this building is - university of washington...bnp = 1500 who most likely has acute heart failure? 70...
TRANSCRIPT
This building is:1. Amazon headquarters2. Veterans Affairs Medical facility3. Pacific Medical Centers4. Washington State Mental Hospital
PacMed Medical Education 8 continuity clinic residents at BH and Madison 4 thematic specialty block rotations for R2/R3s:
Cardiorespiratory Neuromusculoskeletal Dermatology‐Endocrinology Hematology‐Oncology
UW School of Medicine IM Clerkship students GI Fellowship rotation
Management of Heart Failurein the Outpatient Setting
Christopher H Smith, MD, FACPDirector of Medical Education
Pacific Medical CentersSeattle, Washington
June, 2012
Which of these patients have CHF?1. 76 year old man with AS presents with increasing fatigue,
reduced exercise tolerance, and perihilar edema on CXR.2. 64 year old woman with uncontrolled type 2 DM and
AMI two months ago comes to the office with cough, wheezing, bilateral inspiratory rales and edema.
3. 58 year old woman with poorly controlled HTN and ESRD on HD reports abrupt onset of SOB and a 5 pound weight gain since last dialysis.
4. 83 year old man with chronic A fib c/o lightheadedness and fatigue. His BP is 110/72, pulse is irregular @ 132 and and he has bilateral wheezing on chest auscultation.
What is Heart Failure?
2005 ACC/AHA statement
HF is “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.”
DescriptionHeart Failure is a clinical syndrome consisting of:
Signs and symptoms of intravascular and interstitial fluid overload: SOB, rales, edema
‐OR‐ Symptoms of inadequate tissue perfusion:
fatigue or poor exercise tolerance‐OR‐
Asymptomatic LV systolic dysfunction (LVEF < 40%)
Usually associated with an elevation of B‐type natriuretic polypeptide (BNP)
What are the common causes of HF?
Who is at risk for developing it?
Etiology Ischemic heart disease
(CAD is the underlying cause of HF in 2/3 of the patients with LV systolic dysfunction)
Hypertension Diabetes Valvular heart disease Cardiotoxic substances: alcohol, cocaine, anthracycline Thyroid disorders Tachyarrythmias Infiltrative disorders (amyloid, sarcoid)
Burden of disease
More than 5 million people in the US have CHF 1 million hospitalized annually 300,000 deaths per year Most frequent cause of hospitalization in those > 65
The direct and indirect costs of heart failure totaled $39.2 B in 2010
Cost of HF US indirect and direct cost $39.2 billion in 2010
AHA Heart Disease and Stroke Statistics – 2010 and 2011 UpdatesJancks SF. N Engl J Med 2009;360:1418
1975 1980 1985 1990 1995 2000 20070
200
400
600
Discharges in 1000s
WomenMen
30‐day readmission rate 27%
How does HF present?
What are typical presenting signs and symptoms?
Manifestations
Symptoms Dyspnea Orthopnea PND Fatigue Weight gain
Signs Pulmonary congestion: Rales on chest exam CXR findings
Third heart sound Jugular venous distention Dependent edema
What is in the differential diagnosis?
What is in the differential diagnosis?
Pulmonary conditions including: Pneumonia Pulmonary embolism Pleural effusion COPD
Pericardial diseases Interstitial volume overload due to cirrhosis or nephrotic syndrome
EvaluationA 72 year old man with a history of hypertension and hypothyroidism presents with a cough, fatigue and dyspnea on exertion gradually worse over three weeks.His chest exam is notable for faint rales at both lung bases, 1+ edema at the ankles and a four pound weight gain over the last month.
What tests would you order to determine the cause of his symptoms?
Think “CCCUTEE”CMP (complete metabolic panel)CBCCXRUrine analysisTSHEKG Echocardiogram (TTE)
Findings of HF on chest xray Cardiomegaly (heart : thoracic width ratio > 50%) Cephalization of pulmonary vessels Interstitial edema (Kerley B lines) Pleural effusions
CXR has higher specificity (83%), but lower sensitivity (68%) than BNP or EKG for establishing the diagnosis
Think “CCCUTEE” CMP CBC CXR Urine analysis TSH EKG ECHOcardiogram (TTE)
What about BNP?
B‐type Natriuretic Peptide Neurohormone secreted by myocardium in response to stretch
Serum levels increase with increases in ventricular volume and pressure
BNP can be helpful in risk stratification and prognosis NT‐proBNP has a longer half‐life BNP can be elevated due to other conditions and factors (reduced specificity)
Routine monitoring remains controversial
Factors other than HF that may affect BNP
Renal failureAcute tachycardia
ACS, AMILVH
FemaleOlder age
Obesity
Levels higher Levels lower
BNP = 1500Who most likely has acute heart failure? 70 year old woman, non‐ischemic cardiomyopathy, lightheaded after recent increase in diuretics, baseline creatinine 1.0 and now 3.7
65 year old man with diabetes, acute shortness of breath, ECG changes, + troponin
50 year old man with ischemic cardiomyopathy, COPD, several days of increasing dyspnea
BNP = 1500Who most likely has acute heart failure? 70 year old woman, non‐ischemic cardiomyopathy, lightheaded after recent increase in diuretics, baseline creatinine 1.0 and now 3.7 BNP due to acute renal failure
65 year old man with diabetes, acute shortness of breath, ECG changes, + troponin BNP due to acute coronary syndrome/MI
→50 year old man with ischemic cardiomyopathy, COPD, several days of increasing dyspnea→BNP most likely due to acute decompensated HF
BNP as diagnostic tool Added value to ED clinical assessment for HF as cause of acute dyspnea (using BNP ≥ 100 pg/ml)
Best with intermediate clinical probability
Interpret in context of other, non‐HF factors which will influence levels
Cannot distinguish between systolic HF vs. HF with preserved EF
What are the types of HF?
Classification of cardiomyopathies based on structure: Dilated
Most common (ischemic and non‐ischemic) Hypertrophic
Due to hypertension or genetic abnormalities
RestrictiveSystemic infiltrative disorders (amyloid, sarcoid,
hemochromatosis), radiation, rare familial causes
Classification based on function:(as observed on Echo)
SystolicHeart is dilatedEF less than 50%
HF with preserved EF (HF pEF)Seen in older patients with HTNLess dilation and normal EF“Diastolic dysfunction” on ECHO
Classification of HF severityNYHA functional class ACC/AHA stage
I No limitations A At high risk for HF, no structuralheart disease
II Symptoms withordinary activity
B Structural heart disease without s/sx HF
III Symptoms with < ordinary activity
C Structural heart disease + sx HF
IV Symptoms at rest D Advanced structural heart disease + sx at rest despite max medical therapy
HF with Preserved Systolic Function “Diastolic Dysfunction” Valvular Heart Disease
Severe mitral regurgitation Severe mitral stenosis Severe aortic insufficiency Severe, end‐stage aortic stenosis
Uncontrolled arrhythmias: Atrial Fibrillation Incessant PAT, VT>> ”rate‐related cardiomyopathy”
Pericardial constriction Restrictive cardiomyopathy
Amyloidosis Radiation Genetic
Diastolic DysfunctionGreater incidence of
HTNDiabetesObesity
Equal incidence ofSleep apneaAtrial fibrillation
Lesser incidence ofCoronary disease
Older age
More women
Preserved LVEF
Small LV cavity
More LVH
Variable cardiomegaly
S4 rather than S3
TreatmentWhich medications and in what order?Does it matter what type of HF?Which drugs have been proven to reduce bad
outcomes (hospitalization and mortality)?
Pharmacologic therapy
ACE inhibitor/ARBBeta‐blocker
Aldosterone antagonistHydralazine/isosorbide dinitrate
Modify course of disease(reduce mortality, morbidity, etc)
Relieve symptoms
DiureticsDigoxin
Paradigm for Management of Heart Failure due to systolic dysfunction
Treat Residual Symptoms
Digoxin
Control volume
Diuretic Beta Blocker+
Slow Progression of Disease
ACEinhibition
Aldo Blocker ?+
ISDN/Hydr ?+
ACE Inhibitors in HFGeneric Name Starting Dose Target Dose ½ Life-hr
Captopril 6.25 mg tid 50 mg tid < 2
Enalapril 2.5 mg bid 10 mg bid 11
Lisinopril 5 mg qd 10-40 mg qd 13
Ramipril 1.25 mg bid 5 mg bid;10 qd 13-17
Quinapril 5 mg bid 10 mg bid 2+
Trandalopril 1 mg qd 4 mg qd 16-24
Angiotensin Receptor Blockers (ARBs) in HFARB Name Starting Dose Target Dose
Losartan(Cozaar)
25 mg BID or 50 mg once daily
12.5 mg BID or 25 mg once dailyif liver disease
75 mg BID
Candesartan(Atacand)
4 to 8 mg once daily 32 mg once daily
Valsartan(Diovan)
80 mg once daily160 mg once daily
80 mg once daily if liver disease
Irbesartan(Avapro)
150 mg 300 mg once daily
Clinical challenge: angioedemaYou are seeing a 65 year old woman in the office for asymmetric facial edema involving her upper lip and adjacent cheek noted when she awoke four hours ago. There is no tongue swelling or dyspnea, history of trauma or known insect bite. Her meds include lisinopril 20 mg daily which she has taken for 3 years for systolic HF . She is anxious but not in distress and has normal VS. There is no facial ecchymosis or laceration, oral mucosal lesion or other abnormality apart from the edema as described.
Clinical challenge: angioedemaOptimal management at this time would be to:
1. Give epinephrine 1 amp IM and intubate to protect the airway.
2. Admit to the hospital for observation.3. Discontinue lisinopril and switch to an ARB;
caution the patient that angioedema may recur.4. Continue lisinopril and refer for allergy
consultation.
ACE inhibitor vs. ARB
Angiotensin II
Angiotensin I
Bradykinin
ARB
ACE inhibitor
Inactive breakdownproducts
Angiotensin IIreceptors
Angiotensin converting enzyme
CoughARB• Consider if cough with ACEi• Less risk of angioedema than with ACEi• Similar incidence of renal failure, K
• Routine combination ACEi + ARB not recommended• Risk of complications (hyperkalemia, renal failure)• May consider if persistent symptoms on ACEi + BB ( hospitalizations?)
Beta‐blockers
Start when clinically compensated (after diuresis) Avoid initiating or increasing dose when decompensated
Hypotension without hypoperfusion is okay Fatigue for a few weeks may follow initiation or dose increase, and is usually self‐limited
Copyright ©2012 American College of Cardiology Foundation. Restrictions may apply.
Fiuzat, M. et al. J Am Coll Cardiol 2012;0:j.jacc.2012.03.023v1-S0735109712011448
All-Cause Death or Hospitalization by Beta-Blocker Dose at Baseline
Which beta‐blocker? Based on testing in clinical trials
Bisoprolol, carvedilol, metoprolol succinate (CR/XL)
Non‐selective 1, 2 1 selective
Carvedilol (also 1 blocker) Metoprolol, bisoprolol
May have more problems with hypotension
Consider if reactive airway disease
Both meds for all patients with systolic HF ACE inhibitor + beta‐blocker indicated for all patients with LV systolic dysfunction* Regardless of symptom status (asymptomatic to severely symptomatic) or cause of HF
Combination reduces mortality by 46% v placebo
*Unless contraindications or intolerance: ACEi: angioedema, ↑K+, renal failure, cough Beta‐blocker: bradycardia, high‐degree AV block, severe reactive airway disease
Both: Hypotension (usually symptomatic)
Aldosterone antagonistsSpironolactone, eplerenone
For NYHA class II* ‐ IV; not currently indicated for class I
Add to combination of ACEi + beta‐blocker + diuretic Eplerenone
*Benefit for mild systolic HF (NYHA class II) Consider if gynecomastia from spironolactone Currently approved for HTN or post‐MI HF
Similar incidence of renal insufficiency, ↑K+
* EMPHASIS. N Engl J Med 2011;364:11
Hydralazine + isosorbide dinitrateUse for
ACEi/ARB‐intolerant Due to CKD, K+
Hyd/ISDN ~30% mortality vs placebo (vs ~50% with ACEi vs placebo)
African‐American pts
NYHA III‐IV On top of standard background med therapy
mortality (43%)
Morbidity benefit (symptoms, hospitalizations) No effect on mortality Use for symptomatic patients, or for a‐fib rate control
Lower target serum levels for HF treatment ‐ higher levels (≥ 1.2 ng/mL vs. 0.5‐0.8 ng/mL ) are associated with higher mortality
If clinically stable on digoxin, don’t routinely withdraw digoxin (may risk decompensation)
Digoxin
Clinical challenge: now what? 78 year old man with ischemic CM (EF 25%) comes in with progressive fatigue and edema (sacral, scrotal and 4 + pitting to the mid calf bilaterally). He is taking lisinopril 40 mg QD, carvedilol 25 mg BID, simvastatin, aspirin, spironolactone 25 mg QD and furosemide 40 mg BID.
Despite doubling his furosemide at the last visit two weeks ago he hasn’t lost weight and is still 15 pounds over his baseline dry weight.Now what do you do?
Diuretics With more severe HF, combination diuretics may be needed and can produce a synergistic effect Loop + thiazide ? ± aldosterone antagonist
When adding thiazide, consider metolazone 2.5 – 5 mg TIW due to long half life.
Close follow‐up with monitoring of daily weight, electrolytes and creatinine is essential
Absorption may be impaired with severe edema Consider bumetanide, torsemide, or IV diuretics
NYHA I(asymptomatic)
NYHA II(symptoms with moderate activity)
NYHA III(symptoms with mild activity)
NYHA IV(symptoms at rest)
Medical therapy for systolic HF● ACE inhibitor (or ARB)
Hyd/ISDN if ACEi/ARB intolerant● Beta‐blocker
If black, Hyd/ISDN
DigoxinDiuretic(s)
Hyd/ISDN = hydralazine/isosorbide dinitrate
Spironolactone(or eplerenone)
Which (if any) of below medications are indicated for the following patients to prolong survival?
50 year old woman, non‐ischemic cardiomyopathy for 20 years, EF 35%, asymptomatic (NYHA class I)
60 year old man, ischemic cardiomyopathy, EF 15%, short of breath at rest (NYHA class IV)
40 year old man, non‐ischemic cardiomyopathy, EF 20%, symptoms with moderate exertion (NYHA class II)
35 year old African‐American man, non‐ischemic cardiomyopathy, EF 30%, asymptomatic (NYHA class I)
ACE inhibitor Beta‐blocker• Metoprolol
succinate• Carvedilol• Bisoprolol
Aldosterone antagonist
• Spironolactone• Eplerenone
Digoxin
Hydralazine + isosorbide dinitrate
Diuretic
Which (if any) of below medications are indicated for the following patients to prolong survival? 50 year old woman, non‐ischemic cardiomyopathy for 20 years, EF 35%, asymptomatic (NYHA class I) ACE inhibitor, Beta‐blocker
60 year old man, ischemic cardiomyopathy, EF 15%, short of breath at rest (NYHA class IV) ACE inhibitor, Beta‐blocker, Aldosterone antagonist
40 year old man, non‐ischemic cardiomyopathy, EF 20%, symptoms with moderate exertion (NYHA class II) ACE inhibitor, Beta‐blocker, Aldosterone antagonist
35 year old African‐American man, non‐ischemic cardiomyopathy, EF 30%, asymptomatic (NYHA class I) ACE inhibitor, Beta‐blocker NOT hydralazine + isosorbide dinitrate
What caused this patient’s HF decompensation?
50 year old man, long standing non‐ischemic cardiomyopathy, usually asymptomatic (NYHA class I)
Went on a cruise for vacation Forgot some of his medications Sprained ankle hiking, treated with ice and ibuprofen Enjoyed eating at many buffets
Presents to your office because of 8 pound weight gain, new orthopnea, edema, and dyspnea with activity
Exam notable for JVD, crackles, irregularly irregular rhythm, peripheral edema
Inappropriate drug therapyNegative inotropy
Beta‐blocker Dose too high, uptitrated too quickly
Early generation calcium channel blocker Verapamil, nifedipine, diltiazem
Fluid retention Thiazolidinedione (rosiglitazone, pioglitazone)
Renal impairment NSAIDs Over‐diuresis
What caused this patient’s HF decompensation?
50 year old man, long standing non‐ischemic cardiomyopathy, usually asymptomatic (NYHA class I)
Went on a cruise for vacation Forgot some of his medications (medication compliance)
Sprained ankle hiking, treated with ice and ibuprofen (inappropriate drug therapy ‐ NSAID)
Enjoyed eating at many buffets (sodium, alcohol?) Presents to your office because of 8 pound weight gain, new orthopnea, edema, and dyspnea with activity
Exam notable for JVD, crackles, irregularly irregular rhythm, peripheral edema (new onset arrhythmia)
HF with preserved EF
Redfield MM. JAMA 2003;289:194
Prevalence of HF2.2%
EF > 50%
EF ≤ 50%
44%56%
Medical therapy for HFPEF Systolic HF prognosis has improved with use of evidence‐based therapies
But not for HFPEF despite trials of same meds – why? Different mechanisms for remodeling Methodologic issues with trials
Many pts with HFPEF treated with same meds as for systolic HF (ACEi, BB, etc) Similar comorbid conditions (HTN, CAD, etc)
Acute management
Venous congestion (pulm, systemic edema)
Diuretics Consider IV NTG, morphine, O2
for pulm edema
Hypertension Standard therapy – multiple
agents available If severe, IV nitroprusside
Myocardial ischemia Standard therapy – aspirin, BB, heparin, etc
Tachycardia (atrial fibrillation)
Rate control, prn cardiovert
Chronic management Very few large trials to guide management
Reasonable to target risk factors for LV hypertrophy (diabetes, HTN) → ?prevent development of diastolic dysfunction, HF
Once HFPEF present, Control hypertension, heart rate Treat ischemia if present
ACC‐AHA guidelines (2009): Pts with HF + normal LVEF
Class I: benefit >>> risk, “should be done” Control systolic and diastolic hypertension Control ventricular rate if in atrial fibrillation Diuretics for pulmonary congestion, edema
Class IIa: benefit >> risk, “reasonable to do” Coronary revascularization if CAD + symptoms or ischemia on testing, thought to adversely affect cardiac function
Patient Education
What do you tell your patients with HF so that they can take better care of themselves?
What caused this patient’s HF decompensation?
50 year old man, long standing non‐ischemic cardiomyopathy, usually asymptomatic (NYHA class I)
Went on a cruise for vacation Forgot some of his medications (medication compliance)
Sprained ankle hiking, treated with ice and ibuprofen (inappropriate drug therapy ‐ NSAID)
Enjoyed eating at many buffets (sodium, alcohol?) Presents to your office because of 8 pound weight gain, new orthopnea, edema, and dyspnea with activity
Exam notable for JVD, crackles, irregularly irregular rhythm, peripheral edema (new onset arrhythmia)
At each visit Reconcile medications
Review guidance for patient and caregiver Diet Medications Activity level Follow up appointments Daily weight monitoring What to do if HF symptoms worsen
Post‐discharge care, rapid clinic follow up
Which of the following is true regarding exercise with systolic HF?
? Patients with systolic HF should in general avoid regular cardiovascular exercise
? Cardiac rehabilitation improves survival in systolic HF
? Patients with systolic HF who participate in exercise are at increased risk for arrhythmic events
? Patients with systolic HF should include maximal isometric exercise in their routine
Exercise training Useful adjunctive treatment of stable outpatients with HF, along with drug therapy
Improved exercise capacity (peak VO2), subjective symptoms, quality of life
ACC/AHA Class I recommendation but no effect on “hard outcomes” – mortality, etc (Level of evidence = B)
Which of the following is true regarding exercise with systolic HF? Patients with systolic HF should in general avoid regular cardiovascular exercise
Cardiac rehabilitation improves survival in systolic HF
Patients with systolic HF who participate in exercise are at increased risk for arrhythmic events
Patients with systolic HF should include maximal isometric exercise in their routine
→None of the above
Palliative care Consider if
There are severe functional limitations End‐organ dysfunction due to hypoperfusion Disease progression despite optimal therapy
Potential treatment options for advanced HF include several invasive procedures (RCT, VAD) which may not be consistent with patient wishes or best interest
Particular issues in late stage HF include persistent dyspnea, malnutrition, renal failure and edema leading to anasarca
End of Life Care Planning Advanced directives Delegate surrogate decision maker Document into Epic Problem List (EMR) POLST (DNAR and limited interventions) Hospice Death with Dignity‐ Compassion and Choices
Medical therapy for systolic HFConsider HF? Think CCCUTEE
ACE inhibitor and beta‐blocker indicated for all, regardless of symptom status
For mild ‐ severe HF (NYHA class II‐IV), add aldosterone antagonist
For severe HF (NYHA class III‐IV) and African‐American, above + hydralazine‐isosorbide dinitrate
Use digoxin for symptoms and atrial fibrillation rate control (no survival benefit)
BNP Interpret in context of other, non‐HF factors which will influence levels
Cannot distinguish between systolic HF vs. HFPEF
Benefits of outpatient management guided by BNP mainly driven by closer follow up and more aggressive titration of medications
When to consider admissionEvidence of severe acute decompensated HF
Dyspnea at rest
Hemodynamically significant arrhythmia
Acute coronary syndrome
Major electrolyte disturbance
Associated comorbid condition
Repeated ICD firing
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