Heart Failure Background » Heart Failure (HF) is a major public health problem resulting in substantial morbidity, and healthcare expenditures » Major cost-driver of HF is high incidence of hospitalizations » Despite treatment advances large number of eligible patients are not receiving one or more evidence-based HF therapies Prevalence of HF: 5,100,000 Incidence of HF: 825,000 Mortality: 50% at 5 yrs Hospital discharges: 1,023,000 Cost: $30.7 billion American Heart Association. 2014 Heart and Stroke Update Dallas, TX: AHA; 2014
Heart Failure Definition » Systolic Heart Failure New Definition: » Heart Failure with Reduced Ejection Fraction (HFrEF) » LVEF < 40% ACC/AHA Heart Failure Guidelines 2013. Yancy, C, Jessup, M. J Am Coll Cardiol. 2013; 62:1495-1538
Types of Cardiomyopathy » Idopathic dilated: the cause is unknown » Ischemic: coronary artery disease, decreased blood supply to the heart muscle.
Heart Failure Definition Diastolic Heart Failure New Definition: Heart Failure with Preserved Ejection Fraction (HFpEF) LVEF > 50% ACC/AHA Heart Failure Guidelines 2013. Yancy, C, Jessup, M. J Am Coll Cardiol. 2013; 62:1495-1538
Acute Decompensated Heart Failure (ADHF ) Heart Failure : Complex clinical syndrome, Can result from any structural or functional cardiac disorder that impairs ability of ventricle to fill with or eject blood. Cardinal symptoms: fatigue dyspnea Clinical signs: fluid retention exercise intolerance Hunt SA et al. Circulation. 2001;104:2996
Myocardial Toxicity Change in Gene Expression ANP BNP Pathophysiology of ADHF Myocardial Injury Fall in LV Performance Activation of RAAS and SNS (endothelin, AVP, cytokines ) Peripheral Vasoconstriction Sodium/Water Retention HF Symptoms Morbidity and Mortality Remodeling and Progressive Worsening of LV Function Shah M et al. Rev Cardiovasc Med. 2001;2(suppl 2):S2
Therapies in the Hospitalized HF Patient Treated with IV diuretics: Loop diuretics dose greater than or equal to chronic oral daily dose, the serially adjusted Monitor electrolytes, BUN, Creat. Measured during titration of HF medications and IV diuresis Initiation of beta blocker at a low dose recommended after optimization of volume status and discontinuation of IV agents ACC/AHA Heart Failure Guidelines 2013. Yancy, C, Jessup, M. J Am Coll Cardiol. 2013; 62:1495-1538
Therapies in the Hospitalized HF Patient (Cont) Ultrafiltration may be considered for patients with obvious volume overload and refractory congestion IV Nitroglycerin, Nitroprusside of Nesiritide may be considered an adjunvant to diuretic therapy for stable patients with HF Patients with volume overload and severe hyponatremia, vasopressin antagonists may be considered. ACC/AHA Heart Failure Guidelines 2013. Yancy, C, Jessup, M. J Am Coll Cardiol. 2013; 62:1495-1538
Class I: No limitations Class II: Slight limitations of physical activity Class III: Marked limitation of physical activity Class IV: Symptoms at rest Unable to carry on any physical activity without discomfort. Stage A: At risk for developing HF Stage B: Structural heart disease associated with HF but asymptomatic Stage C: Known systolic heart failure & current or prior symptoms Stage D: Systolic heart failure and presence of advanced symptoms after receiving optimal care Stages of Heart Failure NYHA Functional Classifications in patients with HF
Pharmacological Treatment of Heart Failure ACE Inhibitors: Inhibit renin-angiotensin system in all HF patients with LV dysfunction ARB: Recommended to patients with LVEF <40% intolerant of ACE -I Beta Blockers: Shown effective in patients with HF with LVEF < 40% (start when euvolemic) Aldosterone blockade: Recommended in patients with NYHA class III or IV, LVEF <35% while receiving standard therapy
Dosing ACE/ARB Start with low dose ie: Lisinopril/Enalapril 2.5mg BID Stagger away from Beta Blocker dose Avoid Orthostatic Hypotension Usually Lunch and Bedtime “Stair step” the dosing when up titrating Monitor Renal function Can use in mild, stable renal insufficiency
Dosing Beta Blockers Carvedilol and Metoprolol Succinate are the Beta Blockers that have an indication for Heart Failure Start low dose and titirate up slowly Stagger away from ACE I/ARB Start or up titrate when the patient is euvolemic “Stair step” the dosing when up titrating Titrate one drug at a time.
Dosing Aldosterone Blockers Spironolactone, Eplerenone Helpful in the setting of Hypertension for better BP control Monitor Renal function : can use in mild, stable renal insufficiency Does have mortality benefit in patients with LVEF < 35 %.
Diuretic Therapy Agent Initial Daily Dose (mg) Maximum Total Daily Dose (mg) Duration of Action (hr) Furosemide 20-40mg qd or bid 600mg4-6 Bumetanide0.5-1mg qd or bid qd or bid10mg6-8 Torsemide 10-20mg qd 200mg12-16 Metalozone(thiazide) 2.5mg qd 20mg12-24 Equivalent doses: Furosemide 40mg=bumetanide 1mg=torsemide 20mg
Dosing Thiazide Diuretic Metolazone (Zaroxlyn) Usually 2.5 – 5mg Hydrochlorothiazide Usually 25mg Usually give 30 min prior to the Loop Diuretic More effective and increases the diuretic effect of the Loop
Dosing Potassium and Magnesium Potassium: Goal 4.0 – 5.0 Usually 10-20mEq / Furosemide 40mg dose equivelent. Usually will double the Potassium dose when you double the Loop diuretic dose Depending on renal function of the patient Magnesium: Goal 2.0 – 2.5 Usually 250mg BID for 1 week then once a day Check the Mg level in 1 month after starting Mg supplement
Use of Devices in Heart Failure Prophylatic ICD considered LVEF <30% Ischemic or Nonischemic Biventricular (CRT-D) considered for patients with SR, QRS >120ms, LVEF < 35% with persistent, moderate to severe HF (NYHA II- III) despite medical therapy
Patient Compliance » Low sodium diet * 2 gm Na restriction » Fluid restriction * < 2 liters / day » Medication compliance » Daily weight * Call if 2 - 3 pound weight gain overnight. * Diuretic adjustment
Ultrafiltration Alternative treatment in Diuretic resisitant patients
What Is Diuretic Resistance ? > 10 lbs or more over dry weight Previous hospitalizations with ineffective diuretic effect Patient cannot achieve a goal of -2 liters at 24 hrs No significant difference in patient’s global assessment of symptoms in 24 hrs Non-significant symptom improvement noted after escalating to high-dosing strategy Worsening renal function during diuretic therapy Post-operative fluid overload Peri-operative fluid overload
Ultrafiltration Indicated for patients with Heart Failure not responding to diuretic therapy 24 hour diuretic dose >80mg Furosemide or equivalent Removes excess salt and water from patients with fluid overload Need to monitor Renal function closely esp. during inpatient ultrafiltration Fluid removal rate should not exceed 200ml/hr (inpatient) or 350ml/hr (outpatient for 8 hrs)
Goals of Ultrafiltration Reduction in hospital readmission: Prevent patients from being discharged when they are still “wet” Reduction of Length of Stay: If ultrafiltration is started early (< 24 hr of admission). Stable renal function during treatment: Monitor BMP every 12 hours while on ultrafiltration to prevent worsening renal function. Can reduce rate of fluid removal as needed.
Pearls after Ultrafiltration Hold diuretic while on ultrafiltration Restart diuretic after ultrafiltration completed usually the next day at a lower dose May respond better to diuretics after ultrafiltration due to reduction of “gut edema”
Deborah J. Crawford, MS, APRN-CNS Alan M. Kaneshige, MD, FACC Poster Presentation 16 th Annual Scientific Meeting Heart Failure Society of America Sept. 18,2012, Seattle, WA
Abstract Introduction: Many times, effective fluid removal is difficult despite aggressive diuresis. Ultrafiltration provides another method for effective fluid removal for patients with volume overload. Hypothesis: Ultrafiltration safely and effectively removes excess water and salt from patients who are volume overloaded, and resistant to diuretic therapy. Methods: Data were reviewed and extracted during a retrospective chart review of patients receiving outpatient ultrafiltration in a hospital based heart failure clinic setting.
All Cause and HF Hospital Readmissions 19.9 % 10.6%
Conclusions Ultrafiltration in an outpatient heart failure clinic setting was found to be both clinically and cost effective method for fluid removal in patients with diuretic resistance and experiencing volume overload.
Ultrafiltration Pre-treatment Day of treatment: 1. Obtain IV access: a. 6Fr. Dual lumen ELC venous access catheter with stainless steel coil reinforcement. (CHF Solutions) 2. Obtain Laboratory: CMP or BMP, Mg CBC, PT/INR (if on Coumadin) 3. Obtain Aquadex Flexflow pump (Prime the filter / circuit with the Normal Saline) 4. Obtain UF 500 Circuit set and 10ml syringe 5. Heparin 20,000units/500ml D5W Anticoagulation: a. Heparin infusion 1000-1200 units/hour b. Infuse Heparin through the infusion port of the Aquadex filter c. Heparin bolus 2000 units IV bolus for selected patients d. Start 30min prior to starting Ultrafiltration. Oklahoma Heart Institute Heart Failure CARE Center Outpatient Ultrafiltration Algorithm
1.Patient check In 2Obtain patient's weight 3. Obtain sitting & standing BP and HR for baseline 4. Place on cardiac monitor (telemetry) 5. Assess patency of catheter. Flush & withdraw each port 10ml in 10 sec. If does not infuse or withdraw may reposition the catheter or use 2mg of Cathflo (Activase) per protocol to open up line. Patient Treatment 1.Heparin infusion: 1000 -1200 units/hour. Start 30min prior to starting Ultrafiltration. 2. Vital Signs monitoring: Every 15 min x 1 hour then, Every 30 - 60 min for the remainder of the treatment. 3. Strict intake and output while on the treatment. (IV, ultra filtrate bag emptying, and po fluids only) 4. Fluid restriction 2000ml/24 hours 5. Cardiac telemetry while on Aquapheresis 6. Pre and post treatment weight 7. Assess Catheter site hourly during treatment. 8. Max outpatient treatment time is 8 hours. Aquadex FlexFlow Monitoring: 1. Evaluate for signs of clotting: a. Frequent alarms, withdrawal occlusion, infusion occlusion, or infusion disconnect. 2. Monitor for Pressure changes: Normal Ranges: Pw (withdrawal) -300 to -20 Pu (UF pressure) -250 to +200 Pi (Infusion) +20 to +300 3. Follow Aquadex Flex Flow User's Guide to trouble shoot alarms. Completion of Treatment: 1.Disconnect patient from Aquadex Flex Flow, flush and cap catheters per hospital policy. 2. Patient achieved euvolemia or 8 hours of outpatient therapy is completed. 3. Discuss therapy completion with prescribing cardiologist: a.Remove IV catheter/hospital policy b. If euvolemia is achieved, schedule F/U appointment. In the next 1-2 weeks c. If euvolemia, not yet achieved, schedule f/u Ultrafiltration appointment in 1 week 4. Obtain weight prior to discharge. 5 Have patient call their weight in the AM after Ultrafiltration.
Discharge Criteria for Patients with Heart Failure Exacerbating factors addressed At least near optimal volume status achieved Transition from IV to oral diuretic therapy completed (stable for 24 hours) Optimization of chronic oral HF therapy Follow up clinic visit scheduled (7 – 14 days) and/or telephone f/u within 3 days of hospital discharge. Plans for post discharge management (scale present in home, HF teaching completed ACC/AHA Heart Failure Guidelines 2013. Yancy, C., Jessup, M. J Am Coll Cardiol. 2013; 62:1495-1538