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Presented by: Bethany Westerfeldt RN, CCRN, MSN, NP-C, ANP, BC For WITNS October 13, 2012.

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Presentation on theme: "Presented by: Bethany Westerfeldt RN, CCRN, MSN, NP-C, ANP, BC For WITNS October 13, 2012."— Presentation transcript:

1 Presented by: Bethany Westerfeldt RN, CCRN, MSN, NP-C, ANP, BC For WITNS October 13, 2012

2   1. Discuss types of Heart Failure  LV systolic dysfunction  HF with preserved LV systolic function (HFpEF) aka diastolic dysfunction  2. Discuss brief pathophysiology of Heart Failure  3. Assessment of Heart Failure  4. Treatments of Heart Failure Objectives

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4   Many etiologies:  Most common etiologies: CAD, HTN, DM, substance abuse(cocaine, alcohol), chemo, peripartum, uncontrolled tachycardia, viral, valvular heart disease, severe illness  Affects cardiac output or quantity of blood pumped to rest of body  Can be improved or controlled with medication and lifestyle changes  Frequency of diagnosis increases with age, more prevalent after age 65 though affects pts at any age point  Syndrome of neurohormonal activation affecting many body systems Types of Heart Failure: Systolic Dysfunction

5   Defined as HF with preserved LV systolic function (normal LVEF) or EF more than 40%  LV often with hypertrophy, concentric remodeling with increased extracellular matrix, abnormal relaxation and filling, decreased diastolic dispensability  Shares activation of neurohormonal activation with systolic dysfunction  Prevalence: 40-50% of all pts diagnosed with HF, often seen in conjunction with systolic dysfunction  More commonly in elderly, females and pts with hypertension Types of Heart Failure: Diastolic dysfunction

6  Heart Failure Classifications:  New York Heart Association (NYHA) functional classification of HF: 1.No limitations of physical activity, no symptoms with ordinary activity 2.Slight limitation, symptoms with ordinary activities 3.Marked limitation, symptoms with less than ordinary activities 4.Severe limitation, symptoms of HF at rest

7  ACC/AHA classification

8   Prolong life  Slow/reverse cardiac remodeling  Reduce visits and admissions to hospital  Improve overall functional capacity and quality of life  Reduce dyspnea and fatigue  Control/minimize edema and fluid retention Therapeutic Goals:

9   At risk for conditions the increase HF risk (both types):  Hypertensive disease, DM, sleep apnea and CAD  Antirejection meds that increase BP, renal disease, risk DM  Solid weight gain: risk for DM, HTN, sleep apnea, atrial arrhythmias  Preexisting conditions:  Limiting activity: Gout, arthritis/DJD, other musculoskeletal disorders, obesity  Structural heart disease: valve disorders, storage diseases (amyloid, hemochromatosis, saroidosis) Transplant population:

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14  CKD and CV disease:  Known high risk of development of CVD in pt. with HTN  Systolic BP more significant than DBP on CV all cause mortality  Pulse pressure (SBP minus DBP)  Independent predictor of MI, HF and CV death  Reflects stiffness larger arteries  Increases with advancing age from 50 yr. on up  Reliable prognostic factor for mortality CKD  Pts on HD or renal transplant patients

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17   SNS activity: “whipping a dying horse”-the catecholamine stimulation  Stimulation of Alpha 1 & Beta 1&2 receptors  Increases cardiac output by increasing heart rate& stroke volume  Prolonged stimulation leads to myocyte hypertrophy, dilation, ischemia, arrhythmias, deterioration and death of cardiac cells  Activates Renin-Angiotensin-Aldosterone System (RAAS)-> (further) vasoconstriction & sodium retention Neurohormonal effects of Heart Failure

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20  Prevalence of specific signs & symptoms in systolic & diastolic HF

21  Signs & Symptoms  Dyspnea & fatigue  Limitation of exercise tolerance  Fluid retention-may lead to pulmonary edema  PND & orthopnea  Cough, can be primarily nocturnal  Poor appetite  Early satiety & bloating  Chest pain: not always in pts with CAD  Palpitations  Lightheadedness  Especially positional  Edema, ascites, anasarca  Poor sleep quality  Difficulty thinking clearly, or concentrating  These abnormalities can impair functional capacity & quality of life

22   Increased adrenergic activity  peripheral vasoconstriction (cool extremities)  pallor &/or cyanosis of digits  diaphoresis  tachycardia  loss of normal sinus rhythm  distention (obvious) of peripheral veins due to vasoconstriction (prominent JVD)  narrowed pulse pressure Clinical signs:

23   Pulmonary rales & /or wheezes:  usually an acute heart failure finding  Chronic HF pts mobilize pulm fluid into lymph nodes:  are enlarged on x-ray & CT  JVD: indication of right atrial pressure (preload)  Normal JVD is under 10 cm  HJR: compression over liver causes distention of JVD further  Indicates congested abdomen/liver and/or inability of right heart to accept or eject the transiently increased volume Clinical signs

24   Ischemic: CAD is the cause of approximately 2/3 of pts LV dysfunction  Remodeling: change in tissue & geometry of LV  Neurohormonal changes:  affect endothelium of vessels as well as cardiac muscle with deposition of fibrinous material  alters contraction and electrical pathways of myocardium  Neurohormonal activation of Renin-Angiotensin-Aldosterone system & Norepinephrine  Down-regulation of alpha, beta 1 & beta 2 adrenergic receptors LV systolic dysfunction

25   Diuretics, ACE-Inhibitors, Beta blockers, Digoxin, Aldosterone blockers, Vasodilators & IV Inotropic agents  Value of these agents shown in multiple clinical trials  Shown to decrease symptoms & increase length/quality of life Treatment of Systolic HF

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27  Diastolic Dysfunction  Abstracted charts from 37,500 Medicare pts from National Heart Failure Project database  Only 57% of pts had LV fxn assessed  Of 19,710 pts with documented EF, 1/3 had EF> 50%  This group was 79% women with mean age of 79.7 yrs

28   Overwhelmingly female (85%) & elderly(70 yo)  Marked increase in LV mass/volume ratio  Higher BMI  More likely to have HTN  Exercise limitation similar to systolic HF pts Characteristics of Outpatient Diastolic HF

29   Increased myocardial stiffness  Ventricular interaction or pericardial restraint  Abbreviated LV filling time  Multifactorial: thyrotoxicosis, AV fistula, beriberi  Volume overload stress  Obesity  Impaired LV relaxation  Myocardial ischemia  Hypertrophy  Systolic dysfunction  DM  Hypothyroidism Diastolic Dysfunction

30   Required criteria:  Normal EF (> 50%)  Clinical Evidence of Heart Failure  Framingham of Boston Criteria  Plasma BNP &/or chest x-ray  Cardiopulmonary exercise testing  Confirmatory Criteria:  LVH or Concentric Remodeling  Left Atrial Enlargement (in absence of AF)  Echo Doppler or Cath Evidence of Diastolic Dysfunction  Exclusions: Non-Myocardial Disease Diastolic Dysfunction Diagnostic Criteria

31   Class I  Control systolic & diastolic BP  Control ventricular rate in AF  Use diuretics to control edema  Class IIA  Coronary revascularization  Class IIB  Restore & maintain NSR  Beta blocker, ACE-I, ARB, Calcium antagonists, digitalis Treatment of Diastolic HF

32   General approach:  Symptom reduction  Control blood pressure  Decrease circulating volume  Salt & fluid restriction  Diuretics  Nitrates  Neurohormonal blockade (ACEI/ARB)  Treat tachycardia  Increase duration of diastole (slow HR) in select pts  Maintain synchronous atrial contraction Treatment of DHF

33   Lifestyle modification & education  Salt & fluid restriction  Exercise program  Other dietary concerns  Weight control  Target underlying mechanisms  Drugs:  that improve calcium homeostasis  blunt hormonal activation  prevent & regress fibrosis are in existence or development Treatment DHF

34   Look at underlying disease processes contributing to DHF & choose drug combinations to combat them  Eg: Diabetic elderly female  Angiotensin blocking drug  Diuretic  beta blocker  CCB if resting HR>70.  Most often requires antihypertensive  Lots of trial & error to finding right combination of meds that minimize symptoms & side effects Treatment of DHF

35   Weigh daily  same time  same clothing amount  Report daily gain of >3 lbs. or overall >5 lbs.  Low salt diet (2 grams)  Take all meds as prescribed  Report any side-effects or problems with meds  Know symptoms of HF & report worsening:  SOB or decreased activity tolerance  Increased fatigue, unable to sleep lying down  Swelling of ankles or abdomen  Frequent colds  Decreased urination, increase in weight Patient self care at home: systolic & diastolic HF

36   Participate in regular exercise & stress reduction  Plan daily activities in advance to conserve energy  Plan strategies to help reduce fatigue:  delegate jobs  take naps or rest periods  Withdrawal of meds known to affect clinical status:  NSAIDS  antiarrhythmic  most calcium channel blockers Pt. care at home:

37   OTC medications to stay away from:  NSAIDS:  ASA (high dose)  ibuprofen  naproxen  Decongestants:  Sudafed  anything with ephedrine  Most diet pills Lifestyle & monitoring

38   44 yo male, previous hx DM and DD renal tx ‘05, no known CAD (negative stress prior to tx)  Presents with 4-6 wk hx progressive DOE, weight gain, decreased appetite, cough that worsens at night  States he’s having hard time at work, carries 60 lb. bags & other equipment road construction  Believes he has “bad cold”, treated by PCP for bronchitis/pneumonia without relief of symptoms Case Study

39   Sx not improved after steroids  abx  History reveals change in appetite, bloating, PND-wakes up after 2 hrs coughing, sits on side of bed or walks around  Reports chest “soreness”, mid sternal area, no radiation, no palpitations, no diaphoresis, n/v  What would you suspect?  What would you do next? Case study

40   CXR shows cardiomegaly, pulmonary congestion  12 lead ecg shows NSR  no evidence of acute MI  normal voltage  TTE shows  LV systolic dysfunction  LVEF 25%  moderately dilated RA & LA  normal RV function  LVEDD 65 mm (nl= 56)  no thrombus  Labs: lytes wnl, bun/cr:35/1.8, t bili 1.6, ast 66, alt 94, TSH 8.7 with normal fT4, TT3.

41   If possible:  Start or increase ACE inhibitor or ARB  Diurese  Once near euvolemic  Start or increase beta blocker (preferably carvedilol or metoprolol succinate) Treatment

42   Calls with SOB without weight gain  Appetite poor  Decreased activity tolerance  Increased fatigue  PND and orthopnea 6 months later…

43   Assess over the phone:  What brings on SOB/activity limitations  Assess for edema  Other symptoms:  chest discomfort  palpitations  Early satiety, bloating, nausea…  Labs:  Creatinine rise from 1.4 to 1.8  BUN rise from 28 to 36  Serum potassium 3.6, sodium 130 What to do next?

44   Most likely, increased renal indices from volume overload  Diurese, based on symptoms and labs  Leave ACE-I unchanged  F/u labs in 3-7 days  If equivocal, get pt to be assessed in clinic  TTE can be done in pts difficult to assess volume status  Can always schedule for RH cath (may need anticoag management in pts on warfarin) What do you do next?

45   78 yo female s/p OH Tx ‘02 presents with progressive SOB, weight gain  longstanding hx htn  obesity  swelling of her legs  bloating over past couple of months  Hx reveals:  poorly controlled BP for past 45 yrs  sedentary lifestyle  no DM  hypothyroid  States she’s been sleeping in her husband’s recliner for past 3 weeks  sleep quality poor r/t fatigue  poor quality of life “unable to do anything” Case study 2

46  What do you suspect? What questions do you want to ask her? What do you want to do with her?

47   Physical exam:  JVP elevated to 15 cm above RA  No scleral icterus  Oropharynx pink, moist  Lungs with few basilar crackles & wheezes  Abdomen soft, obese; Liver WNL  Extremities +2 to knees bilaterally  Blood pressure: 178/92 Case Study 2

48   CXR shows pulmonary congestion  TTE shows:  concentric LV hypertrophy  abnormal E/a ratio (diastolic filling)  LVEF 75%  BNP elevated to 528  lytes normal  creatinine 2.4  LFT’s normal  12 lead ecg shows:  increased voltage in precordial leads ( LV hypertrophy)  NSR  Left heart cath with minor luminal irregs  RHC with elevated PCWP, RA,RV and PA pressures Findings

49  CXR

50   Diurese  Helps relieve symptoms  Labs to evaluate lytes and renal function  Can schedule for clinic visit  Trend home monitoring data What do you do next?

51  Thank you!


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