1. TREATMENT OF HEART FAILURE From Oral Medications to Intravenous Drips Mark Puhlman MSN ANP

3. Heart Failure

4. HF is a chronic condition that can usually be treated with medications

5. Incidence 5.1 million heart failure patients in US 650,000 new cases per year 5-10% (255,000-650,000) with symptoms at rest (NYHA IV) (Yancy, 2013)

9. What is HF?

10. Heart = pump

12. Heart failure = Inefficient pump

13. weak (poor squeeze)

14. stiff (poor filling)

15. Systolic HF Diastolic HF

16. NormalHeart failure

17. What causes HF?

18. Toxins CAD Valve disease Arrhythmia High BP Thyroid disease Idiopathic Myocarditis Familial Peripartum HIV Sarcoid Congenital Cardiomyopathy Anemia Obesity Diabetes

19. Myocardial Infarction (MI)

21. High blood pressure (hypertension)

23. Valve disease

25. What are the symptoms?

26. Shortness of breath Fatigue Rapid or irregular pulse Swelling of legs Dizziness Cough Sudden death Difficulty lying flat

27. No single test to diagnose HF in all cases

28. Echocardiogram

31. How is HF treated?

32. Salt leads to fluid retention

33. I don’t add salt to my food

36. 2 L fluid

37. Fluid pills (diuretic)

39. ACE- inhibitors Angiotensin receptor blockers Beta- blockers Aldosterone antagonist Diuretics

40. What Happens When Medications Fail ? Stage D/Class IV Heart Failure Heart Transplant Destination Heart Failure Palliative Care

41. What Happens When Medications Fail ? Criteria For Heart Transplant CPET < 14 Class IV Heart Failure Failed Medical Therapy End organs intact No cancer within 5 years Social Structure

42. What Happens When Medications Fail ? Criteria For Destination Therapy CPET < 14 Class IV Heart Failure Failed Medical Therapy End organs intact Life Expectancy > 2 years Except for Heart Failure Social Structure Not Candidate for Heart Transplant

43. What Happens When Medications Fail ? Criteria For IV Inotrope Bridge to Advanced Therapies (TX or DT-VAD) Questionable Compliance Questionable Social Structure Palliative Care No increased risk for PICC Line Insertion

44. Intravenous Inotropes Why do we give these drugs? Positive Inotropy Increases power of contraction Vasodilation Decreases the heart’s work

45. Intravenous Inotropes Milrinone: Vasodilates (pulmonary tree and peripheral) Increases strength of contraction of heart muscle Dose.376-.75 mcg/kg/min Side effects Arrhythmia 3% Hypotension 4% Head Ache 3%

46. Intravenous Inotropes Dobutamine: Vasodilates (minor) Increases strength of contraction of heart muscle Dose 2-20 mcg/kg/min Side effects Arrhythmia 10 % Hypertension 7.5% Head Ache 3% Palpitations 5%

47. Survival on Inotropes J Card Fail. 2003;9:180-187. Rematch Trial Randomized to LVAD or Medical Management Inotropes 1-Year Survival (N=46): 24% Circ. 2004;110:975-981.

48. Survival On Inotropes MODERN ERA – Single center retrospective review (University of Alabama) 197 Consecutive patients (2007-2013) – Listed for transplant or awaiting LVAD (60) – Undergoing evaluation for LVAD/transplant (20) – Stabilization prior to CRT or PCI (4) – Offered LVAD but chose inotropes (15) – Palliation (98) Circ Heart Fail. 2015;8:880-886.

49. Survival On Inotropes MODERN ERA Those not candidates for Transplant or LVAD Median Survival: 9 Months 1-Year Survival: 47.6% 2-Year Survival: 38.4% Circ Heart Fail. 2015;8:880-886.

50. Survival On Inotropes Complications of Home Inotropes Complications of home inotropes and prolonged venous access Infection Thrombosis Arrhythmia Sudden Cardiac Death Worsening of end organ function Progression of heart failure Alteration in candidacy for advanced therapies

53. Jacob Abraham, MD Gary Ott, MD * Alicia Ross, MD Josh Remick, MD Mark Puhlman ANP, VAD/TX coordinator Kate Evenson RN, VAD/Tx Coordinator Rebecca Lewis RN, VAD/Tx Coordinator KC Dailey, MSW-LCSW Renee Swanson, RN, Manager Center for Advanced Heart Disease