1. Outpatient Heart Failure Management Common Problems Elaine Winkel, M.D. University of Wisconsin Heart Failure and Transplant Program

2. Who takes care of heart failure patients? 75% -primary care 20%-cardiology 5%-heart failure cardiologist

3. Heart Failure LV systolic dysfunction with an ejection fraction of < 40 %

4. Heart Failure A syndrome characterized by left ventricular dysfunction, reduced exercise tolerance, impaired quality of life, and reduced life expectancy. Cohn

5. Common Problems Diagnosis Physical assessment Drug therapy Non-pharmacologic therapy Education & follow-up Other therapies for heart failure

6. New Approach to the Classification of Heart Failure StagePatient Description A High risk for developing heart failure (HF) Hypertension CAD Diabetes mellitus Family history of cardiomyopathy B Asymptomatic HFPrevious MI LV systolic dysfunction Asymptomatic valvular disease C Symptomatic HFKnown structural heart disease Shortness of breath and fatigue Reduced exercise tolerance D Refractory end-stage HF Marked symptoms at rest despite maximal medical therapy (e.g., those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions) Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

7. Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class 1 Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113. 2 New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897. ACC/AHA HF Stage 1 AAt high risk for heart failure but without structural heart disease or symptoms of heart failure (eg, patients with hypertension or coronary artery disease) BStructural heart disease but without symptoms of heart failure CStructural heart disease with prior or current symptoms of heart failure DRefractory heart failure requiring specialized interventions NYHA Functional Class 2 IAsymptomatic IISymptomatic with moderate exertion IVSymptomatic at rest IIISymptomatic with minimal exertion None

8. Common Problems Diagnosis Physical assessment Drug therapy Non-pharmacologic therapy Education & follow-up Other therapies for heart failure

9. Common Diagnostic Errors LV systolic dysfunction commonly a missed diagnosis No symptoms Symptoms attributed to other diseases Symptoms ignored Signs ignored (CXR)

10. Why screen for LV dysfunction? May be asymptomatic Mortality related to degree of LV dysfunction, not symptoms High mortality once symptoms appear

11. Heart failure is worse than most cancers. -The Fat Man The House of God -The Fat Man The House of God

12. Patients at risk for developing HF (Stage A) Coronary disease or CAD equivalent (DM) Hypertension Hyperlipidemia Congenital heart disease Valvular heart disease Stroke or other vascular disease –30% w/LVD Arrhythmias

13. High risk patients Drug abuse (cocaine, anabolic steroids) Alcohol use Family members with heart failure Sickle cell disease Sarcoidosis/amyloidosis Muscular dystrophies Collagen vascular diseases Immigrant population-Chagas

14. High risk patients End stage renal disease Chronic lung disease-(long time beta- agonist use) Certain malignancies (multiple myeloma) History of cardiotoxic drugs (adriamycin)

15. High risk populations Good history, including family history Screen with echocardiography

16. Diagnostic errors LV systolic dysfunction not completely evaluated No cardiac cath Incomplete echo study Role of endomyocardial biopsy

17. Common Problems Diagnosis Physical assessment Drug therapy Non-pharmacologic therapy Education & follow-up Other therapies for heart failure

18. Common presentations of HF Fatigue SOB GI distress (anorexia, early satiety, abdominal bloating, nausea, vomiting) Chest pain/pressure Lightheadedness/dizziness/palpitations No symptoms

19. Physical Exam Often unhelpful especially in chronic or slowly progressive LV dysfunction Physical signs frequently absent History most important

20. Causes of SOB in patients with known LVD New or worsening CAD New or worsening valve disease Unappreciated arrhythmia Anemia Lung disease Deconditioning

21. Other causes of edema Cirrhosis Severe renal insufficiency Nephrotic syndrome Venous insufficiency Lymphedema

22. Common Problems Diagnosis Physical assessment Drug therapy Non-pharmacologic therapy Education & follow-up Other therapies for heart failure

23. Current medical therapy ACE inhibitors/ARB’s/direct vasodilators Digoxin Diuretics Beta-blockers Aldosterone blockers

24. ACE Inhibitors-common errors Short vs. long acting agent Dose too low ARB substituted- (cough, creatinine rise, etc.) Asymptomatic patient w. LVD

25. Digoxin Not given Wrong dose Dig level Effect of amiodarone, spironolactone Digoxin in women

26. Diuretics Too much Too little Generic vs. brand name Timing

27. Beta Blockers Wrong time (concomitant w/ACE, decompensated, volume overloaded) Wrong agent (atenolol, acebutelol, pindolol, carvedilol vs. metoprolol) Wrong dose Using BB alone Asymptomatic patient w/LVD

28. Aldosterone Blockers Spironolactone vs. eplerenone Too much Wrong patient (nl-hi K+, DM, Type IV RTA, renal insufficiency, non-compliant) No follow-up

29. Drug management Drugs/doses used in clinical trials Generic vs. brand name drugs Short vs. long acting agents Pill bottles each visit Timing to avoid lightheadedness

30. Common Problems Diagnosis Physical assessment Drug therapy Non-pharmacologic therapy Education & follow-up Other therapies for heart failure

31. Non-pharmacologic therapy Sodium restriction-2000 mg/day Fluid restriction Avoid alcohol Small, frequent meals Energy conservation

32. Deleterious drugs Calcium blockers-nefedipine, diltiazem, verapamil Antiarrhythmics NSAID’s, COX-2 inhibitors (inc OTC) Herbal agents (hawthorn, gingko, St. John’s wort) Grapefruit juice Inotropic agents-(milrinone, dobutamine)

33. Common Problems Diagnosis Physical assessment Drug therapy Non-pharmacologic therapy Education & follow-up Other therapies for heart failure

34. Education and follow-up Disease Treatment Diet/fluids Exercise/rest Avoid deleterious agents Involve family Close follow-up

35. Other therapies Coronary intervention (PCI, CABG) Ventricular reconstruction (aneurysm resection or Dor procedure) Valve repair or replacement Correction of arrhythmias-especially AF Pacing (DDD, BiV) ICD

36. “Genius is the infinite capacity for taking pains.” Sherlock Holmes