1. Living with Heart Failure Ayesha Hasan MD, FACC Advanced Heart Failure and Transplantation Program Medical Director Cardiac Transplant Program Contact information: 614-293-6081 (heart failure office)

2. What is Heart Failure? Heart failure is NOT a heart attack Heart failure means the heart is:  Weakened  Cannot pump enough blood to supply the body’s needs... It does not mean the heart has stopped working!

3. Heart Failure is Very Common  Heart failure affects nearly 5 million Americans  50% men and 50% women  An estimated ½ million new cases are diagnosed each year  Expected to rise to 750,000 new cases by 2040  Related to aging population, better treatment of heart disease and risk factors, awareness  Over one million heart failure hospitalizations annually  Rising over past few decades  Accounts for over 20% admissions in people 65 and over

4. Aorta LA LV Normal Thickened or stiff heart walls Diastolic Heart Failure Dilated Systolic Heart Failure Pg 238, Lilly 3rd edition Types of Heart Failure: Difference Between Systolic and Diastolic Heart Failure Weakened pumpRelaxation ± abnormal  Blood backs up and overloads the heart Normal ejection Abnormal relaxation: Stiff or scarred  Won’t allow enough blood to fill the heart before it squeezes Normal ejection (squeeze) =Systolic function Normal relaxation (filling) =Diastolic function

5. Normal Heart Development of Heart Failure Simplified View of Heart Failure

6. What Causes Heart Failure? Heart failure results after injury to the heart High blood pressure Heart attack Damage to heart valves Diabetes High cholesterol Heart muscle disease: damage from drugs, alcohol, or infections Congenital heart disease

7. What Are The Symptoms of Heart Failure? Think FACES... F atigue Constant lack of energy A ctivities limited Difficulty with everyday activities C hest congestion Dry cough or producing white or pink blood- tinged phlegm E dema or ankle swelling Swelling of the feet, ankles, legs, abdomen, or unexplained weight gain S hortness of breath Breathlessness during activity, at rest, or while sleeping Additional symptoms: Lack of appetite, nausea, increased heart rate, irregular heart rhythm

8. How Severe is A Patient’s Heart Failure?  We measure the “ejection fraction” by echo  The fraction of blood that the heart pumps with every beat  We assess the patient’s symptoms  No or mild symptoms  Do symptoms limit activity? If so, how much?

9. High Blood Pressure Left Ventricular Hypertrophy Family History Coronary Artery Disease Symptomatic Heart Failure Diabetes Risk Factors High cholesterol Treatment…Begins with Prevention! Smoking Obesity Poor Diet Lack of Exercise

10. How Do We Treat Heart Failure? Lifestyle Changes  Quit smoking  Monitor diet: low-fat, low sodium  Exercise regularly  Lose weight  Avoid alcohol  Limit caffeine intake

11. Limiting Sodium or Salt Will Improve Your Heart Failure Symptoms Sodium is a component of salt  Naturally occurring in many foods  Added during processing  In most foods eaten away from home Your body needs only a small amount of sodium to keep a normal fluid balance. Too much sodium causes your body to hold onto fluid and cause symptoms of weight gain, shortness of breath, and fatigue. Sodium attracts fluid Fluid build-up in body Extra work on heart & kidneys to get rid of fluid Higher BP often results Heart failure symptoms, heart attack, stroke The more sodium (salt) you take in, the more fluid your body holds on to

12. In addition to heart failure patients, the A merican Heart Association recommends 1) All adults older than 51 2) All African Americans 3) Anyone with high blood pressure limit their daily intake to 1500 mg Plan your meals for 2000 mg intake MEAL mg Sodium Breakfast600mg Lunch 600mg Dinner 600mg Snack 200mg Use alternative seasonings! Basil Parsley Chives Paprika Dill weed Pepper Garlic Sage TarragonMrs. Dash ThymeLemon, lime juice Patients Should Follow a 2000 mg Sodium Diet

13. How It Shakes Out ½ tsp salt = 1 serving = 3 slices of ham =2 packets of = 3 pickles = 14 green pretzelssoy sauce olives ¼ tsp salt = 600 mg sodium ½ tsp salt = 1200 mg sodium 1 tsp salt = 2300 mg sodium More than daily recommendation Even a small amount of salt counts!

14. Some common high sodium foods  Frozen meals  Pickles  Canned foods  Bacon  Breads, baked goods  Anchovies  Lunch & smoked meats  Soy sauce  Cheese  Seasoning mixes  Condiments (salad dressing)  Gravy  Olives  Salted crackers  Pretzels  FAST FOOD Rule of thumb: the more processed the food, the more sodium it contains

15. First step: Learn how to read sodium labels on all food 1.Look for Sodium Listed as milligrams or mg 2.Next, look at serving size If you eat 2 servings of a food you need to double what you see on the label 3.Reduced-sodium products still contain sodium Always read the label

16. Sodium Guidelines < 140 mg = low sodium Enjoy these foods! 140-400 mg = medium sodium Use food in moderation > 400 mg = high sodium Use this food sparingly Low sodium 140 mg or less sodium per serving Very low sodium 35 mg or less sodium per serving Sodium-free Less than 5 mg sodium per serving 1.Use salt substitute or other spices when cooking (watch for high potassium in some substitutes) 2.Don’t add salt at the table

17. Fluid intake & Daily Weights Limiting fluid intake: important in managing heart failure REMEMBER: Anything liquid at room temperature is considered a fluid Daily weights: every morning at the same time using the same scale Keep track of daily weights REMEMBER: You might not see swelling until you are 8-15# up

18. Exercise: Get Off the Couch!

19. Exercise Will Improve Your Quality of Life  Pick a simple aerobic activity that you enjoy  Start slowly and increase gradually  Need to move large muscle groups  Walking is a great first choice  Resume activities you stopped (gardening, bowling, fishing)  Work your way up to 30 minutes most days  Doesn’t have to be 30 minutes in a row  Warm up and cool down  Check with your physician first if  You are really out of shape, uncertain about your abilities, or have shortness of breath with very mild activity

20. Exercising & Precautions  Find an indoor location along with a partner  Build muscle (stretching, elastic bands, light weights)  Overexertion  Shortness of breath that prevents you from completing a sentence or doesn’t get better with rest  Dizziness, chest pain, nausea, vomiting, severe sweating, unusual fatigue (extreme)

21. What Medications Do We Use in Heart Failure and Why?  Diuretics  Digitalis  Beta-blockers  ACE inhibitors  Hydralazine/nitrates  Spironolactone 1. To reduce symptoms 2. To prevent disease progression 3.Keep patients out of the hospital 4.Improve survival Be careful about alternative therapy (chinese herbs, hawthorne, ginseng): No evidence they help & associated with some negative effects

22. Why Do We Use These Treatments? Heart failure limits a patient's ability to perform the routine activities of daily living…

23. Diuretics, ACE Inhibitors Reduce the number of sacks on the wagon (or load on the heart)

24. ß-Blockers Limit the speed, thus saving energy

25. Spironolactone, Cardiac Resynchronization Therapy Increase the heart’s efficiency

26. What if the Heart is Still Weak After Medications? Risk of death from cardiac arrest  Defibrillators can protect the heart from these abnormal rhythms Based on the ejection fraction

27. History of Pacemakers & Defibrillators

28. What if the Heart is Still Weak After Medications? The heart “pump” worsens Newer devices can be implanted to help the heart’s contraction 1.Pacemakers (resynchronization) 2.Ventricular assist devices 3.Clinical trials: investigational devices Heart transplant Pace both ventricles of the heart to make it stronger & more efficient

29. Ventricular Assist Devices Try to be as active as possible with the following limitations:  No driving  No contact sports  No high “bounce” activities like running, jumping, or jumping jacks  No submerging in water. Stay out of bathtubs, hot-tubs, swimming pools, lakes & ponds  Do not drive or operate heavy machinery Continue to follow heart failure recommendations: sodium and fluid restriction, daily weight

30. Indications for Mechanical Circulatory Support in Advanced HF  Bridge to Transplant (BTT)  Non-reversible left heart failure  High mortality risk  Candidate for cardiac transplantation  Destination Therapy (DT)  Not a candidate for cardiac transplantation  Bridge to Recovery  Potentially reversible (post-heart attack, post- pregnancy, myocarditis)

31. ADULT HEART TRANSPLANTATION % OF PATIENTS BRIDGED WITH MECHANICAL CIRCULATORY SUPPORT* (Transplants: 1/2000 – 12/2009) * LVAD, RVAD, TAH Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

33. History of Heart Transplantation at Ohio State University  Heart transplant program started in 1986  To date, have performed 382 transplants  Includes a joint heart/kidney transplant program  Average 15 transplants per year  Around 2000-2500 transplants in the nation per year  Approximately 3500 reported worldwide per year

34. Cardiac Transplantation: Are There Gender Differences in Transplant Rates? Of total reported transplants, what % patients are women? a.25-30% b.50-60% c.70-75% International Statistics (ISHLT registry)  Of 22,387 reported heart transplants between 2002-2010, 77% were men  Improved to 31% women for Jan 2011 to Dec 2011 Is the OSU transplant program similar? 11 of 37 transplants are women – 27% (Past 3 yrs - 1/2010 to present) Current waitlist – around 20% are women Taylor DO, et al. JHLT 2009;28:1007-22 ISHLT online registry www.ISHLT.comwww.ISHLT.com

35. Increased load on the heart Decreased output from the heart Impaired kidney function Increased water & sodium retention Diminished blood flow to the kidney Neurohormonal Activation The Heart-Kidney Relationship in Heart Failure Dysfunction of one affects the other Poor absorption of drugs and drug delivery to kidney Neurohormonal Activation

36. Costanzo MR et al. JACC 2005;46:2047-2051. Ultrafiltration for Acute Heart Failure  Mechanical removal of excess volume  Safe and effective  Patients on high dose diuretic (diuretic-resistance)  Caution: Not a substitute for dialysis as waste products are not removed with this method

37. Clinical Trials at OSU: Measuring Pressures in the Heart Invasively for Heart Failure Management LA RA  Modified PDA  Powers through clothing  Alerts patient to monitor  ‘DynamicRX ®’ calculates pressure and instructs patient on management  Meds  Activity  Clinician contact  Based on physician’s prescription for specific values obtained Measure pressures as an indication of fluid status

38. Clinical Trials at OSU: Measuring Pressures in the Heart Invasively for Heart Failure Management Measure pulmonary artery pressures for assessment of fluid 15 mm No battery No leads

39. Stem Cell Therapy and Heart Failure: Still being studied

40. Sleep Apnea and Heart Failure People with heart failure have a high risk for sleep apnea If not treated, sleep apnea can cause:  Drop in oxygen levels  The heart rate to speed up  A rise in the blood pressure  Changes to the heart rhythm  Stroke  Heart attack or an episode of heart failure Normal breathing pattern Central sleep apnea: no breathing (apnea) alternates with rapid breathing

41. Friends and Family  Emotional support helps a patient have a more positive outlook on life  Allow the patient to make decisions regarding health care and lifestyle behaviors  Positive reinforcement  Discuss fears about heart failure  Discuss advanced care planning  Don’t forget to take care of yourself: eat healthy, exercise, sleep

42. Advanced Care Planning  Not giving up  Focus is on caring for the patient in a way that meets your wishes  Key is communication  Goal is to reduce stress on the patient  Consists of  Advanced care directive  Do-not-resuscitate order  Power of attorney  Living will  Financial plan

43. Advanced Care Planning  Palliative care  Support program that focuses on comfort and reducing symptoms, pain. The disease is no longer responsive to curative treatment.  Hospice care  Support program for the patient and family through the dying process. Focus is also comfort and to help with bereavement.  Nurses, chaplains, therapists, bereavement counselors, social workers and physicians

44. Conclusion: Call your healthcare provider for these symptoms...  A change in shortness of breath, fatigue, or swelling  Requiring more pillows than usual to sleep comfortably at night or needing to sleep in a recliner  Chest pain  Near fainting or fainting  Weight gain of 2 lbs in one day or 5 lbs in one week

45. Conclusion: Living with Heart Failure  See your physician regularly  Weigh yourself daily & call your RN/MD if gaining  Limit salt and fluid intake  Exercise at a level recommended by your physician  Avoid smoking  Keep your flu and pneumonia vaccines current  Take your medications  Take an active role in managing your health!

46. For More Information About Heart Failure… The Heart Failure Society of America via their website: Patients and caregivers– www.abouthf.org