tim sutton, cardiologist counties-manukau dhb and …...renal dysfunction is common in patients with...
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Tim Sutton, CardiologistCounties-Manukau DHB and Auckland Heart
Group
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Exertional dyspnoea
Orthopnea
Paroxysmal nocturnal dyspnoea
Oedema
Third heart sound Elevated JVP Basal rales Swollen ankles
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Temporal trend
Effort tolerance – NYHA classificationFunctional class Symptoms
I No limitation of physical activity : Ordinary physical activity does not cause undue breathlessness, fatigue or palpitations
II Slight limitation of physical activity : Comfortable at rest, but ordinary physical activity does not cause undue breathlessness, fatigue or palpitations
III Marked limitation of physical activity : Comfortable at rest, but less than ordinary physical activity does not cause undue breathlessness, fatigue or palpitations
IV Unable to carry on any physical activity without discomfort :Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased
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ECG
Chest X-ray
Nt-proBNP : ◦ best done pre diuretic Rx / good renal function
“Baseline bloods”◦ FBC, U+Es, Glu, LFTs, INR, Albumen, TFTs and ferritin
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1) Assess LV size and function
◦ Systolic and diastolic
◦ Regional vs global
2) Assess LV wall thickness
3) Assess valve function
4)Assess RV function
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Dilated heart Normal size
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Preserved EF Reduced EF
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Above 50-55%
Mild 40-50%
Moderate 30-40%
Under 30% severe
Under 20% very severe
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Regional Gobal
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Symptoms typical of HF
Signs of typical HF
Reduced EF
Symptoms typical of HF Signs of typical of HF Normal of mildly reduced
EF and LV NOT dilated Relevant structural heart
disease (LVH / LA enlargement) and / or diastolic dysfunction
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Sudden decompensation◦ Patient often euvolaemic – right amount of fluid, just in
the wrong place◦ Transient rise in left atrial pressure causing lungs to
flood with fluid (acute pulmonary oedema)
Sub-acute / chronic decompensation◦ Gradual accumulation of fluid – congestive state with
generalised fluid retention (oedema)◦ Hypervolaemia – too much fluid all over the place
Did the patient previously have a normal heart?◦ Yes….. Ischaemia
◦ No…… Ischaemia / arrhythmia / increased afterload etc
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What is the cause of the heart failure?
What has triggered the presentation?◦ De novo diagnosis
◦ Decompensation secondary to:
Natural history of underlying condition
Intercurrent factor
Anaemia Infection Drugs
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Diagnosis : usually a chronic disease
What is our treatment goal?
◦ “Our aim is to keep you as well as we can for as long as we can, ideally leading as normal life as possible with no restrictions on what you can do, with as few pills as possible, but as many as are needed”
Non pharmacological
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Exercise
Diet – weight loss in the obese, but beware the malnourished
obese patient
Salt “restriction” – stick to the RDA!
Minimise / avoid environmental cardiotoxins
◦ Alcohol Metamephetamine Smoking
No place for fluid restriction except in exceptional situations
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Is essential – regular : daily exercise improves well being and survival
Avoid extremes of dynamic exercise – only mild static exercise
Patient can engage in a formal exercise program – moderate intensity aerobic vs high intensity interval training
“A person should put aside some
part of the day for the care of his
body. He should always make sure
that he gets enough exercise
especially before a meal."
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Diagnosis : usually a chronic disease
What is our treatment goal? “Our aim is to keep you as well as we can for as long as we can,
ideally leading as normal life as possible with no restrictions on what you can do, with as few pills as possible, but as many as are needed”
Non pharmacological
Pharmacological
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Loop diuretics
◦ Use dose that maintains the patient oedema free
◦ Relieve dyspnoea, but usually do not need high doses
◦ Monitor for side effects
Renal dysfunction / electrolyte derangement / gout
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ACE inhibitor / Angiotensin receptor blocker
◦ Any patient with impaired systolic function
◦ Optimal dose – depends on agent
Cilazapril 2.5mg (od) Quinapril 10mg (bd)
Losartan 50mg (od) Candesartan 16mg (od)
◦ Monitor renal function and electrolytes
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◦ Start when euvolaemic
◦ Start low and go slow (increase every 2 weeks)
◦ Warn patient may feel slight worse for a few days
If more breathless increase diuretic dose : sx should settle
◦ Aim for maximum tolerated dose
Metoprolol CR 190mg (od) Bisoprolol 10mg (od)
Carvedilol 25mg (bd)
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When is dose optimised for an individual?
◦ When maximum dose reached
◦ When heart rate in low 50s
◦ Hypotensive symptoms
Can Beta-blockers be used in airways disease?
◦ Generally yes – survival benefit offsets risk : see improvement in lung
function
◦ Not in brittle asthmatics / marked airway hyper-reactivity
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Fatigue – but you can still do more than pre Rx?
Hypotensive Sx – try and cut the other meds
Erectile dysfunction – agents to assist
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Who: Anyone with symptomatic heart failure due to impaired systolic function
Dose : ◦ Spironolactone (12.5mg), 25mg aim 50mg
◦ Eplerenone (25mg) 50mg aim 100mg
Monitor for side effects◦ Renal dysfunction / hyperkalaemia
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Maximum tolerated doses of
◦ ACEi / ARB
◦ Beta blocker
◦ Aldosterone receptor antagonist
◦ +/- diuretic
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Fluid status Weight JVP Lungs Oedema Postural BP Renal function
Hypervolaemia Climbing High Rales Present May be a rise with standing
Stable / worse
Euvolaemia Stable Stable – may be high if TR
Clear Absent No drop Stable
Hypovolaemia Falling Low Clear Absent Present Climbing
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Digoxin
◦ reduces hospitalisation, but not survival
Amiodarone
◦ only for symptomatic arrhythmia, otherwise shortens life
Ivabradine (not in NZ yet)
◦ improves survival in those on optimal dose beta-blocker and HR >77bpm
at rest
Nitrate and hydralazine
◦ Very old school!
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Is more common in:-◦ Elderly◦ Females◦ Obesity / diabetes / hypertension
Is the commonest cause of pulmonary hypertension in the elderly
Prognosis just as bleak as for systolic dysfunction
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◦ Stiff, non compliant heart : squeezes OK, but does not fill well
◦ At rest is usually fine, but anything that increases heart rate can causes symptoms
Infection / anaemia / metabolic derrangement
Exercise
Atrial arrhythmias
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Prevention is better than needing to actually treat!
No proven Rx once established◦ Low dose diuretics
◦ Negative chronotropes to slow heart
◦ Spironolactone if Nt-BNP high (>300) and symptoms
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Polypharmacy with potential side effects
Takes 3-6 months to get right
◦ Drs much better with HF-ReF than HF-PeF!
Treatment is usually for life
◦ There is a risk to suddenly stopping medication
◦ There is a risk to not taking pills and then taking OMT doses
Multiple contacts with medical system
◦ Nurse / primary and secondary care
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Diagnosis : usually a chronic disease
What is our treatment goal? “Our aim is to keep you as well as we can for as long as we can, ideally leading as
normal life as possible with no restrictions on what you can do, with as few pills as possible, but as many as are needed”
Non pharmacological
Pharmacological
Prognosis /general issues that may not be apparent initially
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In the absence of contraindications offered to ◦ Anyone who has survived a sudden cardiac death
◦ Has poorly tolerated VT / LV impairment and syncope that is unexplained
◦ Anyone who has been on and adherent to OMT for three months and has EF of under 30% if non ischaemic CM EF of under 35% if ischaemic CM
◦ Malignant familial history / genotype
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An ICD is permanent
It is not an active therapy : it will not make the patient feel
better
An ICD does not alter the natural history of the underlying
disease – one day pump failure will predominate and
consideration should be given programming shock therapy
off
Not everyone wants an ICD – they do come with risks
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◦ The patient should contact / attend their ICD clinic
ICD will be read and rhythm reviewed
May be a change in ICD settings
◦ The patient cannot drive a car for 6 months
◦ There may be a period of emotional lability / depression or even post traumatic stress disorder (more common after ICD storms)
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Not very common to see, but this will change over time
Improves symptoms and survival
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Wairua(Spiritual health)
Whanau (Family)
Tinana(Physical Health)
Hinengaro(Mental health)
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Class 1 or 6: Driving OK unless very symptomatic
Class 2,3,4,5 or P endorsement: Generally individuals will be unfit to drive – special dispensation is available
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”If can mount 2 flights of stairs, reasonably quickly,
without too much problem then sex should be fine.”
Keep GTN available (not with Viagra though).
Activity is least likely to cause symptoms if engaged in
after a good night’s sleep and with the least affected
partner doing most of the work”
Viagra is safe
Patient plus website – www.patient.co.uk
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Uncontrolled AF can cause heart failure ◦ AF induced tachycardiomyopathy
◦ Rate Rx vs restoration of SR
The onset of AF can cause decompensation of a previously stable cardiac condition
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Anticoagulation (in the absence of contraindications) is a must◦ Warfarin NOAC: Dabigatran, Rivaroxiban, Apixiban
Good rate Rx important◦ Beta blocker◦ Digoxin◦ Amiodarone◦ Ideally avoid diltiazem◦ Interventional Rx : pulmonary vein isolation / CRT and AV nodal
ablation
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Only Rx aspirin / clopidogrel if proven vascular disease
Anticoagulation with warfarin (INR 2-3) or NOAC for◦ Any proven AF◦ Any patient with impaired EF and embolic event when in
SR◦ Documented LV thrombus
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Renal dysfunction is common in patients with heart failure (Cardiorenal
syndrome)
Multiple factors contribute
Renal dysfunction can improve with treatment of heart failure
Renal dysfunction in heart failure is not a contraindication for an ACEi / ARB,
but a reason for caution – can use spironolactone, but only with specialist
input due to risk of hyperkalaemia
Balance risk of a slight worsening in renal function against benefits of
cardioprotective agents
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Actively treat iron deficiency◦ Oral iron replacement may not be effect
◦ Iron infusion excellent way of treating
◦ No clear role for EPO or analogues as yet – may be harmful
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Commonly coexist
Central sleep apneoa common in CHF and
treatment of CHF can improve it
OSA common – cannot easily assess until on OMT
Baseline and post Rx ESS can be useful
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Variable data
Reasonable to continue if one is on a statin
Start if have ACS / high CV risk
But otherwise… just another pill, especially in advanced heart failure
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Address the underlying cause as best as possible – often multifactorial
Correct the reversible – especially hypoxia
Optimise Rx for left heart disease
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Aries Avoid incisions in the head and face and cut no vein in the head.
Taurus Avoid incisions in the neck and throat and cut no veins there.
Gemini Avoid incisions in the shoulders, arms or hands and cut no vein.
Cancer Avoid incisions in the breasts, sides, stomach and lungs and cut
no vein that goes to the spleen.
Leo Avoid incisions of the nerves, lesions of the sides and bones,and
do not cut the back either by opening and bleeding.
Virgo Avoid opening a wound in the belly and in the internal parts.
Libra Avoid opening wounds in the umbellicus and parts of the belly
and do not open a vein in the back or do cupping.
Scorpio Avoid cutting the testicles and anus.
Sagittarius Avoid incisions in the thighs and fingers and do not cut
blemishes and growths.
Capricorn Avoid cutting the knees or the veins and sinews in these places.
Aquarius Avoid cutting the knees or the veins and veins in these places.
Pisces Avoid cutting the feet.
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Address the underlying cause as best as possible – often multifactorial
Correct the reversible – especially hypoxia
Optimise Rx for left heart disease
Diuretics◦ Best taken on empty stomach, 30 minutes before food◦ Frusemide vs bumetanide◦ Oral vs IV◦ Spironolactone◦ Metolazone – use cautiously and watch electrolytes
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Important to identify disease progression
Review medications – any room to push further
Acknowledge disease progression – this is not a failure of treatment, rather the natural
history of the underlying disease
Any non essential medications that could be stopped
Advanced care planning : review ICD status if present
Advanced stages of heart failure are unpredictable and patients can survive months to
years with advanced Sx / poor prognostic markers – aim is to ensure they remain well,
but not to prolong suffering
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Patients with suspected heart failure – newly diagnosed
Patients with known heart failure who are◦ Deteriorating – sub-acute vs chronic
◦ Running into problems with medication side effects
◦ New onset AF
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Help further establish diagnosis and cause of heart failure
Help initiate Rx and optimise Rx
Discuss diagnosis and provide education
Help establish chronic management plan
Offer support through the early phase of the disease
management
Provide follow up once on OMT – usually annual
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Community ◦ Review patients in their own enviroment / clinic
Check for polypharmacy – drug inconsistencies
◦ Once stable – 3 monthly review : Check adherence to Rx and side effects
Review obs and weight chart
Lifestyle and psychosocial issues
Preventative programme : flu jab