1. Outpatient management of heart failure Dr. Rob Wu Feb 2008

2. Case 86 year old woman recently discharged from Team with heart failure arrives at clinic for follow up Echo done in hospital – EF 58%, normal valves PMH: HTN, osteoporosis, osteoarthritis, DM2 Meds: ASA, tylenol, ramipril 5 mg daily, metoprolol 25 mg po bid *, spironolactone 25 mg po daily *, furosemide 40 mg po bid *, arthrotec 75mg po bid, diabeta 5mg bid, avandia 4mg daily, fosamax Currently, feels ok, no orthopnea, PND or ankle swelling * - new medications, started in hospital

3. Case cont Exam: BP 130/68 HR 72 –Chest – clear, no crackles –CV JVP 2 cm ASA, normal HS –Extremities – no pedal edema Labs on discharge: –CBC Normal, Na 140 K 5.5 Cl 108 Cr 140 How would you manage her ?

4. Some questions LVEF>50%! Was it really heart failure? –Maybe not. But diagnosis of HF is clinical including symptoms (PND, orthopnea), signs (elevated JVP, S3, crackles), investigations (CXR, BNP) –If so, likely diastolic dysfunction or preserved systolic function How would you optimize the meds? Further investigations? When to see her back?

5. Resources CCS Heart failure guidelines 2007, 2006

6. Definition Epidemiology Diagnosis Management Quality

7. Some terminology What is Heart Failure (HF)? HF is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion HF is common and reduces quality of life, exercise tolerance and survival NB: calling it CHF is considered inaccurate and uncool Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.

8. Heart Failure Mortality Canada’s average annual in-hospital mortality rate is: – 9.5 deaths/100 hospitalized patients >65 years of age –12.5 deaths/100 hospitalized patients >75 years of age HF patients have a poor prognosis, with an average 1-year mortality rate of 33% Lee DS et al. Can J Cardiol 2004;20(6):599-607.

9. Projected number of incident hospitalizations for CHF patients, using high, medium and low population growth projections in Canada 1996-2050 HF – An epidemic ? Johansen et al. Can J Cardiol 2003;19(4):430-5.

10. HF Readmissions Hospital readmission rates are high, and mainly due to recurrent heart failure Canadian Hospital Readmission Rates for Any Heart Failure Lee DS et al. Can J Cardiol 2004;20(6):599-607.

11. Management Overview Management of HF requires an accurate diagnosis aggressive treatment of known risk factors (e.g. hypertension, diabetes) rational combination drug therapy Care should be individualized for each patient based on: symptoms clinical presentation disease severity underlying cause

12. Diagnosis and investigations Clinical history, physical examination and laboratory testing –BNP (available at UHN, cost $65, ~2d turnaround) Transthoracic echocardiography (ventricular size and function, valves, etc.) Coronary angiography in patients with known/suspected CAD NYHA classification should be used to document functional capacity in all patients Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.

13. Management CCS HF guidelines 2006. Can J Cardiol 2006;22(1):23-45.

14. Non pharmacologic therapy I am supposed to counsel what again ? –Diet How much salt – no added or low salt Is that 1gm, 2gm? Is fluid restriction necessary ? –Symptoms of heart failure –Self care including daily weights

15. Salt and Fluid Salt –All patients with heart failure No added salt diet (2-3 gm / day) –If difficult to control, low salt diet 1-2 gm/day May just need some educational literature for ~ 2gm/day Likely needs to see a dietitian (TWH referral) for <2gm/day Fluid restriction –Not necessarily all patients, just those with difficult to control HF or sodium issues (1.5 – 2 L / day)

16. Medications ACE ARB BB Spironolactone Digoxin Diuretics

17. ACE All HF patients with LVEF <40% should be treated with an ACE-I and a beta-blocker, unless a specific contraindication exists (Class I, Level A)

18. Check supine and erect BP for symptomatic hypotension If symptomatic hypotension persists, separate timing of dose from other medications that could also lower BP Reduce dose of diuretic if patient stable and reassess need for other vasodilators (e.g., long- acting nitrates) An increase in creatinine of up to 30% is not unexpected after introduction of an ACE-I/ARB Adding spironolactone to an ACE-I plus an ARB is discouraged, unless followed closely in a specialist HF clinic Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. Practical Tips for ACE-I/ARB Use

19. All HF patients with LVEF  40% (use clinically proven beta-blocker) (Class I, Level A) In stabilized HF patients with NYHA Class IV symptoms (Class I, Level C) MERIT-HF Study Group. Lancet 1999;353:2001-7. CIBIS II Investigators. Lancet 1999;353:9-13. Packer M et al. Circulation 2002;106:2194-9. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. When to Use Beta-blockers?

20. Practical Tips for BB Use Dose of BB should be increased slowly, e.g., double dose every 2-4 weeks if stable If bradycardia or AV block is present, reduce or stop digoxin or amiodarone (where appropriate) If hypotensive, consider reducing other medications or change timing of doses Objective improvement in LV function may not be apparent for 6-12 months or longer Major reduction of BB dose or abrupt withdrawal should generally be avoided Consider using beta blocker proven effective in HF trials –Bisoprolol, carvedilol (or long-acting metoprolol but not available in Canada) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

21. When to Use Aldosterone Blockers? Pitt B et al. N Engl J Med 1999;341:709-17. Spironolactone: Patients with LVEF  30% and severe symptoms despite optimized other therapies (and Creat <200, K <5.2) (Class I, Level B) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

22. To relieve symptoms and reduce hospitalizations in patients in sinus rhythm who have persistent moderate- to-severe symptoms despite optimized HF medical therapy (Class I, Level A) When To Use Digoxin? The Digitalis Investigation Group. N Engl J Med 1997;336:525-33. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

23. When To Use Nitrates + Hydralazine? Other HF patients unable to tolerate ACE inhibitors and ARBs (Class IIb, Level B) African-Americans with systolic dysfunction in addition to standard therapy (Class IIa, Level A) Cohn et al. N Engl J Med 1986;314:1547-52. Taylor AL et al. N Engl J Med 2004;351:2049-57. Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

24. Drug Interactions and Additive Adverse Effects of Common Medications (Class I, Level B) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

25. HF with Preserved Systolic Function Diagnosis is generally based on typical signs and symptoms of HF in patient with normal LVEF and no valvular abnormalities Important to control comorbidities, such as hypertension and diabetes, which are often associated with HF with PSF Systolic and diastolic hypertension should be controlled according to published guidelines (Class I, Level A) The ventricular rate should be controlled in patients with atrial fibrillation at rest and during exercise (Class I, Level C) Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

26. HF with Preserved Systolic Function Diuretics should be used to control pulmonary congestion and peripheral edema (Class I, Level C) ACE inhibitors, ARBs, and beta-blockers should be considered for most patients (Class IIa, Level B) Coronary revascularization may be considered for patients with symptomatic or demonstrable ischemia that is judged to have an adverse effect on cardiac function (Class IIa, Level C) Excessive diuresis should be avoided as this can easily lead to reduced CO and renal dysfunction Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

27. Remainder of Slides are Optional…. Review if time permits….

28. Heart Failure and Renal Dysfunction A Caution (and a recommendation) Routine use of ACE-I, ARBs or spironolactone in the setting of severe renal dysfunction (serum creatinine >250 µmol/L or an increase of > 50% from baseline) is not recommended due to a lack of evidence for efficacy in HF patients (Class IIa, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.

29. Geriatric HF (this is us) Frailty score –predicts Death Need for institution

30. Other evidence-based therapies Multidisciplinary heart failure clinics –Reduces readmissions and mortality –Most have RNs doing monitoring, counselling –But… –Most only see systolic dysfunction –Many wont see older patients who may not benefit from devices

31. Which Patients Should be Referred to a Heart Failure Specialist? New onset HF Recent HF hospitalization HF associated with ischemia, hypertension, valvular disease, syncope, renal dysfunction, other multiple comorbidities HF of unknown etiology Intolerance to recommended drug therapies Poor compliance with treatment First degree family members if family history of cardiomyopathy or sudden cardiac death (Class I, Level C) CCS HF guidelines, Can J Cardiol 2006;22(1):23-45.

32. Practically, which referrals will be accepted by a Heart Failure Specialist? Definitely pre-transplant candidates Age <60 Candidates for devices (AICD, biventricular pacer, LVAD) LV systolic dysfunction (LVEF <40%)

33. Conclusions Make an accurate and timely diagnosis Initiate treatment to Reduce HF risk factors Reduce HF symptoms Reduce hospitalizations Improve quality of life Prolong survival Refer patients at higher risk to specialist or HF clinic Continue to translate new knowledge into practice Combine available healthcare resources to improve delivery of best care and practices to HF patients Improve HF outcomes in Canada Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.

34. Case 86 year old woman recently discharged from team with heart failure arrives at clinic for follow up Echo done in hospital – EF 58%, normal valves PMH: HTN, osteoporosis, osteoarthritis, DM2 Meds: ASA, tylenol, ramipril 5 mg daily, metoprolol 25 mg po bid *, spironolactone 25 mg po daily *, furosemide 40 mg po bid *, arthrotec 75mg po bid, diabeta 5mg bid, avandia 4mg daily, fosamax Currently, feels ok, no orthopnea, PND or ankle swelling * - new medications, started in hospital

35. Case cont Exam: BP 130/68 HR 72 –Chest – clear, no crackles –CV JVP 2 cm ASA, normal HS –Extremities – no pedal edema Labs on discharge: –CBC Normal, Na 140 K 5.5 Cl 108 Cr 140 How would you manage her ?

36. Some answers? Management –Etiology – consider ischemia –Counseling – daily wts, NAS diet, symptoms, meds –Meds – D/C NSAID, rosiglitazone, spironolactone, try titrate down diuretic Further investigations –Lytes, Creat, ECG When to see her back? –High risk of readmission (elderly, recent admit) 1-2 weeks would be reasonable

37. web resources www.heartfunction.com –Counseling info –HF guidelines –Flow sheets for your hf patients