1. Deborah Crawford, APRN-CNS

2. Speaker for Otsuka Disclosures

3. 1 Identify the treatment objectives for acute heart failure vs chronic heart failure. 2. Identify the stages and classifications of Heart Failure. 3. Describe the exercise guidelines for Heart Failure patients. 4. Describe the Pharmacoligical treatment for Heart Failure. Objectives

4. 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

5. 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

6. HFSA 2010 Practice Guideline (12.5-12.20) Overview of Treatment Options for Patients with Acute Decompensated HF  Fluid and sodium restriction  Diuretics, especially loop diuretics  Ultrafiltration/renal replacement therapy (in selected patients only)  Parenteral vasodilators (nitroglycerin, nitroprusside, nesiritide)  Inotropes * (milrinone or dobutamine) *See recommendations for stipulations and restrictions.

7. Treatment Objectives Chronic Heart Failure 2 1.  Survival 2.  Mortality 3.  Exercise capacity 4.  Quality of life 5.  Neurohormonal changes 6.  Progression of CHF 7.  Symptoms Acute Heart Failure 1 1. Improve symptoms 2. Optimize volume status 3. Identify etiology 4. Identify precipitating factors 5. Optimize chronic oral therapy 6. Minimize side effects 7. Identify patients who might benefit from revascularization 8. Educate (medications/self assessment of HF) 1 2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e. 2 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.

8.  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

9. Pharmacoligical 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  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

10. 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

11. 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.

12. 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 %.

13. Compensated/Decompensated ?

14. 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

15. 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

16. 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

17. CMS recommendations for Cardiac Rehab for CHF patients  CMS determined that the evidence is sufficient to expand coverage for Cardiac Rehabilitation services to beneficiaries with stable chronic heart failure. Stable chronic HF  LVEF < 35%  NYHA class II-IV despite optimal HF therapy for at least 6 weeks  Stable patients  No recent (< 6 wks ) or planned (< 6 mo) major CV hospitalizations or procedures

18. Exercise Guidelines for HF patients  Start slow, warm up and cool down  Start by walking 5-10 min 1-2 times a day.  Walk 3 - 5 times a week  Increase the time and frequency as tolerated  Goal is 30 min, 5 times a week

19. Don’t Let this Happen to Your Patient

20. Aquapheresis (Ultrafiltration) Alternative treatment in Diuretic resisitant patients

21. 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

22. 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 250ml/hr (inpatient) or 350ml/hr (outpatient for 8 hrs)

23. The Aquadex System is indicated for: Temporary (up to 8 hours) ultrafiltration treatment of patients with fluid overload who have failed diuretic therapy AND Extended (longer than 8 hours) ultrafiltration treatment of patients with fluid overload who have failed diuretic therapy and require hospitalization.

24. 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.

25. Pearls after Ultrafiltration  Hold diuretic while on ultrafiltration  Restart diuretic after ultrafiltration complted usually the next day at a lower dose  May respond better to diuretics after ultrafiltration due to reduction of “gut edema”

26. Patient selection Inclusion / Exclusion Criteria for Outpatient Ultrafiltration Inclusion Criteria: 1.24 hour Diuretic dose > 80mg Furosemide or equivalent * OR 2. Fluid overloaded diuretic resistant a.< 10 lbs over stable weight b.Serum Creatinine 20ml/min or on fluid restriction or frequent hospitalizations * 1mg Bumetanide or 20mg Torsemide = 40mg Furosemide Exclusion Criteria: 1 Fluid overloaded and diuretic resistant a.> 10 lbs over stable weight b.Consider hospital admission for in patient Ultrafiltration c.Serum Creatinine > 3.0 consider Renal consult

27. Ultrafiltration Pre-Treatment Day of Treatment 1.Obtain IV access: a.6Fr Dual lumen ELC venous access catheter 2.Obtain Laboratory: CMP or BMP, Mg, CBC, PT/INR (if patient on Coumadin) 3.Obtain Aquadex Flexflow pump 4.Obtain UF 500 Circuit set : a.Prime filter/tubing with Normal Saline 5.10 ml syringe 6.Heparin 20,000/500ml D5W a.Heparin infusion 1000-1200 units/hr or as need by the patient 7.Start Heparin 30min prior to starting Ultrafiltration

28. Thank You !!