2. Define the clinical presentation of congestive heart
failure
Describe different management options for patients with
CHF
Determine suitable candidates for inotropic therapy in
the home
Provide patient and caregiver education for patient on
home inotropic therapy
3. Definition:
o Heart failure is a condition in which the heart has lost the ability
to pump enough blood to the body's tissues. With too little blood
being delivered, the organs and other tissues do not receive
enough oxygen and nutrients to function properly.
o HF or congestive heart failure (CHF) is a disease state that
afflicts approximately 6.6 million people. It is more common in
African American and Hispanic males. Half of HF diagnosed
patient will die within 5 years, there are limited treatment options.
4. Symptoms of HF
o Shortness of breath
o Orthopnea
o Paroxysmal nocturnal dyspnea
o Generalized exercise intolerance
o Fluid retention/edema
o Weight gain
o Jugular distention
o Hepatomegaly
o Ventricular gallop / cardinal sign in older adults
5. As the heart loses the ability to pump an adequate
supply of blood throughout the body, blood is diverted to
the heart and brain.
Less vital organs (i.e. kidneys or the digestive system)
receive sufficient amounts to function properly.
o Over time this can result in decreased urine production,
nocturnal urination, and nausea and vomiting.
The “worst symptoms” as defined by patients during
hospitalization for HF are fatigue and abdominal swelling
6. Doctors usually classify patients' heart failure according
to the severity of their symptoms.
o The following tables describes the most commonly used
classification system, the New York Heart Association (NYHA)
Functional Classification.
o It places patients in one of four categories based on how much
they are limited during physical activity.
For Example:
o A patient with minimal or no symptoms but a large pressure
gradient across the aortic valve or severe obstruction to the left
main coronary artery is classified:
• Function Capacity 1, Objective Assessment D
o A patient with severe anginal syndrome but angiographically
normal coronary arteries is classified :
• Functional Capacity lV, Objective Assessment A
7. Class Functional Capacity: How a patient with cardiac disease feels during physical activity
I Patients with cardiac disease but resulting in no limitation of physical activity. Ordinary physical
activity does not cause undue fatigue, palpitation, dyspnea or anginal pain.
II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable
at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain.
III Patients with cardiac disease resulting in marked limitation of physical activity. They are
comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea or anginal
pain.
IV Patients with cardiac disease resulting in inability to carry on any physical activity without
discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If
any physical activity is undertaken, discomfort increases.
Class Objective Assessment
A No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary
physical activity
B Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during
ordinary activity. Comfortable at rest.
C Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due
to symptoms, even during less-than-ordinary activity. Comfortable only at rest.
D Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms
even while at rest.
8. Device Therapy for Patients with Heart Failure
o Implantable cardiac defibrillator
• An implantable cardiac defibrillator (ICD) is an electronic device that
constantly monitors the patient’s heart rhythm.
• When the device detects certain abnormal heart rhythms, it delivers
a small shock to the heart muscle to restore a normal heart rhythm.
• The shock will be brief and may feel very uncomfortable.
• Studies show that an ICD can reduce the risk of sudden cardiac
arrest (SCA).
9. o LVAD
• What is a left ventricular assist device (LVAD)?
• The left ventricle is the large, muscular chamber of the heart that pumps
blood out to the body.
• A left ventricular assist device (LVAD) is a battery-operated, mechanical
pump-type device that's surgically implanted.
• It helps maintain the pumping ability of a heart that can't effectively work on
its own.
• These devices are available in most heart transplant centers.
• When is an LVAD used?
• This device is sometimes called a "bridge to transplant," but is now used in
long-term therapy.
• People awaiting a heart transplant often must wait a long time before a
suitable heart becomes available.
• During this wait, the patient's already-weakened heart may deteriorate and
become unable to pump enough blood to sustain life.
• An LVAD can help a weak heart and "buy time" for the patient or eliminate
the need for a heart transplant.
• Most recently, LVADs are being used longer-term as ‘destination therapy’ in
end-stage heart failure patients when heart transplantation is not an option.
10. • How does an LVAD work?
• A common type of LVAD has a tube that pulls blood from the left
ventricle into a pump.
• The pump then sends blood into the aorta (the large blood vessel
leaving the left ventricle). This effectively helps the weakened ventricle.
• The pump is placed in the upper part of the abdomen.
• Another tube attached to the pump is brought out of the abdominal wall
to the outside of the body and attached to the pump's battery and
control system.
• LVADs are now portable and are often used for weeks to months.
• Patients with LVADs can be discharged from the hospital and have an
acceptable quality of life while waiting for a donor heart to become
available.
11. • Promising study results for LVADs
• In a study published in Circulation in 2005, LVADs restored failing
hearts in some patients with heart failure, eliminating the need for a
transplant.
• According to an abstract presented at the American Heart Association's
2005 Scientific Sessions, LVADs reduced the risk of death in end-stage
heart failure patients by 50 percent at six and 12 months and extended
the average life span from 3.1 months to more than 10 months
12. o Cardiomems Device
• What is a cardiomems device?
• The CardioMEMS HF System measures and monitors the pulmonary
artery (PA) pressure and heart rate in certain heart failure patients.
• The System consists of an implantable PA sensor, delivery system, and
Patient Electronics System.
• The implantable sensor is permanently placed in the pulmonary artery,
the blood vessel that moves blood from the heart to the lungs.
• The sensor is implanted during a right heart catheterization procedure.
• The PA sensor is about the size of small paper clip and has a thin,
curved wire at each end.
13. • How does a Cardiomem work?
• This sensor does not require any batteries or wires.
• The patient uses the CardioMEMS HF System at home or other non-
clinical locations to wirelessly obtain and send PA pressure and heart
rate measurements to a secure database for review and evaluation by
the patient’s doctor.
• The Patient Electronics System includes the electronics unit, antenna
and pillow. Together, the components of the Patient Electronics System
read the PA pressure measurements from the sensor wirelessly and
then transmit the information to the doctor.
• The antenna is paddle-shaped and is pre-assembled inside a pillow to
make it easier and more comfortable for the patient to take readings.
14. • When is a cardiomem used?
• The CardioMEMS HF System is used to wirelessly measure and
monitor PA pressure and heart rate in New York Heart Association
(NYHA) Class III heart failure patients who have been hospitalized for
heart failure in the previous year.
• The PA pressure and heart rate are used by doctors for heart failure
management and with the goal of reducing heart failure
hospitalizations.
• What will it accomplish?
• Access to PA pressure data provides doctors with another way to better
manage a patient’s heart failure and potentially reduce heart failure-
related hospitalizations.
• In a clinical study in which 550 participants had the device implanted,
there was a clinically and statistically significant reduction in heart
failure-related hospitalizations for the participants whose doctors had
access to PA pressure data.
15. Inotropic drugs are given by injection or IV.
Inotrope therapy for HF is usually offered when patient’s
are decompensated and in the hospital.
It should always be started in the hospital.
Inotropic drugs come in 2 categories
o B-adrenergic antagonists
o Phosphodiesterase-III inhibitors
16. Indications
o Short term therapy for decompensation management
o Used as a bridge to heart transplant
o Palliative end of life care
Purpose
o Improve blood flow
o Reduce symptoms and improve quality of life
o Increase organ perfusion
Goals
o Prevent exacerbation of Congestive Heart Failure
o Prevent readmissions to hospitals
o Decrease emergency room visits
18. Figure 2. Recommended approach to the use of inotropic
support in patients hospitalized with acute HF exacerbation.
o As long as patients appear clinically well perfused, usually with a
systolic blood pressure (BP) >80 mm Hg, inotropes provide no
outcome benefit and subject patients to significant risks of
arrhythmia, remodeling, and death.
o Well-perfused patients with impaired functional capacity and
frequent hospitalizations for HF exacerbation may benefit from
digoxin.
o In hospitalized patients with worsening cardiorenal syndrome
despite intravenous diuretic and vasodilator therapy, it is reasonable
to add an inotrope in an attempt to acutely rescue renal function.
o If patients are hospitalized with clinical evidence of shock, inotropic
support is clearly indicated as a temporary measure until stabilized
on oral agents or bridged to transplant or mechanical assist device.
o Continuous home inotropes may also be considered for end-stage
patients as a palliative measure. ACE-I indicates angiotensin-
converting enzyme inhibitors.
19. Dopamine
o Improves heart output and may raise blood pressure.
o Administered as a continuous IV infusion.
o It increases the amount of norepinephrine active in the body.
o Patients can become tolerant to dopamine, so larger and larger
doses are necessary to get the same effect over time.
o Dopamine is often used to eliminate edema because of the
affects of the receptors in the kidney's blood vessels.
o Potential side effects include irregular heart rhythm, and
increased demand for oxygen by the heart
20. Dobutamine
o Improves heart function and may lower blood pressure.
o It is used as a continuous IV infusion.
o It helps the body make more use of norepinepherine.
Norepinephrine stimulates the heart to work harder.
o Patient’s can become tolerant to dobutamine faster than to
dopamine, and larger doses are necessary to get the same
effect over time.
o Eventually it may cease to be therapeutic.
o Potential side effects include irregular heart rhythm (although
less than with dopamine), and increased demand for oxygen by
the heart
21. Milrinone (Primacor)
o This drugs make the heart beat more strongly and also relax the
blood vessels.
o Most widely used drug of this type.
o Usually given by IV at 0.375 to 0.75 micrograms per kilogram of
body weight per minute.
o Since milrinone does not increase the heart's oxygen demand, it
is preferred over other inotropes in patients with ischemic
cardiomyopathy.
o Preferred drug for treating severe CHF episodes in patients
taking beta-blockers.
22. Milrinone is the most common Inotropic drug used for
home therapy
Dopamine is rarely used in the home
D5W is the preferred diluent due to sodium restrictions
Standard Dosing:
Drug Dosage
Milrinone 0.25mcg/kg/min-0.75mcg/kg/min
Dobutamine 2.0mcg/kg/min-20mcg/kg/min
Dopamine 0.5mcg/kg/min-3mcg/kg/min
23. Risks
Catheter related
bloodstream infections
Increase in mortality
Arrythmias
Hypotension
Family Burden
Benefits
Enables patient to go
home from the hospital
Increases quality of life by
decreasing s/s
Fewer hospitalizations
24. During discharge planning the following issues should be
addressed to determine whether patient is an
appropriate candidate for home inotropic therapy.
o Patient must be clinically stable on current dose
o Home environment (water supply, electricity, phone service, and
emergency services available)
o Central venous access-Picc/Tunnelled Central line/Port
o Insurance/reimbursement criteria met or costs to patient
established
o Patient/Caregiver ability and willingness to participate
o Patient compliance
25. Patient must have 2 pumps in the home, one as a back-
up
Routine pump battery changes
Importance of monitoring of drug expiration dates
Double lumen access preferred for labs and alternate
lumen available
A continuous inotrope infusion should not be flushed
26. Vital Signs (Heart rate, BP, Respiratory rate and temperature)
Daily weight and evaluate record
Assess degree and location of edema
Record fluid intake and output
Assess cardiac status (heart rate and rhythm and heart
sounds. Use of nitroglycerin)
Assess respiratory status ( rate, orthopnea, cough, activity
tolerance, O2 use)
Assess diet and compliance with sodium and fluid restrictions
Measure and record patients abdominal girth
Central line assessment and documentation, dressing change
if needed
Lab monitoring ( commonly CBC, Creatinine, electrolytes
,liver functions)
27. Infection control-Line
care
Storage and handling
of medications
Pump operations,
troubleshooting and
alarms
Inotropic infusion
administration
Medication therapeutic
effects and side effects
Emergency plan
Low sodium diet
Fluid restriction
Activity Level
Telecommunication
system (if available)
Oral medication use
and side effects
MD notification
Daily weight
Recording I&O
28. Weigh daily, call if weight increase > 2 lbs daily
Unusual medication side effects
Significant blood pressure or pulse changes
Nocturnal dyspnea
Increased cough, swelling, adventitious heart or lung
sounds
Decreased urination
S/S confusion, dizziness, nausea or vomiting, increased
fatigue, muscle cramps or weakness
29. CHF is the #1 cause of hospital re-admissions within 30
days.
Heart Failure readmissions are estimated to cost
Medicare $12 Billion annually
Studies show 50% of re-admissions can be prevented
With Health Care reform, hospitals are now being
penalized by Medicare and other payors for Heart failure
readmissions within 30 days and have cut or refused
reimbursement
30. Discharge Teaching-intensive education about congestive heart
failure and its treatment by an experienced cardiovascular nurse.
Medication reconciliation – Within forty-eight hours of discharge, a
physician or nurse reviews a list of the patient’s medications with
explicit instructions on how to properly take them.
Post-discharge appointments – Before being discharged, patients
are scheduled for follow-up care. When possible, patients at high
risk for readmission are scheduled to be seen within seven days of
discharge; all others are scheduled to be seen within 14 days.
Post-discharge phone calls – Within a specified time frame
following discharge (again based on the patient’s level of risk for
readmission), a member from the coordinated care team calls
patients to assess their condition and see if they have any questions
or are having any problems with their medications.
Home Health Follow up-intensive follow-up after discharge with
home care services and coordination of care with cardiology.
31. Currently there are limited alternatives other than
inotropic therapy and LVADS for End stage CHF
patients.
New pharmacologic agents are in research and develop
phase
Stem cell research being done with goal of replacing
dead tissue from an acute MI with new tissue, improving
cardiac function
Gene therapy : process of altering defective genes to
correct organ function
Development of more sophisticated mechanical devices
such as heart pumps.
Improved availability of donor organs
32. Sherrod, M., Graulty, R.,Crawford, M., Cheek, D. Intravenous Heart Failure Medication.
Home Health care Nurse Vol 27,no. 10 Nov/Dec 2009; 613-619
Lyons, M.,Carey, L.Parenteral Inotropic Therapy in The Home: An Update for Homecare
and Hospice. Home Healthcare Nurse; April 2013 Vol 31 Issue 4; 190-204
IV Heart Failure Drugs: www.CHFpatients.com/Inotropes; June 12 ,2006
Harjai, K.,Mehra, M., Ventura,H.,Lapeyre, Y.,Murgo, J.,Stapleton, D. Smart, F.Home
Inotropic Therapy in Advanced Heart Failure: Cost analysis and Clinical Outcomes: Chest
Journal; Nov 1997;5.112; 1298-1303
Boger, J.,DeLuca, S.,Watkins, D.,Vershave, K.,Thomley, A. Infusion Therapy With Milrinone
in the Home Care Setting for Patients Who Have Advanced Heart Failure: Journal of
Intravenous Nursing: Vol 20,3 May/June 1997; 148-154
Samkowiak,J. Home Inotopic-therapy: www.slideshare.net
McCloskey, W.Use of Intravenous Inotropic Therapy in the Home: American Society of
Health-System Pharmacists Inc. Vol 55 May 1,1998; 930-935
Stevenson, L.Clinical use of Inotropic Therapy for Heart Failure Looking Backward or
Forward part 11: Chronic Inotropic Therapy: AHA journal 2003,108: 492-497
Rich, M., Beckham, V., Wittenberg, C., Leven, C., Freedland, K. and Carney, R. A
Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with
Congestive Heart Failure: AJM N ENGL J MED 1995; 333: November 2, 1995 1190-1195
http://www.sjm.com/cardiomems
