DIAGNOSIS OF CHF

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DIAGNOSIS OF CHF

• Jan M Kornder MD
• Cardiologist, Surrey Memorial Hospital
• CHF Clinic Physician, SMH
• Presentation to CHF Collaborative Learning
  Session 1
• May 26 2003

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CHRONIC CONGESTIVE HEART FAILURE
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Introduction

• CHF is a significant cause of morbidity and
  mortality
• Important cause of hospitalizations among elderly
• Recommended therapies
• ACE-Inhibitors, Beta-Blockers, Digoxin ,
  diuretics and Spironolactone

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CHF Incidence Canada
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CHF Mortality
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COST OF CHF in US(Death Dollars)

• 250,000 deaths/yr, 6-fold increase in last 40
  yrs.
• Mortality
• 5-10 annually if mild,
• 30-40 if severe.
• 20-40 billion/year in direct costs
• 8-15 billion on costs of hospitalization
• Twice the cost of all forms of cancer

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Cognitive Function and CHF
What People Know About Their Disease
of Patients Can explain CHF 5 Can explain
what each med is for 10-40 Know to restrict
NaCl 20 Know to weigh self frequently 10 Know
warning signs of volume overload 5-20
We should not be so surprised to see them in ER.
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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 follow-up
• out patient HF clinic - crisis avoidance

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CHF Clinic ideal setting to

• implements treatment plan
• ß blocker titration/adjust medications
• IV Lasix
• schedules tests/appointments/referrals
• review all tests results intervene
• liaisons with clinic and community caregivers
  regarding pt. status
• database entry/analysis
• teaching, teaching, teaching.

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Congestive Heart Failure

• Definition CHF is a complex clinical syndrome
  which is characterized by
• inability of the heart to provide sufficient
  blood to meet the bodys metabolic demands
• progression
• CHF is likely the final common pathway for a
  variety of myocardial insults
• A common disease about 1.5 and increasing!
• Associated with high mortality morbidity

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Evolution of Our Understanding of CHF
Pathophysiology

• CHF as a disorder of excessive sodium and water
  retention (the cardio-renal model)
• CHF as a hemodynamic disorder (reduced cardiac
  output, excessive vasoconstriction)
• CHF as a neurohormonal model

Inotropes, vasodilators
Neurohormonal antagonists (beta blockers, ACE
inhibitors)
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A New View of CHF
Activation of Cytokines
Hemodynamic Stress
Neurohormonal Activation
increased expression of proto-oncogenes
inducible NO synthase
auto- oxidation
persistent
transient
oxygen free radicals
hypertrophy entry into cell cycle
Packer, 1995
Apoptosis Cardiodepression
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Classification The New York Heart Association
Functional Class (NYHA-FC)
symptoms includes fatigue, dyspnea/SOB,
palpitation, angina
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DIAGNOSIS OF CHF

• Clinical
• Imaging
• Lab

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Signs and Symptoms of CHF

• Due to LEFT heart failure dyspnea, orthopnea,
  paroxysmal nocturnal dyspnea (PND), hemoptysis
• Due to RIGHT heart failure ankle edema,
  abdominal pain/swelling/ascites, nausea
• Due to low cardiac output fatigue, reduced
  exercise tolerance, nocturia

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Physical exam CHF

• Rhales
• S3
• Edema
• JVP
• Ascites
• Murmers etc

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Imaging Dx of CHF

• CXR
• Congestion
• Heart size
• C/T ratio
• Nuclear Ventriculogram (MUGA)
• EF lt 50
• ECHO
• Method of CHOICE
• EF lt 50
• Gives info on RWMA, Valves, Hypertension etc

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Lab Dx of CHFBNP

• New lab test appears sensitive and specific for
  CHF
• Available as Lab bench test or Point of care test
• Can follow status with serial testing
• Needs more research
• WE HAVE A GREAT OPPORTUNITY !!!

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BNPB-type Natiuretic Peptide

• Found predominantly in Cardiac Ventricles
• Released in response to wall stretch and
  increased venticular volume
• BNP levels DIRECTLY related to
• LVEDP
• NYHA Classification
• Prognosis

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BNP

• PRIMARY CARE
• Screening of asymptomatic CHF
• Monitoring disease progression
• Post diagnosis management
• ACUTE CARE
• Differential Dx dyspnoea in ER
• Diagnosis diastolic heart failure
• Follow management
• Risk stratification
• Post AMI
• ? ACS uses and other

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BNP Buts

• But it is not widely available
• But it costs money
• But we need more research and data
• BUT WE SHOULD BE USING THIS POWERFUL TOOL!!!

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TREATMENT OF CHF General Measures

• Decrease risk of new cardiac injury
• Maintain fluid balance (lt 3 gm NaCl)
• Improve Aerobic conditioning
• Control VR to Afib
• Revascularize if symptomatic with Angina
• Treat secondary causesvalves, BP,
• CLOSE FOLLOWUP, ie. CHF CLINICs
• Anti-arrhythmics generally avoided
• ? CHF COLLABORATIVE ?

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Treatment of CHF
Normal
AsymptomaticLV dysfunction EF lt40
Symptomatic CHF NYHA - II
Symptomatic CHF NYHA - III
ACEI ß-Blocker (post-MI)
Symptomatic CHF NYHA - IV
ACEI diuretics ß-Blocker /- Digoxin
ACEI diuretics ß-Blocker /- Digoxin Spiro
Inotropes ACEI diuretics Digoxin
ß-Blocker Spiro
Secondary prevention Modification of physical
activity
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CHF at SMH

• Data Driven Decisions

Jan Kornder M.D. Division of Cardiology Surrey
Memorial Hospital
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Improving the Care of Patients with Congestive
Heart Failure The Review of Education on ACE
Inhibitors in Congestive Heart Failure Treatment
(REACT) Study, Stage I Ross T. Tsuyuki, Miriam
Fradette, Thomas Ashton, Wendy Gordon, Roland
Ikuta, Jeffrey A. Johnson, Jan Kornder, Elizabeth
MacKay, Dante E. Manyari, Kenneth V. OReilly,
William Semchuk, Ivan D. Witt, for the REACT
Study Investigators University of Alberta,
Edmonton, Alberta, Canada
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REACT Background Although ACE
inhibitors (ACEs) are of proven benefit in the
management of heart failure, only about one-half
of such patients receive them. As well, many
patients are receiving sub-optimal doses. The
purpose of Stage I of REACT was to determine the
effect of in-hospital interventions on ACEI usage
and dosage titration.
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REACT Methods REACT was a 10 center trial
of 766 patients. During Stage I, consecutive
patients with heart failure (primary or secondary
diagnosis) were identified in hospital by a
pharmacist or nurse, assessed for ACEI
eligibility/dosage titration, and recommendations
were made to the physician. The primary endpoint
was the proportion of patients receiving ACEIs at
hospital admission compared to at discharge. The
secondary endpoint was ACEI dose at discharge
compared to hospital admission.
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REACT Results Of the 2,250 patients
screened, approximately 65 were excluded from
entry, most often for preserved systolic function
and cognitive impairment. Average age was 74
(12.8) years and 45 were female. Eight percent
were in New York Heart Association Functional
Class I, 48 in II, 37 in III, and 5 in iv. The
primary etiology of heart failure was coronary
artery disease in 58, hypertension in 12, and
idiopathic dilated in 7. Half of the patients
had heart failure for gt1 year and the average
ejection fraction was 0.31 (0.12). As a result
of the intervention, ACE inhibitor use increased
from 58 on admission to 83 at discharge
(pltO.000 1). Average daily dose (in enalapril
equivalents) increased from 11.3mg at admission
to 14.5mg at discharge (p0.0001).
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React Results

• Significant improvement in ACE use in both
  intervention and usual care
• Intervention group had less repeat
  hospitalizations and
• Intervention group care was resourse efficient

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Methods
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Aulakh, A. New Drug Therapies for Heart Failure
Discovering Current Trends at a Community
Hospital. 2001
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Results
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Results
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Limitations

• Small sample size
• Information limited in patient record
• Study not designed to assess changes to drug
  therapy post-discharge
• Long-term adherence information not collected

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Conclusions

• Study was too small to assess the study question
• Physicians were more likely to change therapy
  with an ACE-inhibitor than add spironolactone
• Larger study needed over a longer period, taking
  limitations into consideration

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Whats Next?

• Questionnaire for physicians regarding CHF
  therapy?
• Spironolactone education for physicians?
• Similar study, but larger and longer?
• Study involving Heart Function Clinic?
• ? CHF COLLABORATIVE leading to
• Patient empowerment