Heart Failure 2011 Cardiac Issues Robert A. Ortiz, M.D., F.A.C.C. Yakima Heart Center

Heart Failure Definition Syndrome Caused by Cardiac Dysfunction: Myocardial Muscle Dysfunction or Loss. LV dilatation and/or hypertrophy. Neurohormonal and Circulatory Abnormalities: Fluid Retention. Dyspnea. Fatigue. Progressive decline if left untreated. Symptoms vary with time and sometimes do not correlate with the degree of heart dysfunction.

Subgroups of HF Heart Failure with a Reduced LVEF Dilated Cardiomyopathy Ischemic Cardiomyopathy Commonly associated with Chamber Enlargement Heart Failure with a Preserved LVEF Commonly Non-Dilated LV Potential Causes Valvular disease, Cardiac Ischemia (RVMI), Pericardial disease, HTN, Renal disease, Hypertrophic HD, Rhythm problems, …

To Do List First - Make the Diagnosis Second - Determine the Potential Causes Third - Clinical Assessment (Brief) Forth - Initiate Early Treatment Frequent Reevaluation (Treatment Adjustment) Fifth - Transition to Chronic Treatment Surgery, Bi-V pacing, ICD, Sleep Apnea Rx, … Sixth - Patient Education

Diagnosis * Primarily on Signs and Symptoms * If uncertain BNP or pro-BNP may help support the diagnosis BNP or pro-BNP should not be viewed in isolation to make the diagnosis of heart failure.

Treat the Cause Not Just the Symptoms This is especially True for HF with Preserved LV systolic function, since there may be a structural problem that requires surgical intervention. The History is frequently the Key to determining the Cause. Diagnostic Tests just help confirm the initial impression. ECG, Echo, Cath, X-rays and Labs. Look for things that don’t make sense: Expect the Unexpected. Heart Failure is a Syndrome with many potential causes, which may occur simultaneously.

References: 1. Stevenson LW. Tailored therapy to hemodynamic goals for advanced heart failure. Eur J Heart Fail. 1999;1: Available at: 2. Fonarow GC. The treatment targets in acute decompensated heart failure. Rev Cardiovasc Med. 2001;2(suppl 2):S7-S12. Warm & Dry PCWP* normal CI † normal (compensated) Warm & Wet PCWP elevated CI normal Cold & Dry PCWP low/normal CI decreased Cold & Wet PCWP elevated CI decreased Congestion at rest Low perfusion at rest Vasodilators, diuretics No Yes Normal SVRHigh SVR *Pulmonary capillary wedge pressure. †Cardiac index. Clinical Assessment

Initial Treatment Early Treatment leads to better outcomes and shorter hospital stays. Treatment should begin immediately following the clinical assessment. Oxygen therapy, IV access. ABC of CHF - This is a heart failure CODE. Don’t Assume the Initial Treatment will work. Early reassessment at 15 minute intervals until clinical improvement becomes apparent. Use Tests and Labs to guide treatment! Even better - Use your brain to guide treatment.

Initial Treatment Loop Diuretic Therapy - For elevated volume status. At least the home dose in an IV bolus or drip. ACE Inh, ARB, Hydralazine, NTG/Nipride - Perfusion? IV versus Oral versus Topical? How stable? Is the BP low or high? Beta blockers - Appropriate or not? Is their elevated HR their method for compensation? Is the HR already too slow? What other medical problems do they have?

Initial Treatment Inotropic support? Poor perfusion or shock? Hemodynamic monitoring - Art line? ECG, Oxygen saturation and ICU monitoring. Monitor urine output - Foley catheter is not always needed. Central venous line is not always needed. Ultrafiltration or Dialysis? Sodium and water removal or is more needed.

Initial Treatment Rhythm Support? Temporary Pacing? Atropine, Dobutamine, Dopamine? IABP/Impella support? Revascularization - PCI? Intubation and Mechanical Ventilation? Other Treatments? Blood transfusion, phlebotomy, SCD, CPAP/Bipap, narcotics or reversing agents, …

Initial Treatment Concepts to Remember: Stabilize first. Monitor vitals, urine output and Wt. Prioritize and treat the various problems. Example: If they are volume overloaded and anemic, get the fluid off first then transfuse. First do no harm. If the patient is still unstable avoid adding a treatment that might make them better but has a significant risk of causing an acute decompensation - commonly seen with Beta blocker therapy for a compensatory sinus tachycardia. Non-invasive test are preferred to tests that might impair kidney function or respiratory status. Keep the patient as informed as possible, given the circumstances. Patient comfort is also key to recovery.

Chronic Treatment The goal now is to transition from acute care management to chronic therapy: Stable oral meds for at 24 hours prior to discharge. Arrange any surgical referrals if needed: CABG, valve surgery, pericardial surgery, pacing/ICD therapy, dialysis catheter, … Chronic outpatient treatments to be arranged: Sleep apnea evaluation. Dialysis. Cardiac rehab and diet education. Out patient follow-up and Home Health Care.

Patient Education What Questions Should Patients be Asking? What is Heart Failure? (Their type) What is the Prognosis? (For them) What can they do to Prevent further problems? Would any Surgery help? What Special Treatments might help? Pacemakers/ICD, Dialysis, CPAP/Bipap, … Would Rehab and additional Education help? Understanding the Patient and their problems are key to finding the right answers.

Death due to Heart Failure 50% due to progressive multisystem failure. 50% due to sudden cardiac death. Presumably V-fib or V-tach. Other causes: Pulmonary emboli, aortic dissection, stroke. “Yes, but how soon before I die?!” Depends!

Clinical Trials and the Real World Clinical Trials Demographics: 80% Male. Average age 60 years. Low LVEF. Few Co-morbidities. Yearly mortality: About 20%. Real World Demographics: 60% Female. Average age 80 years. Half the patients had preserved LVEF. 5 or more Co-morbidities. Yearly mortality: About 35%.

Goals for Medical Treatment Address the Risk Factors. Predictors of Higher Mortality: BUN >43, Creatinine >2.75, SBP <115 Is Sleep Apnea or Renal Failure present? Is there a need for CRT and/or ICD? CRT can improve symptoms and possibly survival. ICD may improve survival but not symptoms. Determine if Surgery is needed: PCI or surgical revascularization. Valve surgery or pericardial stripping. Heart transplant or a cardiac assist device. Determine if Hospice is Appropriate.

CRT: Bi-Ventricular Pacing

ACC Update for 2009

Old and New Ideas What’s more important Pulmonary Artery Pressure or Cardiac Index in determining outcome? The rational for medical therapy. Atrial Fibrillation: Is rhythm control better than rate control? Equivalent. What is Ultrafiltration and is there any measurable benefit beyond the rapid removal of fluid and a potentially shorter hospital stay? Drug Therapy may vary based on Race. Blacks may benefit from Fixed dose Hydralazine/Isosorbide on top of standard drug therapy. Side effects of medical therapy may also vary between races.

Old and New Ideas What ever happened to Nesiritide? The IV drug nesiritide isn't especially better than standard treatment for patients with acute decompensated heart failure (ADHF), nor does it seem to hurt the kidneys or increase mortality, suggests a >7000-patient trial now published in the July 7, 2011 issue of the New England Journal of Medicine. FUSION 2: No advantage to outpatient nesiritide infusions in advanced chronic heart failure, but no harm either. "Clearly," Yancy said, "an unmeasured, but we think very substantial, benefit of intensive heart-failure disease management—based on the once- or twice-weekly clinic visits, four to six hours at a time, with a concomitant observed improvement in medical therapy during the initial 12-week assessment period—mattered. We believe that the patients in FUSION-2 received not standard care but extraordinary care."

PCWP predicts mortality 1 CI † does not predict mortality 1  1-year survival rate for patients with PCWP 18 mm Hg 1 *Pulmonary capillary wedge pressure. †Cardiac index. Hemodynamic assessment of 456 heart failure patients after tailored therapy. Reference: 1. Fonarow GC. The treatment targets in acute decompensated heart failure. Rev Cardiovasc Med. 2001;2(suppl 2):S7-S12. n=236 n=220 p=NS Time (months) Mortality risk (%) Cardiac index >2.6 L/min-M 2 Cardiac index ≤2.6 L/min-M 2 n=199 n=257 p= Time (months) Mortality risk (%) PCWP >16 mm Hg PCWP ≤16 mm Hg Adapted from: Fonarow GC. Rev Cardiovasc Med Rational for Vasodilator Therapy

Epilog Heart Failure is the common final pathway of Life. Many effective treatments have been developed to correct the acute problem, but real success in the form of decreased morbidity and mortality is likely to depend on chronic outpatient management. This problem really is too big for Cardiology or Internal Medicine or Family Practice to manage without some help. The patient’s willingness to take responsibility for their own health is the factor that will likely determine their long-term outcome. The education that they receive in the process of being treated will hopefully empower them to control their own destiny.