Heart FailureOrthopedic Nurses

Education Day

Jeffrey P Schaefer MSc MD FRCPC

October 30, 2006

Objectives

• Heart Failure– definition– epidemiology– prognosis– diagnosis– management

What is Heart Failure?

A complex clinical syndrome that can result

from any structural or functional cardiac

disorder that impairs the ability of the

ventricle to fill with or eject blood.

American College of Cardiology 2001

Cardinal Manifestations of HF

dyspnea fatigue

limits exercise tolerance

fluid retention

peripheral edemapulmonary congestion

impairment ofFunctional Capacity and QOL

“and / or”

Incidence of CHF

Staging of Heart Failure

NYHA Cardiac Status

• Class I: uncompromised• Class II: slightly compromised

• Class III: moderately compromised

• Class IV: severely compromised

– updated from old NYHA Classification• ‘usual activities’ ‘minimal exertion’

Specific Activity ScaleGoldman Circulation 64:1227, 1981

Stage I

• patients can perform to completion any activity requiring 7 metabolic equivalents – can carry 24 lb up eight steps

– carry objects that weigh 80 lb

– do outdoor work [shovel snow, spade soil]

– do recreational activities [skiing, basketball, squash, handball, jog/walk 5 mph]

Specific Activity ScaleGoldman Circulation 64:1227, 1981

Stage II

• patients can perform to completion any activity requiring 5 metabolic equivalents – have sexual intercourse without stopping

– garden, rake, weed, roller skate

– dance fox trot, walk at 4 mph on level ground

– but cannot and do not perform to completion activities requiring 7 metabolic equivalents

Specific Activity ScaleGoldman Circulation 64:1227, 1981

Stage III

• patients can perform to completion any activity requiring 2 metabolic equivalents – dress, shower without stopping, strip and make

bed, clean windows

– walk 2.5 mph, bowl, play golf, dress without stopping

– but cannot and do not perform to completion any activities requiring 5 metabolic equivalents

Specific Activity ScaleGoldman Circulation 64:1227, 1981

Stage IV

• patients cannot or do not perform to completion activities requiring 2 metabolic equivalents– CAN’T:

• dress without stopping

• shower without stopping

• strip and make bed

• walk 2.5 mph

• bowl, play golf

Prognosis of HF = generally poor

JACC 1993;22:6A-13A

Progression of Cardiac Status

• most patients do not show an uninterrupted and inexorable deterioration

• deterioration may be independent of LV function

Drug Therapy Improves Outcome

Diagnosis of Heart Failure

• Heart Failure is mainly a clinical diagnosis

• HF is correctly diagnosed initially in 50% of

affected patients. Eur Heart J 1991

• High Index of Suspicion

– is your patient at risk???

• “““Rapid Onset Heart Failure””” …

– did we under appreciate the findings?

Symptoms of Heart Failure

• pulmonary– resting or exertional dyspnea– orthopnea– paroxysmal nocturnal dyspnea– cough– wheezes ‘Cardiogenic Asthma’

Symptoms of Heart Failure

• other volume issues– nocturia– lower limb edema– gastrointestinal symptoms

• abdominal bloating• anorexia• fullness in the right upper quadrant

• fatigue• cachexia

Signs of Heart Failure

• delirium

• vital signs - normal or abnormal

• fluid weight gain

• peripheral edema– detected when extracellular volume > 5 l– stasis dermatitis– chronic venous stasis– hyperpigmentation– ulceration

Signs of Heart Failure

Distinguishing JVP/CPvariation with respiration

variation with position

varies with hepatic pres

occludes

non-palpable

wave form

elevation of JVP > 4.5 cmspec = 90% sens = 30%

Palpate Contralateral Carotid Artery

- if what you FEEL is not= to what you SEE --> JVP

Signs of Heart Failure

– S3 (Ken-tuc-ky)• sensitivity for HF = 24%• specificity for HF = 99%

– S4 (Ten-nes-see)• reduced ventricular compliance

– pulmonary examination• crackles (may be absent even with edema)• signs of pleural effusion• wheezes

B-type Natriuretic Peptide (BNP)

Post-op HF LabsCBC exclude anemia, adequate platelets

Electrolytes diuretic effect on potassium

low sodium is c/w heart failure

Creatinine diuretic response

safety of ACE / ARB

Mg arrhythmia risk

Albumin edema issues

Troponin T recent myocardial infarction?

INR and PTT in case of heparin or thrombolytics

Type & Screen in case transfusion needed

Post-OP HF: labs

• Chest Radiography– ‘the best chest examination’

• Electrocardiography– confirm rhythm– LVH?– ischemia?

• Echocardiography– variably helpful

• Thallium– variably helpful

Diagnostic Imaging

‘Congestive’ heart failure

Pulmonary Edema indistinct arteries

interstitial markings

increased

redistributed

peribronchial cuff pleural effusions

Ventricle enlargedincreased CT ratio

enlarged silhouette

Interstitial Pulmonary Edema

What’swronghere?

Small Cardiac

Silhouette

this effusionis from

tuberculosis

Common causes of Heart Failure

• Heart Failure = High Operative Risk– patients should not go to OR if heart failure is

not controlledRisk Calculator

http://www.vasgbi.com/riskscores.htm

• Poor left ventricular function– coronary artery disease– hypertension

• Valvular heart disease• Fluid Retention

Other causes of Heart FailureInfections (viruses (including HIV) bacteria, parasites)

Pericardial diseases

Drugs (alcohol, doxorubicin, cyclophosphamide, cocaine)

Connective tissue disease

Infiltrative disease (e.g., amyloidosis, sarcoidosis, hemochromatosis, malignancy)

Persisting tachycardia

Obstructive cardiomyopathy

Neuromuscular disease (e.g., muscular or myotonic dystrophy, Friedreich's ataxia)

Metabolic disorders (e.g., glycogen storage disease type 2 [Pompe's disease] and type 5 [McArdle's disease])

Nutritional disorders (e.g., beriberi, kwashiorkor)

Pheochromocytoma

Radiation

Endomyocardial fibrosis

Eosinophilic endomyocardial disease

High-output heart failure (e.g., intracardiac shunt, atrioventricular fistula, beriberi, pregnancy, Paget's disease, hyperthyroidism, anemia)

Peripartum cardiomyopathy

Dilated idiopathic cardiomyopathy

Approach to causes of Heart Failure

• Cardiac causes– pericardium– myocardium– endocardium– neuro-electrical system

• Non-cardiac causes– pre-load & after-load– other organ dysfunction

• anemia, respiratory disease, sepsis…

– iatrogenesis & adherence

Cardiac Causes of HF

• 1 Pericardium– tamponade, constrictive pericardial disease

Cardiac Causes of HF

• 2 Myocardium– ischemia

• coronary, non-coronary ischemia (hypoxia / anemia)

– cardiomyopathy• dilated: idiopathic, alcoholic, end stage CAD-HTN,

peripartum, post-viral• hypertrophic obstructive cardiomyopathy• restrictive: hemochromatosis, amyloidosis, sarcoidosis

– endocrinopathy• thyroid, adrenal disease (cortico / pheo)

Cardiac Causes of HF

• 3 Endocardium– valvular heart disease (including infective)– tumors (myxomas, sarcomas, melanomas)

Cardiac Causes of HF

• 4 Conducting System– tachycardia

• mostly atrial fibrillation• hyperthyroidism• sepsis (use acetaminophen in vulnerable febriles)

– bradycardia• excess medication effect• third degree heart block

Atrial Fibrillation - with rapid rate

Bradycardia - 28 / min

Non-cardiac Causes of HF• Pre-load issues

– too much (or too little) fluid to the heart

• Afterload issues– too much (or too little) resistance to arterial flow

• Examples of causes– saline, renal dysfunction versus blood loss

– medication effect or lack of adherence

– other organ dysfunctions• respiratory, sepsis, anemia, thyroid, liver, neuro...

PreloadSalt + Water (Saline)

=Pulmonary and Tissue Edema

Fluid Shifts Post-Op

Salt, NSAIDS, Coxibs, TZDs, Nephrotoxins --> Fluid Retention

IVcontrast(not po)

Afterload --> Hypertension

Medication

• Bioavailability

• Adherence– we didn’t give– patient didn’t take

• Clin Phar Ther 1995

20 mg IVtwice as useful as

40 mg poin Heart Failure

Management of Heart Failure

Post-operative Period

versus

Chronic Ambulatory

Management of Chronic HF

Ahigh risk

normal heartno HF

Babnormal

heartno HF

Cabnormal

heartprior or

current HF

D

refractory

HF

Asmoking

hypertensionlipid / DMlifestyle

B‘A’+

ACE / ARBBB

valve dxrevascularize

C‘B’ +

diureticsdigoxin

salt restrict

D‘C’ +

transplantmech assistIV inotrope

hospice

Management of Post-op Heart Failure

• Diagnose It !!!

• Determine the cause(s) !!!

• Remove things that make it worse– cardiac related– non-cardiac related

• Initiate things that make it better– cardiac related– non-cardiac related

Cardiac Medications are just Tools

Cardiac EffectsDRUG HR PRE AFTER

diuretics ace-inhibitors arbs beta-blockers ccb

- diltiazem - nefidipine

- amlodipine digoxin nitrates morphine

Case #1POD 2 - total knee replacement

• 75 yr old• past medical history

– heart failure 2 yr ago– MI 3 yr & 7 yr ago– hypertension

• Meds– Pre-op: ASA, ramipril, atorvastatin

• Normal Saline 125 ml/hr since OR– Saline Boluses post-op

• Now: SOB, edema, crackles

• Diagnostics– hx: sob, no chest pain– pe: ++ edema, + crackles, + wheezes– lab: Hgb 100 g/l, CXR: ++ heart size, edema

• What’s the Diagnosis?– HF owing to poor LV fx + saline loading

• What’s the Intervention?– oxygen– stop saline– diuretics– reduce afterload: especially ACE-I / ARB

Case #2POD 3 - ORIF hip

• 87 yr old

• past medical history– moderate hypertension

• Meds– amlodipine, benazepril, HCTZ

– Normal Saline 100 ml/hr since OR

– 2 units blood yesterday

• Now: BP 85/43, HR 150/min, SOB

• Diagnostics– hx: feels weak– pe: tachycardia, JVP elevated– lab: Hgb 105 g/l, K= 3.2, CXR: enlarged heart– ECG: Atrial Fibrillation + LVH

• What’s the Diagnosis?– HF: Atrial Fib + LVH + Volume Expansion

• What’s the Intervention?– oxygen– stop saline– diuretics & +++ potassium– rate control

Case #3POD 4 - pathological hip #, ORIF

• 79 yr old

• past medical history– advanced prostate cancer (no heroics)– hypertension– diabetes

• Meds– Pre-op: ASA, Adalat XL, metformin

• Now: Chest Pain, SOB, edema, crackles,

• Diagnostics– hx: chest pain relieved with S/L NTG– pe: HR 110, 190/100, JVP normal– lab: Hgb 70 g/l, CXR: mild edema– ECG: LVH with ST-T wave changes

• What’s the Diagnosis?– HF: anemia, myocardial ischemia, HTN-> LVH

• What’s the Intervention?– oxygen– transfuse RBCs (pre-diuretic!)– beta-blocker +/- CCB– ASA + (already on heparin)

Summary

• Heart Failure– high index of suspicion– preventative strategies

• Work-up– what are the contributers?

• Therapy– cause oriented

Acknowledgements

• You– thank you for your kind attention