5-year survival in symptomatic HF cannot
be excluded from the definition of HF
Cardiomyopathy
“HEART MUSCLE DISEASE”
EF <40-45%
Primary-in the heart
Genetic/mixed/acquired
Secondary-occurs from other organ
dysfunction
Prevalence of Congestive Heart
Failure
An estimated 5.8 million Americans
have congestive heart failure (CHF).
(Source: excerpt from NHLBI,
Congestive Heart Failure Data Fact
Sheet: NHLBI)
Survival at 5 yrs. 50%
Mortality
Estimates of mortality rate per year for
patient subgroups
Class II = 5-15%
Class III = 20-50%
Class IV = 30-70%
http://www.heartfailure.org/eng_site/faq.asp
#longlife
Hospitalizations and Mortality
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Number one reason for admission
High readmission rate
 27% within one month
 50% within six months
 17% two or more admissions
1 in 5 people die within one year of diagnosis
 Systolic dysfunction: poorer prognosis
 50% die within five years (median survival)
Over 1 million hospitalizations per year
 Leading cause of Medicare admissions
Heart Failure: The Epidemic
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Prevalence
 5.8 million (US)
 25 million (worldwide)
Incidence 670,000/ year.
ETIOLOGY
CAD 65%
IDIOPATHIC DILATED 50%
TOXIN-INDUCED ALCOHOL,COCAINE,CHEMOTHERAPUTIC
DRUGS,RADIATION
INFECTIOUS /INFLAMMATORY COXSACKIE B, LYME DISEASE,
HIV,HCV,CHAES,LUPUS,RA,GIANT CELL MYOCARDITIS,
INFLUENZA,MYCOPLASMA PNA
FAMILIAL DILATED CARDIOMYOPATHY 20-30% OF “IDIOPATHIC
“DCM, ARVD,MUSCULAR DYSTROPHIES,HYPERTROPHIC CM,
HEREDITARY HEMOCHROMATOSIS
ETIOLOGY
PERIPARTUM: IN THE LAST MONTH OR FIRST 5 MONTHS
POSTPARTUM ( IMMUNE VS. OCCULT LV DYSFUNCTION)
STRESS-INDUCED: “TAKO-TSUBO”
ENDOCRINE/NUTRITIONAL:DM,OBESITY,THYROID,ACROMEG
ALY AND GH DEFICIENCY,PHEO
IRON OVERLOAD: HEREDITARY HEMOCHROMATOSIS
TACHYCARDIA INDUCED HYPERTENSIVE
INFILTRATIVE: (RESTRICTIVE) AMYLOID,SARCOID
New York Heart Association (NYHA) Class
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, or dyspnea (shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest, but ordinary physical
activity results in fatigue, palpitation, or dyspnea.
Class III (Moderate)
Marked limitation of physical activity. Comfortable at rest, but less than ordinary
activity causes fatigue, palpitation, or dyspnea.
Class IV (Severe)
Unable to carry out any physical activity without discomfort. Symptoms of cardiac
insufficiency at rest. If any physical activity is undertaken, discomfort is
increased.
Types of Heart Failure
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Acute
Chronic
Systolic
Diastolic
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Mixed
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TYPES OF HEART FAILURE
FUNCTION
Systolic: Decreased EF:
½ the cases HF
*Mild 45-50%
*Moderate 35-40%
*Severe <35%
Diastolic: HFnEF
(heart failure normal EF)
½ the cases HF
DIASTOLIC
Older, female, HTN, less CAD
LVEDP >16, EF > 50%
Echo
Impaired relaxation=grade 1
Pseudo normalization=grade 2
Reversible Restrictive=grade 3
Irreversible Restrictive=grade 4
Types
Location
Left side: ischemic/valvular
Right side: CorPulmonale, usually caused
by LHF as pressure backs up into lungs.
PHTN/PEs/chronic lung disease
History
CAD/angina
HTN
OSA/OHV
Alcohol/drugs/chemo
Viral illness
Trips
Pregnancy problems
Goals of Treatment
1) Prevent functional decline
2) Prevent complications
3) Prevent hospitalizations
4) Prevent progression of HF
Medications
*BB-selective/nonselective 35-65%RRR
*ACE 20% mortality reduction/ARB
*Diuretic-thiazide/loop/aqua
*Nitrates /AA Hydralazine+ Nitrates
*Morphine/anxiolytic
*Digoxin-0.5-0.8 ng/mL in low EF
*Aldosterone inhibitors (class II/III)
*CCB avoid non-dihydropyridines/CS
Labs
CBC/BMP/Na/LFT
BNP good neg. predictive value
Albumin/Pre-Albumin
Renal failure may be reason for or cause by HF
Survival over time in patients with severe chronic heart failure
(HF) and a left ventricular ejection fraction less than 30 percent
who, at study entry, had either a normal plasma sodium
concentration (greater than 137 meq/L, solid line) or hyponatremia
(plasma sodium less than or equal to 137 meq/L, dashed line).
Survival was significantly reduced in the patients with
hyponatremia. The survival rate was very low (approximately 15
percent at 12 months) in those with a baseline plasma sodium
concentration less than or equal to 130 meq/L.
Data from: Lee, WH, Packer, M, Circulation 1986; 73:257.
Tests
Echo- poor quality, thin/obese
EKG
Stress test-function, new HF
Coronary angiography
MRI-CAD,MI,HCM,ARVC,Amyloid
CT
SPECT (single photon emission computed
tomography)
IMAGING IN HF
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Echocardiography
Nuclear cardiology
Cardiac CT and Cardiac MRI
 Very high resolution
 Very good tissue characterization
 Very good quantitative analysis
 Viability assessment
 Functional assessment, including
valve function
Cardiac MRI
Benefits
*High quality measurement of LV volume.
*Comprehensive evaluation of virtually every aspect of
cardiac anatomy and function.
*Viability
Disadvantage
ICD/PPM-relative contraindication
Claustrophobia
Motion
HR <60
Society for Cardiac Magnetic Resonance
http://www.scmr.org/
Exercise and
Functional Capacity in
Heart Failure
HF-ACTION trial
HF-ACTION Primary Hypothesis
Patients with LV systolic dysfunction and NYHA class II-IV
symptoms who undergo exercise training in addition to
usual care will have a 20% lower rate of all-cause death or
hospitalization(primary endpoint) over two years than
patients who receive usual care alone
Whellan DJ, O’Commor CM, LeeKL et al. Am Heart J 2007;
153:201-2-11
Percent of Patients with Clinical
Improvement
Exercise training
Usual care
3M
54%
28%
12M
53%
33%
Conclusion HF-ACTION
Based on the main analysis adjusted for HF etiology,
exercise training produced a modest, non-significant
decrease in the primary endpoint (all-cause mortality or allcause hospitalization) and key secondary clinical endpoints.
In protocol-specified analyses adjusted for prognostic
factors, the treatment effect was statistically
significant for the primary endpoint and for the secondary
endpoint of CV mortality or HF hospitalization.
Peak VO2
Most objective assessment of functional
capacity in HF pt.
Only of value in pt. whose exercise
capacity is limited by HF.
Influenced by age, gender, BMI.
The percent predicted value may be a
more reliable indicator of prognosis.
VO2 max has been defined as:
"the highest rate of oxygen
consumption attainable during
maximal or exhaustive exercise"
Cumulative survival in patients with heart failure according to
maximal oxygen consumption (VO2) in mL/kg per min.
Survival is markedly reduced in patients with a peak VO2
below 10 mL/kg per min.
Data from: Mancini, DM, Eisen, H, Kussmaul, W, et al,
Circulation 1991; 83:778.
Six-min. walk test
correlates with VO2 max.
Measures the distance ambulated on a level hallway
surface during six minutes. In a retrospective analysis of
440 patients from a randomized controlled trial with NYHA
class III-IV HF baseline distance significantly predicted
mortality and hospitalization; for each 100 m (328 ft)
increase in distance walked. Similarly, in a series of 476
patients form a single referral center, the distance walked
at baseline was an independent predictor of two-year
survival.
See 2002 Thoracic Society statement.
Hemofilteration
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UNLOAD (UltrafiltratioN versus IV Diuretics for Patients Hospitalized
for Acute Decompensated Congestive Heart Failure; J Am Coll Cardiol,
2007; 49:675)
200 patients, 28 medical sites, randomization to UF or diuretics
At 48 hours into treatment, the UF group:
 38 percent greater weight loss
 28 percent greater net fluid loss
At 90 days following hospital discharge, the UF group:
 43 percent reduction in rehospitalizations for HF
 52 percent reduction in ED or clinic visits
 63 percent total reduction in days rehospitalized
The benefits seen in all subgroups analyzed
Today's Devices
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Impella
 GHS – first to use in SC
 2.5 or 5.0L/min
 Directly unload the left
ventricle in the heart
 Reduce myocardial workload
and oxygen consumption
 Increase cardiac output and
coronary and end-organ
perfusion
ICD Indications
EF<35%
 Nonischemic vs. Ischemic
 Asymptomatic NSVT
 SCA,VF or unstable VT
 NYHA class I-III
 Optimum OPT
BiV-ICD Indications
*EF < 35%
*NYHA Class I ischemic or
*NYHA Class II ischemic or
nonischemic HF
*Stable OPT
*LBBB/QRS > 120ms
Indications for Transplant
*Refractory cardiogenic shock
*Dependence on inotropes
*Peak VO2 <10ml/kg/min
*Severe ischemia and poor function
not amendable to CABG/PCI
*Recurrent symptomatic vent. *Arrhythmias
refractory to Rx.
Jarvik
HeartMate
HeartWare international
HVAD pump
Today’s surgical
options
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Revascularization
RF Ablation for
Arrhythmia
Aneurysm Resection
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Dor
Batista
VAD
Valve surgery
Transplant
Cor Pulmonale
What the heck is this
COR=CORONARY
PULMONALE=PULMONARY
Right ventricular hypertrophy and
or dilatation from pulmonary
hypertension which results from any
disease of the lung parenchyma,
thorax or pulmonary vasculature
unrelated to the left side of the
heart.
RIGHT VENTRICLE SIZE: RVEDD/RVESD
(RV end diastolic/systolic diameter)
Normal: 0.9-2.0cm;1.5-2-2cm
RIGHT ATRIAL SIZE:
Normal: 2.8-4.0cm
RV HYPERTROPHY
RV FAILURE = LATE COR PULMONALE
PREDISPOSING FACTORS
COPD-80%
CHRONIC BRONCHITIS/BRONCHIECTASIS
OSA
CHRONIC PE/ACUTE PE
CYSTIC FIBROSIS
DIFFUSE INTERSTITIAL LUNG DISEASE
PNEUMONITIS
PRIMARY PHTN
MARKED OBESITY
ALTITUDE SICKNESS
ANY THING THAT CAUSES PHTN
SYMPTOMS
CHEST DISCOMFORT/ANGINA
EXERCISE INTOL./FATIGUE
DOE
EDEMA
ASCITES
WHEEZE/COUGH
SYNCOPE
SOMNOULENCE
TREATMENT
TREAT UNDERLYING CAUSE OF THE PULMONARY
HYPERTENSION
GOAL TO DECREASE PULMONARY VASCULAR RESISTANCE
OXYGEN IMPROVES SURVIVAL OF HYPOXIC PATIENTS WITH
COPD
CAREFUL DIURETICS COULD DROP CARDIAC OUTPUT
(WATCH BUN/CR)
EXAM-RIGHT HEART/
PERIPHERAL
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SPLIT S2
TR SYSTOLIC MURMER
JVD
HEPATOMEGALY/HJR
PERISTERNAL HEAVE AT 2ND LICS
PERIPHERAL EDEMA
TESTS:
CXR: TEAR DROP HEART/PULM ART. ENLARGED
ECHO
PFT/VQ
RHCATH
BNP
CT
EKG: RAD/RVH/RAH- “P” PULMONALE II,III,AVF,V1-V2
S1,Q3,T3,TALL R IN V1-V2, PROMINENT S IN V5-V6
INVERTED TWAVES AND ST DEPRESSION IN
V1-3=RVSTRAIN
Cardiomyopathy
Disease of the heart muscle
best suited to refer to genetic
diseases.
*HCM
*DCM
*Restrictive CM
*Arrhythmogenic RV Cardiomyopathy
*Left vent non compaction
*Unclassified
Critical thinking is the intellectually
disciplined process of actively and skillfully
conceptualizing, applying, analyzing,
synthesizing, and/or evaluating information
gathered from, or generated by,
observation, experience, reflection,
reasoning, or communication, as a guide to
belief and action.
http://www.criticalthinking.org/aboutCT/define_critical_thinking.cfm
Exam- Objective
JVD/HJR
Edema-pulm/crackles/peripheral/scrotal
Ascites, effusions
Gallop S3, S4
Murmur (http://www.blaufuss.org)
Arrhythmias
Displaced apical pulse
Diaphoresis
Pulse press <25mmHG
Pulses Alternans
Peripheral constriction
Inc. sympathetic tone, tachy
Daily thoughts at
Bedside
Perform routinely!!
Medication-right the first time
Read progress notes
Telemetry
V-scan (visual)
Exam-objective/subjective
I &O/Wt.
Lifestyle/eating/activity/family
Heart Sounds
S1-TV/MV closed=TV/MV regurg.----PV/AV
stenosis
S2-PV/AV closed=PV/AV regurg.----TV/MV stenosis
A stenosed valve is open and a regurgitant valve is
closed
Exam-Subjective
Dyspnea/SOB/DOE
PND/Orthopnea
Fatigue/exercise intolerance
Weight/abdominal girth