Outpatient management of heart failure

Dr. Rob Wu

Feb 2008

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

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 ?

Some questions

• LVEF>50%! 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?

Resources

• CCS Heart failure guidelines 2007, 2006

• Definition

• Epidemiology

• Diagnosis

• Management

• Quality

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 2006;22(1):23-45.

Heart Failure Mortality

• Canada’s average annual in-hospital mortality rate is:– 9.5 deaths/100 hospitalized patients >65

years of age– 12.5 deaths/100 hospitalized patients >75

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 2004;20(6):599-607.

Projected number of incident hospitalizations for CHF patients, using high, medium and low population growth projections in Canada 1996-2050

HF – An epidemic ?

Johansen et al. Can J Cardiol 2003;19(4):430-5.

HF Readmissions

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

8.7

14.1

23.6

0

5

10

15

20

25

30 days 90 days 1 year

Ra

te p

er

10

0 c

ase

s

Canadian Hospital Readmission Rates for Any Heart Failure

Lee DS et al. Can J Cardiol 2004;20(6):599-607.

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

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 2006;22(1):23-45.

Management

CCS HF guidelines 2006. Can J Cardiol 2006;22(1):23-45.

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

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 <2gm/day

• Fluid restriction– Not necessarily all patients, just those with difficult to

control HF or sodium issues (1.5 – 2 L / day)

Medications

• ACE

• ARB

• BB

• Spironolactone

• Digoxin

• Diuretics

ACE

• All HF patients with LVEF <40% should be treated with an ACE-I and a beta-blocker, unless a specific contraindication exists

(Class I, Level A)

• 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 2006;22(1):23-45.

Practical Tips for ACE-I/ARB Use

• 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 1999;353:2001-7. CIBIS II Investigators. Lancet 1999;353:9-13. Packer M et al. Circulation 2002;106:2194-9.

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

When to Use Beta-blockers?

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 2006;22(1):23-45.

When to Use Aldosterone Blockers?

Pitt B et al. N Engl J Med 1999;341:709-17.

Spironolactone:• Patients with LVEF 30% and severe symptoms

despite optimized other therapies (and Creat <200, K <5.2) (Class I, Level B)

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

• 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)

When To Use Digoxin?

The Digitalis Investigation Group. N Engl J Med 1997;336:525-33.Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

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 1986;314:1547-52. Taylor AL et al. N Engl J Med 2004;351:2049-57.

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

Drug Interactions and Additive Adverse Effects of Common Medications

(Class I, Level B)

Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

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 2006;22(1):23-45.

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 2006;22(1):23-45.

Remainder of Slides are Optional….

Review if time permits….

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 >250 µmol/L or an increase of > 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 2007;23(1):21-45.

Geriatric HF

• (this is us)

• Frailty score – predicts

• Death• Need for

institution

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

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 2006;22(1):23-45.

Practically, which referrals will be accepted by a Heart Failure Specialist?

Definitely pre-transplant candidatesAge <60Candidates for devices (AICD, biventricular pacer, LVAD)LV systolic dysfunction (LVEF <40%)

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 2006;22(1):23-45.

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

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 ?

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

web resources

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