Outpatient management of heart failure

1
Outpatient management of heart failure

• Dr. Rob Wu
• Feb 2008

2
Case

• 86 year old woman recently discharged from Team
  with heart failure arrives at clinic for follow
  up
• Echo done in hospital EF 58, normal valves
• PMH HTN, osteoporosis, osteoarthritis, DM2
• Meds ASA, tylenol, ramipril 5 mg daily,
  metoprolol 25 mg po bid , spironolactone 25 mg
  po daily , furosemide 40 mg po bid , arthrotec
  75mg po bid, diabeta 5mg bid, avandia 4mg daily ,
  fosamax
• Currently, feels ok, no orthopnea, PND or ankle
  swelling
• - new medications, started in hospital

3
Case cont

• Exam BP 130/68 HR 72
• Chest clear, no crackles
• CV JVP 2 cm ASA, normal HS
• Extremities no pedal edema
• Labs on discharge
• CBC Normal, Na 140 K 5.5 Cl 108 Cr 140
• How would you manage her ?

4
Some questions

• LVEFgt50! Was it really heart failure?
• Maybe not. But diagnosis of HF is clinical
• including symptoms (PND, orthopnea), signs
  (elevated JVP, S3, crackles), investigations
  (CXR, BNP)
• If so, likely diastolic dysfunction or preserved
  systolic function
• How would you optimize the meds?
• Further investigations?
• When to see her back?

5
Resources

• CCS Heart failure guidelines 2007, 2006

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• Definition
• Epidemiology
• Diagnosis
• Management
• Quality

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Some terminology

• What is Heart Failure (HF)?
• HF 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
• HF is common and reduces quality of life,
  exercise tolerance and survival
• NB calling it CHF is considered inaccurate and
  uncool

Arnold JMO et al. Can J Cardiol 200622(1)23-45.
8
Heart Failure Mortality

• Canadas average annual in-hospital mortality
  rate is
• 9.5 deaths/100 hospitalized patients gt65 years
  of age
• 12.5 deaths/100 hospitalized patients gt75 years
  of age
• HF patients have a poor prognosis, with an
  average 1-year mortality rate of 33

Lee DS et al. Can J Cardiol 200420(6)599-607.
9
HF An epidemic ?
Projected number of incident hospitalizations for
CHF patients, using high, medium and low
population growth projections in Canada 1996-2050
Johansen et al. Can J Cardiol 200319(4)430-5.
10
HF Readmissions

• Hospital readmission rates are high, and mainly
  due to recurrent heart failure

Canadian Hospital Readmission Rates for Any Heart
Failure
Lee DS et al. Can J Cardiol 200420(6)599-607.
11
Management Overview

• Management of HF requires
• an accurate diagnosis
• aggressive treatment of known risk factors(e.g.
  hypertension, diabetes)
• rational combination drug therapy
• Care should be individualized for each patient
  based on
• symptoms
• clinical presentation
• disease severity
• underlying cause

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Diagnosis and investigations

• Clinical history, physical examination and
  laboratory testing
• BNP (available at UHN, cost 65, 2d turnaround)
• Transthoracic echocardiography (ventricular size
  and function, valves, etc.)
• Coronary angiography in patients with
  known/suspected CAD
• NYHA classification should be used to document
  functional capacity in all patients

Arnold JMO et al. Can J Cardiol 200622(1)23-45.
13
Management
CCS HF guidelines 2006. Can J Cardiol
200622(1)23-45.
14
Non pharmacologic therapy

• I am supposed to counsel what again ?
• Diet
• How much salt no added or low salt
• Is that 1gm, 2gm?
• Is fluid restriction necessary ?
• Symptoms of heart failure
• Self care including daily weights

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Salt and Fluid

• Salt
• All patients with heart failure
• No added salt diet (2-3 gm / day)
• If difficult to control, low salt diet 1-2 gm/day
• May just need some educational literature for
  2gm/day
• Likely needs to see a dietitian (TWH referral)
  for lt2gm/day
• Fluid restriction
• Not necessarily all patients, just those with
  difficult to control HF or sodium issues (1.5 2
  L / day)

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Medications

• ACE
• ARB
• BB
• Spironolactone
• Digoxin
• Diuretics

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ACE

• All HF patients with LVEF lt40 should be treated
  with an ACE-I and a beta-blocker, unless a
  specific contraindication exists (Class I,
  Level A)

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Practical Tips for ACE-I/ARB Use

• Check supine and erect BP for symptomatic
  hypotension
• If symptomatic hypotension persists, separate
  timing of dose from other medications that could
  also lower BP
• Reduce dose of diuretic if patient stable and
  reassess need for other vasodilators (e.g.,
  long-acting nitrates)
• An increase in creatinine of up to 30 is not
  unexpected after introduction of an ACE-I/ARB
• Adding spironolactone to an ACE-I plus an ARB is
  discouraged, unless followed closely in a
  specialist HF clinic

Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
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When to Use Beta-blockers?

• All HF patients with LVEF ?40
• (use clinically proven beta-blocker) (Class
  I, Level A)
• In stabilized HF patients with NYHA Class IV
  symptoms
• (Class I, Level C)

MERIT-HF Study Group. Lancet
19993532001-7. CIBIS II
Investigators. Lancet 19993539-13.
Packer M et al. Circulation
20021062194-9.
Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
20
Practical Tips for BB Use

• Dose of BB should be increased slowly, e.g.,
  double dose every 2-4 weeks if stable
• If bradycardia or AV block is present, reduce or
  stop digoxin or amiodarone (where appropriate)
• If hypotensive, consider reducing other
  medications or change timing of doses
• Objective improvement in LV function may not be
  apparent for 6-12 months or longer
• Major reduction of BB dose or abrupt withdrawal
  should generally be avoided
• Consider using beta blocker proven effective in
  HF trials
• Bisoprolol, carvedilol (or long-acting metoprolol
  but not available in Canada)

Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
21
When to Use Aldosterone Blockers?

• Spironolactone
• Patients with LVEF ?30 and severe symptoms
  despite optimized other therapies (and Creat
  lt200, K lt5.2) (Class I, Level B)

Pitt B et al. N Engl J Med 1999341709-17.
Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
22
When To Use Digoxin?

• To relieve symptoms and reduce hospitalizations
  in patients in sinus rhythm who have persistent
  moderate-to-severe symptoms despite optimized HF
  medical therapy
• (Class I, Level A)

The Digitalis Investigation Group. N Engl J Med
1997336525-33. Arnold JMO, Liu P et al. Can J
Cardiol 200622(1)23-45.
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When To Use Nitrates Hydralazine?

• Other HF patients unable to tolerate ACE
  inhibitors and ARBs
  (Class IIb, Level B)
• African-Americans with systolic dysfunction in
  addition to standard therapy (Class IIa,
  Level A)

Cohn et al. N Engl J Med 19863141547-52.
Taylor AL et al. N Engl J Med 20043512049-57.
Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
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Drug Interactions and Additive Adverse Effects of
Common Medications
(Class I, Level B)
Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
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HF with Preserved Systolic Function

• Diagnosis is generally based on typical signs and
  symptoms of HF in patient with normal LVEF and no
  valvular abnormalities
• Important to control comorbidities, such as
  hypertension and diabetes, which are often
  associated with HF with PSF
• Systolic and diastolic hypertension should be
  controlled according to published guidelines
  (Class I, Level A)
• The ventricular rate should be controlled in
  patients with atrial fibrillation at rest and
  during exercise (Class I, Level C)

Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
26
HF with Preserved Systolic Function

• Diuretics should be used to control pulmonary
  congestion and peripheral edema (Class
  I, Level C)
• ACE inhibitors, ARBs, and beta-blockers should be
  considered for most patients (Class IIa,
  Level B)
• Coronary revascularization may be considered for
  patients with symptomatic or demonstrable
  ischemia that is judged to have an adverse effect
  on cardiac function (Class IIa, Level C)
• Excessive diuresis should be avoided as this can
  easily lead to reduced CO and renal dysfunction

Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
27
Remainder of Slides are Optional.

• Review if time permits.

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Heart Failure and Renal Dysfunction

• A Caution (and a recommendation)
• Routine use of ACE-I, ARBs or spironolactone
  in the setting of severe renal dysfunction (serum
  creatinine gt250 µmol/L or an increase of gt 50
  from baseline) is not recommended due to a lack
  of evidence for efficacy in HF patients
• (Class IIa, Level C)

Arnold JMO, Howlett JG, et al. Can J Cardiol
200723(1)21-45.
29
Geriatric HF

• (this is us)
• Frailty score
• predicts
• Death
• Need for institution

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Other evidence-based therapies

• Multidisciplinary heart failure clinics
• Reduces readmissions and mortality
• Most have RNs doing monitoring, counselling
• But
• Most only see systolic dysfunction
• Many wont see older patients who may not benefit
  from devices

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Which Patients Should be Referred to a Heart
Failure Specialist?

• New onset HF
• Recent HF hospitalization
• HF associated with ischemia, hypertension,
  valvular disease, syncope, renal dysfunction,
  other multiple comorbidities
• HF of unknown etiology
• Intolerance to recommended drug therapies
• Poor compliance with treatment
• First degree family members if family history of
  cardiomyopathy or sudden cardiac death
• (Class I, Level C)

CCS HF guidelines, Can J Cardiol 200622(1)23-45.
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Practically, which referrals will be accepted by
a Heart Failure Specialist?

• Definitely pre-transplant candidates
• Age lt60
• Candidates for devices (AICD, biventricular
  pacer, LVAD)
• LV systolic dysfunction (LVEF lt40)

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Conclusions

• Make an accurate and timely diagnosis
• Initiate treatment to
• Reduce HF risk factors
• Reduce HF symptoms
• Reduce hospitalizations
• Improve quality of life
• Prolong survival
• Refer patients at higher risk to specialist or HF
  clinic
• Continue to translate new knowledge into practice
• Combine available healthcare resources to improve
  delivery of best care and practices to HF
  patients
• Improve HF outcomes in Canada

Arnold JMO, Liu P et al. Can J Cardiol
200622(1)23-45.
34
Case

• 86 year old woman recently discharged from team
  with heart failure arrives at clinic for follow
  up
• Echo done in hospital EF 58, normal valves
• PMH HTN, osteoporosis, osteoarthritis, DM2
• Meds ASA, tylenol, ramipril 5 mg daily,
  metoprolol 25 mg po bid , spironolactone 25 mg
  po daily , furosemide 40 mg po bid , arthrotec
  75mg po bid, diabeta 5mg bid, avandia 4mg daily ,
  fosamax
• Currently, feels ok, no orthopnea, PND or ankle
  swelling
• - new medications, started in hospital

35
Case cont

• Exam BP 130/68 HR 72
• Chest clear, no crackles
• CV JVP 2 cm ASA, normal HS
• Extremities no pedal edema
• Labs on discharge
• CBC Normal, Na 140 K 5.5 Cl 108 Cr 140
• How would you manage her ?

36
Some answers?

• Management
• Etiology consider ischemia
• Counseling daily wts, NAS diet, symptoms, meds
• Meds D/C NSAID, rosiglitazone, spironolactone,
  try titrate down diuretic
• Further investigations
• Lytes, Creat, ECG
• When to see her back?
• High risk of readmission (elderly, recent admit)
• 1-2 weeks would be reasonable

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web resources

• www.heartfunction.com
• Counseling info
• HF guidelines
• Flow sheets for your hf patients