living with heart failure ayesha hasan md, facc advanced heart failure and transplantation program...
TRANSCRIPT
Living with Heart FailureLiving with Heart Failure
Ayesha Hasan MD, FACCAdvanced Heart Failure and Transplantation Program
Medical Director Cardiac Transplant Program
Contact information: 614-293-6081 (heart failure office)
What is Heart Failure?
Heart failure is Heart failure is NOTNOT a heart attack a heart attack
Heart failureHeart failure means the heart is:means the heart is: WeakenedWeakened Cannot pump enough blood to supply the Cannot pump enough blood to supply the
body’s needsbody’s needs
. . . . . . It does not mean the heart has stopped It does not mean the heart has stopped working!working!
Heart Failure is Very Common
Heart failure affects nearly 5 million Americans 50% men and 50% women
An estimated ½ million new cases are diagnosed each year Expected to rise to 750,000 new cases by 2040 Related to aging population, better treatment of heart disease
and risk factors, awareness
Over one million heart failure hospitalizations annually Rising over past few decades Accounts for over 20% admissions in people 65 and over
Aorta
LA
LV
Normal
Thickened or stiffheart walls
Diastolic Heart Failure
Dilated
Systolic Heart Failure
Pg 238, Lilly 3rd edition
Types of Heart Failure: Difference Between Systolic and Diastolic Heart Failure
Weakened pump
Relaxation ± abnormal
Blood backs up and overloads the heart
Normal ejection
Abnormal relaxation: Stiff or scarred
Won’t allow enough blood to fill the heart before it squeezes
Normal ejection (squeeze)=Systolic functionNormal relaxation (filling)=Diastolic function
Normal Heart
Development of Heart Failure
Simplified View of Heart Failure
What Causes Heart Failure?
Heart failure results after injury to the heartHeart failure results after injury to the heartHigh blood pressureHigh blood pressureHeart attackHeart attackDamage to heart valvesDamage to heart valvesDiabetesDiabetesHigh cholesterolHigh cholesterolHeart muscle disease: damage Heart muscle disease: damage
from drugs, alcohol, or from drugs, alcohol, or infectionsinfections
Congenital heart diseaseCongenital heart disease
What Are The Symptoms of Heart Failure?
Think FACES...• Fatigue Constant lack of energy
• Activities limited Difficulty with everyday activities
• Chest congestion Dry cough or producing white or pink blood-tinged phlegm
• Edema or ankle swelling Swelling of the feet, ankles, legs, abdomen, or unexplained weight gain
• Shortness of breath Breathlessness during activity, at rest, or while sleeping
Additional symptoms: Lack of appetite, nausea, increased heart rate, irregular heart rhythm
How Severe is A Patient’s Heart Failure?
We measure the “We measure the “ejection fractionejection fraction” by echo” by echo The fraction of blood that the heart pumps with every beatThe fraction of blood that the heart pumps with every beat
We assess the patient’s We assess the patient’s symptomssymptoms No or mild symptomsNo or mild symptoms Do symptoms limit activity? If so, how much?Do symptoms limit activity? If so, how much?
High Blood Pressure
Left VentricularHypertrophy
Family History
CoronaryArtery Disease
Symptomatic Heart Failure
Diabetes
Risk Factors
High cholesterol
Treatment…Begins with Prevention!
Smoking Obesity
Poor DietLack of Exercise
How Do We Treat Heart Failure?
Lifestyle Changes Quit smoking Monitor diet: low-fat, low sodium Exercise regularly Lose weight Avoid alcohol Limit caffeine intake
Limiting Sodium or Salt Will Improve Your Heart Failure SymptomsSodium is a component of salt
Naturally occurring in many foods
Added during processing
In most foods eaten away from home
Your body needs only a small amount of sodium to
keep a normal fluid balance.
Too much sodium causes your body to hold onto fluid
and cause symptoms of weight gain, shortness of breath,
and fatigue.
Sodium attractsfluid
Fluid build-up in body
Extra work on heart &kidneys to get rid of fluid
Higher BP often results
Heart failure symptoms,heart attack, stroke
The more sodium (salt) you take in, the more fluid your body holds on to
In addition to heart failure patients, theAmerican Heart Association recommends
1) All adults older than 51
2) All African Americans
3) Anyone with high blood pressure
limit their daily intake to 1500 mg
Plan your meals for 2000 mg intake MEAL mg Sodium
Breakfast 600mgLunch 600mgDinner 600mg
Snack 200mg
Use alternative seasonings!
Basil ParsleyChives PaprikaDill weed PepperGarlic Sage Tarragon Mrs. DashThyme Lemon, lime juice
Patients Should Follow a 2000 mg Sodium Diet
How It Shakes Out
½ tsp salt = 1 serving = 3 slices of ham =2 packets of = 3 pickles = 14 green pretzels soy sauce olives
¼ tsp salt = 600 mg sodium½ tsp salt = 1200 mg sodium1 tsp salt = 2300 mg sodium More than daily recommendation
Even a small amount of salt counts!
Some common high sodium foods
Frozen meals Pickles
Canned foods Bacon
Breads, baked goods Anchovies
Lunch & smoked meats Soy sauce
Cheese Seasoning mixes
Condiments (salad dressing) Gravy
Olives Salted crackers
Pretzels FAST FOODRule of thumb: the more processed the food, the more sodium it contains
First step: Learn how to read sodium labels on all food
1. Look for SodiumListed as milligrams or mg
2. Next, look at serving sizeIf you eat 2 servings of a foodyou need to double what yousee on the label
3. Reduced-sodium products still contain sodium
Always read the label
Sodium Guidelines < 140 mg = low sodium Enjoy these foods!
140-400 mg = medium sodium Use food in moderation
> 400 mg = high sodium Use this food sparingly
Low sodium 140 mg or less sodium per serving
Very low sodium 35 mg or less sodium per serving
Sodium-free Less than 5 mg sodium per serving
1. Use salt substitute or other spices when cooking (watch for high potassium in some substitutes)
2. Don’t add salt at the table
Fluid intake & Daily Weights
Limiting fluid intake: important in managing heart failure
REMEMBER: Anything liquid at room temperature is considered a fluid
Daily weights: every morning at the same time using the same scale
Keep track of daily weights
REMEMBER: You might not see swelling until you are 8-15# up
Exercise: Get Off the Couch!
Exercise Will Improve Your Quality of Life
Pick a simple aerobic activity that you enjoy Start slowly and increase gradually
Need to move large muscle groups Walking is a great first choice Resume activities you stopped (gardening, bowling, fishing)
Work your way up to 30 minutes most days Doesn’t have to be 30 minutes in a row Warm up and cool down
Check with your physician first if You are really out of shape, uncertain about your abilities, or have
shortness of breath with very mild activity
Exercising & Precautions
Find an indoor location along with a partner
Build muscle (stretching, elastic bands, light weights)
Overexertion Shortness of breath that prevents you from completing a
sentence or doesn’t get better with rest Dizziness, chest pain, nausea, vomiting, severe sweating,
unusual fatigue (extreme)
What Medications Do We Use in Heart Failure and Why?
Diuretics Digitalis Beta-blockers ACE inhibitors Hydralazine/nitrates Spironolactone
1. To reduce symptoms
2. To prevent disease progression
3. Keep patients out of the hospital
4. Improve survival
Be careful about alternative therapy (chinese herbs, hawthorne, ginseng): No evidence they help & associated with some negative effects
Why Do We Use These Treatments?
Heart failure limits a patient's ability to perform the routine activities of daily living…
Diuretics, ACE Inhibitors
Reduce the number of sacks on the wagon (or load on the heart)
ß-Blockers
Limit the speed, thus saving energy
Spironolactone, Cardiac Resynchronization Therapy
Increase the heart’s efficiency
What if the Heart is Still Weak After Medications?
Risk of death from cardiac arrest Defibrillators can protect the heart from these
abnormal rhythms
Based on the ejection fraction
History of Pacemakers & Defibrillators
What if the Heart is Still Weak After Medications?
The heart “pump” worsensNewer devices can be implanted to help the heart’s contraction
1. Pacemakers (resynchronization)2. Ventricular assist devices3. Clinical trials: investigational
devicesHeart transplant
Pace both ventricles of the heart to make it stronger & more efficient
Ventricular Assist Devices
Try to be as active as possible with the following limitations: No driving No contact sports No high “bounce” activities like
running, jumping, or jumping jacks No submerging in water. Stay out
of bathtubs, hot-tubs, swimming pools, lakes & ponds
Do not drive or operate heavy machinery
Continue to follow heart failure recommendations: sodium and fluid restriction, daily weight
Indications for Mechanical Circulatory Support in Advanced HF
Bridge to Transplant (BTT) Non-reversible left heart failure High mortality risk Candidate for cardiac transplantation
Destination Therapy (DT) Not a candidate for cardiac transplantation
Bridge to Recovery Potentially reversible (post-heart attack, post-
pregnancy, myocarditis)
ADULT HEART TRANSPLANTATION % OF PATIENTS BRIDGED WITH MECHANICAL CIRCULATORY SUPPORT* (Transplants: 1/2000 – 12/2009)
0
10
20
30
40
50
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
% o
f p
ati
en
ts
* LVAD, RVAD, TAH
Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
History of Heart Transplantation at Ohio State University
Heart transplant program started in 1986 To date, have performed 382 transplants
Includes a joint heart/kidney transplant program Average 15 transplants per year
Around 2000-2500 transplants in the nation per year Approximately 3500 reported worldwide per year
Cardiac Transplantation:Are There Gender Differences in Transplant Rates?
Of total reported transplants, what % patients are women?a. 25-30%b. 50-60%c. 70-75%
International Statistics (ISHLT registry)
Of 22,387 reported heart transplants between 2002-2010, 77% were men
Improved to 31% women for Jan 2011 to Dec 2011
Is the OSU transplant program similar?
11 of 37 transplants are women – 27% (Past 3 yrs - 1/2010 to present)
Current waitlist – around 20% are womenTaylor DO, et al. JHLT 2009;28:1007-22 ISHLT online registry www.ISHLT.com
Increased load on the heart
Decreased output from the heart
Impaired kidneyfunction
Increased water& sodium retention
Diminished blood flow to the kidney
NeurohormonalActivation
The Heart-Kidney Relationship in Heart FailureDysfunction of one affects the other
Poor absorption of drugsand drug delivery to kidney
NeurohormonalActivation
Costanzo MR et al. JACC 2005;46:2047-2051.
Ultrafiltration for Acute Heart Failure
Mechanical removal of excess volume
Safe and effective Patients on high dose diuretic
(diuretic-resistance) Caution: Not a substitute for
dialysis as waste products are not removed with this method
Clinical Trials at OSU:Measuring Pressures in the Heart Invasively for HeartFailure Management
LARA
Modified PDAPowers through clothing
Alerts patient to monitor
‘DynamicRX®’ calculates
pressure and instructs patient
on management
Meds
Activity
Clinician contact Based on physician’s
prescription for specific values
obtained
Left Atrial Pressure SensorLeft Atrial Pressure Sensor
Measure pressures as an indication of fluid status
Clinical Trials at OSU:Measuring Pressures in the Heart Invasively for Heart Failure Management
Measure pulmonary artery pressuresfor assessment of fluid
15 mm
No batteryNo leads
Stem Cell Therapy and Heart Failure: Still being studied
Sleep Apnea and Heart Failure
People with heart failure have a high risk for sleep apnea
If not treated, sleep apnea can cause: Drop in oxygen levels The heart rate to speed up A rise in the blood pressure Changes to the heart rhythm Stroke Heart attack
or an episode of heart failure
Normal breathing pattern
Central sleep apnea: no breathing(apnea) alternates with rapid
breathing
Friends and Family Emotional support helps a patient have a more positive outlook on life
Allow the patient to make decisions regarding health care and lifestyle behaviors
Positive reinforcement
Discuss fears about heart failure
Discuss advanced care planning
Don’t forget to take care of yourself: eat healthy, exercise, sleep
Advanced Care Planning Not giving up Focus is on caring for the patient in a way that meets your
wishes Key is communication Goal is to reduce stress on the patient Consists of
Advanced care directive Do-not-resuscitate order Power of attorney Living will Financial plan
Advanced Care Planning Palliative care
Support program that focuses on comfort and reducing symptoms, pain. The disease is no longer responsive to curative treatment.
Hospice care Support program for the patient and family through the dying
process. Focus is also comfort and to help with bereavement. Nurses, chaplains, therapists, bereavement counselors, social
workers and physicians
Conclusion: Call your healthcare provider for these symptoms. . .
A change in shortness of breath, fatigue, or swelling
Requiring more pillows than usual to sleep comfortably at night or needing to sleep in a recliner
Chest pain
Near fainting or fainting
Weight gain of 2 lbs in one day or 5 lbs in one week
Conclusion: Living with Heart Failure
See your physician regularly
Weigh yourself daily & call your RN/MD if gaining
Limit salt and fluid intake
Exercise at a level recommended by your physician
Avoid smoking
Keep your flu and pneumonia vaccines current
Take your medications
Take an active role in managing your health!
For More Information About Heart Failure…
The Heart Failure Society of America via their website:
Patients and caregivers– www.abouthf.org