PEARLS OF HEART FAILURE MANAGEMENT

Deborah Crawford, APRN-CNS

Speaker for Otsuka

Disclosures

1 Identify the treatment objectives for acute heart failure vs chronic heart failure.

2. Identify the stages and classifications of Heart Failure.

3. Describe the exercise guidelines for Heart Failure patients.

4. Describe the Pharmacoligical treatment for Heart Failure.

Objectives

Acute Decompensated Heart Failure (ADHF)

Heart Failure: Complex clinical

syndrome, Can result from any

structural or functional cardiac disorder that impairs ability of ventricle to fill with or eject blood.

Cardinal symptoms:

fatigue dyspnea

Clinical signs: fluid retention exercise

intoleranceHunt SA et al. Circulation. 2001;104:2996

Myocardial ToxicityChange in Gene Expression

ANPBNP

Pathophysiology of ADHF

Myocardial Injury Fall in LV Performance

Activation of RAAS and SNS(endothelin, AVP, cytokines)

Peripheral Vasoconstriction Sodium/Water Retention

HF SymptomsMorbidity and Mortality

Remodeling andProgressive

Worsening ofLV Function

Shah M et al. Rev Cardiovasc Med. 2001;2(suppl 2):S2

HFSA 2010 Practice Guideline (12.5-12.20) Overview of Treatment Options for Patients with Acute Decompensated HF

Fluid and sodium restriction Diuretics, especially loop

diuretics Ultrafiltration/renal replacement

therapy (in selected patients only)

Parenteral vasodilators (nitroglycerin, nitroprusside, nesiritide)

Inotropes * (milrinone or dobutamine)*See recommendations for stipulations and

restrictions.

Treatment ObjectivesChronic Heart

Failure2

1. Survival2. Mortality3. Exercise capacity4. Quality of life5. Neurohormonal

changes6. Progression of CHF7. Symptoms

Acute Heart Failure1

1. Improve symptoms2. Optimize volume status3. Identify etiology4. Identify precipitating factors5. Optimize chronic oral therapy6. Minimize side effects7. Identify patients who might

benefit from revascularization

8. Educate (medications/self assessment of HF)

1 2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e.2 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.

Class I: No limitations

Class II: Slight limitations of physical activity

Class III: Marked limitation of physical activity

Class IV: Symptoms at rest Unable to carry on any physical activity without discomfort.

Stage A: At risk for developing HF

Stage B: Structural heart disease associated with HF but asymptomatic

Stage C: Known systolic heart failure & current or prior symptoms

Stage D: Systolic heart failure and presence of advanced symptoms after receiving optimal care

Stages of Heart Failure

NYHA Functional Classifications in patients with HF

Pharmacoligical Treatment of Heart Failure

ACE Inhibitors: Inhibit renin-angiotensin system in all HF patients with LV dysfunction

ARB: Recommended to patients with LVEF <40% intolerant of ACE

Beta Blockers: Shown effective in patients with HF with LVEF < 40% (start when euvolemic)

Aldosterone blockade: Recommended in patients with NYHA class III or IV, LVEF <35% while receiving standard therapy

Dosing ACE/ARB

Start with low dose ie: Lisinopril/Enalapril 2.5mg BID

Stagger away from Beta Blocker dose Avoid Orthostatic Hypotension

Usually Lunch and Bedtime “Stair step” the dosing when up titrating Monitor Renal function Can use in mild, stable renal insufficiency

Dosing Beta Blockers Carvedilol and Metoprolol Succinate are

the Beta Blockers that have an indication for Heart Failure

Start low dose and titirate up slowly Stagger away from ACE I/ARB Start or up titrate when the patient is

euvolemic “Stair step” the dosing when up titrating Titrate one drug at a time.

Dosing Aldosterone Blockers Spironolactone, Eplerenone

Helpful in the setting of Hypertension for better BP control

Monitor Renal function : can use in mild, stable renal insufficiency

Does have mortality benefit in patients with LVEF < 35 %.

Compensated/Decompensated ?

Diuretic TherapyAgent Initial Daily

Dose (mg)Maximum Total Daily Dose (mg)

Duration of Action (hr)

Furosemide 20-40mg qd or bid

600mg 4-6

Bumetanide 0.5-1mg qd or bid

10mg 6-8

Torsemide 10-20mg qd 200mg 12-16

Metalozone(thiazide)

2.5mg qd 20mg 12-24

Equivalent doses: Furosemide 40mg=bumetanide 1mg=torsemide 20mg

Dosing Thiazide DiureticMetolazone (Zaroxlyn) Usually 2.5 – 5mg

Hydrochlorothiazide Usually 25mg

Usually give 30 min prior to the Loop DiureticMore effective and increases the diuretic effect of the Loop

Dosing Potassium and MagnesiumPotassium:Goal 4.0 – 5.0 Usually 10-20mEq /

Furosemide 40mg dose equivelent.

Usually will double the Potassium dose when you double the Loop diuretic dose

Depending on renal function of the patient

Magnesium:Goal 2.0 – 2.5 Usually 250mg BID

for 1 week then once a day

Check the Mg level in 1 month after starting Mg supplement

CMS recommendations for Cardiac Rehab for CHF patients CMS determined

that the evidence is sufficient to expand coverage for Cardiac Rehabilitation services to beneficiaries with stable chronic heart failure.

Stable chronic HF LVEF < 35% NYHA class II-IV

despite optimal HF therapy for at least 6 weeks Stable patients No recent (< 6 wks ) or

planned (< 6 mo) major CV hospitalizations or procedures

Exercise Guidelines for HF patients

Start slow, warm up and cool down

Start by walking 5-10 min 1-2 times a day.

Walk 3 - 5 times a week

Increase the time and frequency as tolerated

Goal is 30 min, 5 times a week

Don’t Let this Happen to Your Patient

Aquapheresis (Ultrafiltration)

Alternative treatment in Diuretic resisitant patients

What Is Diuretic Resistance ? > 10 lbs or more over dry

weight

Previous hospitalizations with ineffective diuretic effect

Patient cannot achieve a goal of -2 liters at 24 hrs

No significant difference in patient’s global assessment of symptoms in 24 hrs

Non-significant symptom improvement noted after escalating to high-dosing strategy

Worsening renal function during diuretic therapy

Post-operative fluid overload

Peri-operative fluid overload

Ultrafiltration Indicated for patients with Heart Failure not

responding to diuretic therapy 24 hour diuretic dose >80mg Furosemide or

equivalent Removes excess salt and water from patients

with fluid overload Need to monitor Renal function closely esp.

during inpatient ultrafiltration Fluid removal rate should not exceed

250ml/hr (inpatient) or 350ml/hr (outpatient for 8 hrs)

The Aquadex System is indicated for:

Temporary (up to 8 hours) ultrafiltration treatment of patients with fluid overload who have failed diuretic therapy

AND

Extended (longer than 8 hours) ultrafiltration treatment of patients with fluid overload who have failed diuretic therapy and require hospitalization.

Goals of Ultrafiltration Reduction in hospital readmission:

Prevent patients from being discharged when they are still “wet”

Reduction of Length of Stay: If ultrafiltration is started early (< 24 hr of

admission).

Stable renal function during treatment: Monitor BMP every 12 hours while on ultrafiltration

to prevent worsening renal function. Can reduce rate of fluid removal as needed.

Pearls after Ultrafiltration Hold diuretic while on ultrafiltration

Restart diuretic after ultrafiltration complted usually the next day at a lower dose

May respond better to diuretics after ultrafiltration due to reduction of “gut edema”

Patient selectionInclusion / Exclusion

Criteria for Outpatient

Ultrafiltration

Inclusion Criteria:

1. 24 hour Diuretic dose > 80mg Furosemide or equivalent * OR

2. Fluid overloaded diuretic resistanta. < 10 lbs over stable weightb. Serum Creatinine < 3.0 or

Creatinine clearence > 20ml/min or on fluid restriction or frequent hospitalizations

* 1mg Bumetanide or 20mg Torsemide = 40mg Furosemide

Exclusion Criteria:

1 Fluid overloaded and diuretic resistanta. > 10 lbs over stable

weightb. Consider hospital

admission for in patient Ultrafiltration

c. Serum Creatinine > 3.0 consider Renal consult

Ultrafiltration

Pre-Treatment

Day of Treatment

1. Obtain IV access:a. 6Fr Dual lumen ELC venous access

catheter2. Obtain Laboratory: CMP or BMP, Mg, CBC,

PT/INR (if patient on Coumadin)3. Obtain Aquadex Flexflow pump4. Obtain UF 500 Circuit set :

a. Prime filter/tubing with Normal Saline5. 10 ml syringe6. Heparin 20,000/500ml D5W

a. Heparin infusion 1000-1200 units/hr or as need by the patient

7. Start Heparin 30min prior to starting Ultrafiltration

Thank You !!