Congestive Heart Failure

1
Congestive Heart Failure

• Jonathan Howlett MD FRCPC FACC
• Director, QE II Heart Function Clinic
• Division of Cardiology
• Department of Medicine

2
Background
Chronic Heart Failure

• Affects gt 1 of Canadian population
• Responsible for 9 of all deaths
• Most common cause of hospitalization in patients
  gt 65 year of age
• Incidence increasing 4 annually
• National treatment guidelines exist
• Proven treatments remain underutilized

3
A Typical CHF Patient

• What to expect 1 year from now
• 10- 20 mortality rate( 50 sudden)
• 25- 40 total hospitalization rate (80 CHS)
• 11 days average LOS/CHF admission
• Progression 0.5- 1.0 NYHA FC level
• This is not good enough

4
The Care Gap

• Difference in Optimal Care for a Population and
  the Actual Care They Receive

Two Kinds of Gaps Content Process
5
History

• Mr. B., 63 year old male
• admitted with shortness of breath, orthopnea and
  PND to local hospital
• history of coronary bypass surgery in 1998
• preoperatively, his ejection fraction was 36

6
History (contd)

• approximately 6 months ago, patient began to
  develop fatigue and shortness of breath on
  exertion
• deteriorated during past month
• over the last 5 or 6 days, had to sleep in his
  lazy boy recliner

7
History (contd)

• no history of chest discomfort, stroke,
  palpitations or syncope
• cardiac risk factors included hypertension
• positive family history of cardiac disease

8
Examination

• blood pressure 150/90
• heart rate 92 and regular
• pulse volume normal
• mild diaphoresis
• mildly distressed

9
Examination (contd)

• soft systolic ejection murmur heard at left
  sternal border which did not radiate well
• liver was not pusatile, but was tender
• 2 peripheral edema was present

10
Examination (contd)

• pulmonary crackles halfway bilaterally
• JVP elevated at 8 cm ASA
• precordial examination revealed a displaced apex
• cardiac auscultation revealed a soft S1, single
  S-2 and S-4

11
Supplied Data (contd)

• Chest X Ray
• vascular redistribtuion with bilateral pleural
  effusions
• perihilar congestion
• blood work showed a serum sodium of 134 mml/L
• creatinine of 156 mml/L
• blood sugar 5.9
• O2 saturation 89, RA

12
Neurohormonal Activation Contributes to the
Progression of CHF

• Myocardial Disease

LV Dysfunction
Impedance
LV RemodelingVascular Remodeling
Vasoconstriction
Neurohormonal Activation
Renal Blood Flow
Preload
Na Retention
13
Clinically Useful Classifications for the
Symptoms of Heart Failure

• New York Heart Association Class (NYHA)
• Class I - No symptoms with ordinary physical
  activity
• Class II - Slight limitation of physical
  activity. Comfortable at rest,but ordinary
  physical activity results in fatigue,
  palpitation, dyspnea, or anginal pain
• Class III - Marked limitation of physical
  activity. Comfortable at rest, but less than
  ordinary physical activity results in fatigue,
  palpitation, dyspnea, or anginal pain
• Class IV - Unable to carry out any physical
  activity without discomfort. Symptoms of
  cardiac insufficiency may be present even at
  rest.

14
Heart Failure Disease Management
Control Volume Slow Disease Progression

Diuretic
RAAS Inhibition
Beta-Blockade
Treat residual symptoms
DIGOXIN
SPIRONOLACTONE
Am J Cardiol 199983(suppl 2A)9A-38A
15
Course in Hospital

• admitted to step down unit
• received intravenous furosemide, digoxin and
  morphine
• given supplemental oxygen, nitroglycerin patch

16
Role of Diuretics in theTreatment of Heart
Failure

• Produce symptomatic benefits more rapidly than
  any other drug for heart failure
• The only drugs that can adequately control the
  fluid retention of heart failure
• Appropriate use of diuretics is a key element in
  the success of other drugs used in the treatment
  of heart failure

Am J Cardiol 199983(suppl 2A)20A
17
Diuretics Indicated forHeart Failure in Canada
Diuretics Starting Dose Usual Recommended Dose
Loop diuretics Furosemide 40 mg OD 40200 mg
OD Ethacrynic acid 50 mg OD 50200 mg
OD Bumetanide 0.5 mg OD 0.5 mg10 mg
OD Torsemide 10 mg OD 10200 mg OD Thiazide
diuretics Hydrochlorothiazide 25 mg OD 50 mg
OD Chlorthalidone 25 mg OD 50 mg
OD Indapamide 2.5 mg OD 2.5 mg OD Potassium
sparing diuretics Amiloride 5 mg OD 520 mg
OD Triamterene 50 mg OD 50300 mg
OD Spironolactone 12.5 mg OD 2550 mg OD
18
Digitalis Impact on Hospitalization
67.1
64.3
Hospitalizations ()
Digoxin
Placebo
N Engl J Med 1997336525-533
19
Course in Hospital (contd)

• diuresed well
• lost weight
• improved clinically over the next 3 days
• captopril begun at 6.25 mg tid, po
• expressed desire to be discharged after
  ambulating up and down one flight of stairs

20
ACE Inhibitors Indicated forHF Treatment in
Canada
ACE Inhibitor Starting Dose Recommended
Dose Enalapril 2.5 mg BID 5-10 mg
BID Captopril 6.25 mg TID 25-50 mg
TID Cilazapril 2.5 mg OD 2.5 mg-5mg
OD Lisinopril 2.5 or 5 mg OD 10-40 mg
OD Quinapril 10 mg OD 10-40 mg OD
Am J Cardiol 199983(suppl 2A)12A-24A
21
Mortality Data Patients with LV Dysfunction
Treated with ACE Inhibitors
50 40 30 20 10 0
54
ACE Inhibitor Control
40
39
35
Mortality ()
25
23
20
17
Enalapril 10 mg bid plt0.0036
Captopril50 mg bid p0.019
Enalapril 20 mg bid p0.003
Ramipril 5 mg bid p0.002
The CONSENSUS Trial Study Group. N Engl J Med
19873161429-1435 The SOLVD Investigators. N
Engl J Med 1991325293-302 The SAVE
Investigators. N Engl J Med 1992327669-677 AIRE
Investigators. Lancet 1993342821-828
22
Prognostic Value of Neurohormonal Activation
Indicated by Plasma Norepinephrine Levels in
Patients with CHF
1.0
PNE lt400 pg/mL
PNE 400-800 pg/mL
0.8
PNE gt800 pg/mL
0.6
Probability of Survival ()
0.4
0.2
0
0
10
20
30
40
50
60
Elapsed Time in Months
N Engl J Med 1984311819-823
23
Clinical Evidence for Beta Blockers
24
All CHF Should Have BB Therapy!
This Includes Patients With Severe CHF!
25
Beta Blocker Dosing
- Not available in Canada
26
Subsequent Course

• blood pressure 160/80
• some return of edema
• developed some shortness of breath on exertion
• beta blockade begun at discharge
• diuretic increased to 40 mg daily
• captopril and digoxin were continued

27
Beta-Blockade TherapyThe Problem

Clinical Benefit
Clinical Deterioration
0
12
34
56
1112
Months
Am J Cardiol 199779794-798
28
Which CHF Patients are Candidates for ?-blockade ?

• Mild to moderate (NYHA class II) or moderate to
  severe (NYHA class III) heart failure symptoms.
• Ischemic or Non- ischemic
• LVEF lt 35 - 40
• Added to pre-existing treatment with diuretics
  ACE /- digoxin.
• Stable clinical status with above background
  therapy.

29
?-blockade Side Effect Management

• Side effects are predictable during initiation
• Hypotension (asymptomatic is NOT a problem)
• Fluid retention
• Bradycardia/ heart block
• Can be managed by changes in concomitant Rx.
• Generally subside after days or weeks of
  treatment.

Patient education is paramount!!
30
Subsequent Course (contd)

• 3 days later patient presented to ER with
  increasing shortness of breath, increasing edema
  and distress
• admitted with diagnosis of uncontrolled CHF
• told never to take beta blocker medication again
  since it caused his heart failure

31
Congestive Heart Failure- Cause for Hospital
Admission
Other
Non compliance
Ischemia
Arrhythmia
Volume overload
0
10
20
30
40
of Patients
32
Cognitive Function and CHF

• What people know about their disease

Patients
We should not be so surprised to see them in ER
33
Subsequent Course

• continued on digoxin 0.25 mg, po, od
• underwent echocardiography which showed EF of 26
• an anterior akinetic aneurysm
• moderate mitral regurgitation
• RVSP of 55 mm Hg
• posterior wall and basal walls normal

34
Chronic Heart Failure

• Patients present with complex comorbidities and
  medications
• Close monitoring of outpatients is difficult for
  many specialists
• Dedicated heart failure clinics exist but not in
  every community

35
The Care Gap Process of Care

• Delivering Optimal Care to Populations
• Models of CHF Management
• Crisis intervention
• Disease management

36
Why The CHF Clinic?

• Conventional care fosters cycle of acute care
  dependence
• FD office inadequate
• Patient unable to recognize early symptoms
• Emergency leads to admission - quick discharge -
  minimal teaching- no FU
• Out patient HF clinic - Crisis Avoidance

37
Multidisciplinary Team
38
Subsequent Management (contd)

• patient told to separate lisinopril and beta
  blocker and to continue weighing himself
  regularly
• patient seen again in 3 weeks
• felt improved

39
Subsequent Management (contd)

• over next 3 months patient carefully titrated to
  25 mg carvedilol bid
• 6 months later, repeat ejection fraction showed
  ejection fraction of 31
• improvement in inferior wall dysfunction
• RVSP 39 mm Hg

40
Contemporary Treatmentof Heart Failure
Treatment Goals Pharmacologic Treatment ACE
Inhibitors Diuretics Beta-Blockers Digoxin ?
Mortality ? ? ? ? Hospitalization ? ?
? ? ? Symptoms ? ? ? ? ? Quality of Life
? ? Disease Progression ? ? ? ?
Heart Function ? ? aldosterone
antagonist