2. HEART FAILURE
DEFINITION
• A complex clinical syndrome that can
result from any structural or functional
cardiac disorder that impairs ability of the
ventricle to fill with or eject blood.
• Current patients with HF are older, have
more comorbidities and take more
medications than in the past.
Wong et al 2011
3. ADVANCED
HEART FAILURE
• AHF affects 2.4% of adults
• 11% of those are > 80 years old
• Estimated costs reaching 44.6 billion by
2015
• Therapies slow but infrequently reverse
progression
4. TIME TO INTERACT
Any of you with heart
failure patient on your
service right now?
5. TYPES OF HEART FAILURE
LEFT SIDED
RIGHT SIDED
(reduced cardiac output)
(fluid overload)
Systolic Dysfunction:
-decreased contractility
Diastolic Dysfunction:
-abnormal or restrictive
ventricular filling
-Usually from LV failure
6.
7.
8. Stage D – Refractory HF requiring
specialized interventions (Class IV NYHA)
Marked symptoms at rest despite maximal
medical therapy
GOALS – appropriate measures under
Stages A, B, C
Options – compassionate end-of-life
care/hospice, extraordinary measures
including transplant, chronic inotropes,
ventricular assist device, experimental
surgery or drugs
9. WHAT IS THE MOST COMMON SYMPTOM
IN STAGE D HEART FAILURE?
A. Dyspnea
B. Fatigue
C. Anorexia
D. All of the Above
10.
11. MAJOR INTERVENTIONS TO IMPROVE
CARDIAC FUNCTION
• High risk cardiac
surgery
• Temporary mechanical
circulatory support
• Percutaneous
intervention
• Renal replacement
therapy
• Pacing device therapy
• Transplantation
• Implantable
defibrillator
• Ventricular assist
device
• Positive inotropic
agents
12. POTENTIAL BENEFITS OF
SAID THERAPY
• Improves functional status
• Reduces symptoms
• Improves hemodynamics
• Improves echocardiographic parameters
• Improves QOL
13. SHARED DECISION MAKING
• Annual HF review with patients to include
current/potential therapies for the anticipated and
unanticipated events
• Review advanced care decisions on admission to the
hospital
• Clinical milestones such as hospitalization, ICD
shocks should trigger review of the advanced care
plan with discussion of treatment options and
preferences
Circulation 2012
14. SHARED DECISION MAKING
• Discussion should include range of anticipated
outcomes and QOL
• Therapies that lead to dependence should be
weighed carefully
• Referral to palliative team should be considered
Circulation 2012
15. BARRIERS TO
SHARED DECISION MAKING
•
Emotional roadblocks
•
Depression and anxiety
•
Limitations of cognition, literacy, and numeracy
•
Family dynamics
•
Culture and religion
•
Language differences
•
Time
•
Resolving conflict
Circulation 2012
17. COMMON SYMPTOMS EXPERIENCED
BY HF AND CANCER PATIENTS
Similar to cancer
Dyspnea
Fatigue
Anorexia
Cachexia
Pain
Postural hypotension
Anxiety
Depression
Different from cancer
More edema
More renal dysfunction
More signs of poor perfusion
18. TIME TO INTERACT
What percentage of
patients on your service
have cancer?
Have heart failure or
cardiac disease?
19. PROGNOSIS AND THE ADVANCED
HEART FAILURE TRAJECTORY
Heart Failure
Less Predictable
-Loss of functional
abilities at onset of
diagnosis
-Slower decline with
repeated hospitalization
-Pump failure versus
sudden death
20. PROGNOSIS AND THE ADVANCED
HEART FAILURE TRAJECTORY
Compared to Cancer
Predictable Course
-Longer functional
abilities before downward
slide
-Average lifespan of 6
months after begin to
decline
21. PROGNOSIS AND THE ADVANCED
HEART FAILURE TRAJECTORY
Clinical signs of reduced tissue perfusion:
-low MAP
-renal insufficiency
-poor response to diuretics
-lack of improvement with therapy
These patients have worse prognosis…..
22. RISK ESTIMATES
IN ADVANCED HEART FAILURE
•
MDs and RNs always overestimate survival
-In prospective cohort of terminally ill patients:
20% accurate
63% optimistic
17% pessimistic
**inaccuracy increased the longer the relationship
BMJ 2000
23. PROGNOSIS FOR QUANTITY AND
QUALITY OF LIFE
ADAPTED FROM SPILKER
Direct/Indirect
Medical Costs
Caregiver Burden
Lost
Opportunities
Survival
QOL
Outcomes
Relevant to
Individual
Patient
24. WHEN SHOULD HOSPICE BE
CONSIDERED IN AHF?
• Frequent hospitalizations
• Poor QOL with inability to perform ADLs
• Need for intermittent or continuous intravenous
support
• Consideration of assist devices as destination
therapy
• Preference for comfort care over life sustaining
treatment
26. BREATHING
ASSESSMENT
• Have you felt SOB? Do you wake up SOB at
night?
• Can you speak as much as you want?
• What makes breathing easier?
• Do you cough? Is it worse than usual?
• Do you cough up secretions?
• Have you increased your oxygen?
27. SLEEP
ASSESSMENT
• Have HF symptoms kept you from sleeping?
• Do you sleep in bed or a chair?
• Are you able to lay flat in bed?
• How many pillows do you use?
• Have you recently slept more or less than usual?
28. DIET
ASSESSMENT
• Have you recently eaten more salty foods or drank
more water than usual?
• How often do you eat out?
• Have you gained or lost weight recently?
• Have you experienced swelling?
• How far up your legs do you have edema?
• Are your clothes, rings, belt and shoes tighter than one
week or one month ago?
29. MEDICATION
ASSESSMENT
• Have you taken all prescribed meds?
• Did you run out of any medications?
• Have you had diarrhea/vomiting?
• Have you taken extra diuretic meds?
• Have you changed the dose of any meds?
• Do you take any OTC meds or herbal
supplements?
30. ACTIVITY
ASSESSMENT
• How far can you walk?
• Can you dress, bathe, prepare food, climb
stairs without stopping to rest?
• What activities could you do recently but not
now because of worsened symptoms?
• Have you decreased your activity level?
31. CONFUSION
ASSESSMENT
• Do you have difficulty remembering information or
feelings of confusion?
• Have you had other health problems that may make
your heart failure worse?
32. POSSIBLE EXAM FINDINGS
IN HEART FAILURE PATIENTS
• Resting tachycardia
• Increased respiratory rate
• Decreased strength of
peripheral pulses
• Orthostatic changes in
pulse and BP
• JVD
• Rales
• Wheezes
• Decreased breath sounds
(effusions)
• Irregular rhythm
• S3 or S4
• Murmurs
• Ascites
• RUQ pain/tenderness
• Cyanosis
• Peripheral edema
• Muscle wasting
33.
34.
35. EVIDENCE-BASED TREATMENT ACROSS THE
CONTINUUM OF SYSTOLIC LVD AND HF
Control Volume
Diuretics
Renal Replacement
Therapy*
Improve Clinical Outcomes
Aldosterone
ACEI
-Blocker Antagonist
or ARB
or ARB
CRT
an ICD*
HDZN/ISDN*
*In selected patients
Treat Residual Symptoms
Digoxin
HFSA 2010
36. ANGIOTENSIN CONVERTING
ENZYME INHIBITORS (ACE-I):
• Alleviates symptoms, improves clinical status
• Enhances overall sense of well-being
• Improves duration of exercise
• Reduces hospitalization and risk of death
• If target doses cannot be reached,
intermediate doses should be used
Benazepril, Captopril, Lisinopril, Monopril
37. ANGIOTENSIN RECEPTOR
BLOCKERS (ARB):
• ARBs if ACE-I intolerant d/t cough or
angioedema (valsartan and candesartan)
• Reduces hospitalizations and mortality
Candesartan, Losartan, Valsartan
38. ALDOSTERONE ANTAGONISTS:
• Reduced risk of death, reduction in HF hospitalization
• Improvement in functional class
• May help manage volume overload
• D/C K supplements and avoid high K foods
Spironolactone, Eplerenone
39. BETA-BLOCKERS:
I
• Inhibits the adverse effects of the SNS
• Lessens symptoms, improve clinical status,
reduce risk of death
• Begin as soon as LV dysfunction is diagnosed
• Initiate at low dose w/gradual increases
Atenolol, Metoprolol, Carvedilol
40. DIGOXIN:
• Benefit likely due to neurohormonal mechanism
rather than inotropic effect, does not improve
survival
• No loading dose necessary in SR
• Can be used for rate control of AF
• New info supports using lower doses and
targeting a dig level of 0.5-1ng/ml
41. DIURETICS:
• Loop diuretics (furosemide, bumetanide, torsemide)
increase sodium excretion by 20-25% of proximally
filtered load
• Improves exertion and breathlessness
• Thiazides (HCTZ, metolazone) increase sodium
excretion 5-10% (preferred in HTN HF secondary
more persistent antihypertensive effects)
• For optimal synergy, give thiazide 30 min (IV) or 60
min (po) before loop
• Monitor K and magnesium closely
42. ASA & WARFARIN:
• ASA if patient has
CAD
• Warfarin only if
other indication
such as AF or
history/risk of
embolic event
44. INOTROPES
DOBUTAMINE & MILRINONE:
• Dobutamine stimulates beta receptors
• Increases CO and SV
• Milrinone vasodilator via phosphodiesterase inhibition
• Decreases afterload and preload, increases CO
*As a bridge to transplant or in outpatient setting in
pts who could not otherwise be discharged as
palliative measure
48. SYMPTOM MANAGEMENT
DYSPNEA
• Non pharmacologic:
• Dietary sodium restriction
• Fluid restriction
• Upright positioning in bed, recliner or chair
• Utilize fan on face
• Oxygen
53. TIME TO INTERACT
Does Hospice of Union
County have a
deactivation policy?
Did you know that 50% of
Hospices had an ICD
delivery in the last year?
54. END OF LIFE
CARE PLANNING
• Should be consistent with patient values,
preferences and goals
• CLINICIANS SHOULD INITIATE THE
CONVERSATION
• Deactivation of ICD is desirable avoiding
pain/distress
• Active discontinuation VAD is often
appropriate
58. DOCUMENTATION FOR
DEVICE DISCONTINUATION
• Confirm patient has requested the deactivation
• Capacity of the patient or surrogate to make decision
• Confirm alternative therapies have been discussed
• Confirm consequences of deactivation have been
discussed
• Specific device to be deactivated
• Notify family if appropriate
59.
60. BIBLIOGRAPHY
Allen, L, Stevenson, L, Grady, K et al. Decision Making in Advanced Heart
Failure: A Scientific Statement From the American Heart Association.
Circulation. 2012; 125:1928-1952.
Sandesh, D, Abernethy, A, Rogers, J, O’Connor, C. Preferences of People
with advanced heart failure-a structured narrative literature review to inform
decision making in the palliative care setting. Am Heart J 2012; 164:31319.e5.
Morrison, L, Calvin, A, Nora, H, Storey, C. Managing Cardiac Devices Near
the End of Life: A Survey of Hospice and Palliative Care Providers. American
Journal of Hospice & Palliative Medicine. 2010; 27 (8):545-551.
Paul, S, and Glotzer, J. Clinical Evaluation of the Heart Failure Patient.
American Association of Heart Failure Nurses. November 2004 on
www.aahfn.org.
61. BIBLIOGRAPHY
Kutner, J. An 86-Year-Old Woman With Cardiac Cachexia Contemplating the
End of Her Life: Review of Hospice Care. JAMA. 303(4), 27 January 2010:
349-356.
www.aha.org
www.heartfailureguideline.org
NYHA Functional Classification: I-IV. Stage A at high risk w/o heart dz or symptoms, Stage B with structural heart disease w/o S/S HF, Stage C with structural heart dz with prior or current S/S HF, Stage D is refractory.
A group of patients whose symptoms limit daily life despite usual rec therapies and for whom lasting remission into less symptomatic dz is unlikely.
Cardinal symptom of HF: awareness of breathing at rest or when not expected. Fatigue r/t abn of skeletal muscles & other comorbidities. It promotes a vicious cycle.
Any of these therapies may reset the trajectory. Hi risk surgery anticipates there will be residual cardiac dysfunction.PCI: contrast induced nephropathy and 30D mortality increased.Pacing Device/CRT: Contingencies should be made ? ThoracotomyICD: improves survival by aborting lethal arrhythmias but don’t improve functionTemp mech support: may create indefinite dependenceInotropes: clinically significant milestone. Chronic? Goals should be established in advanceRRT: kidney dz increases dramatically. May not extend life in HF.Transplant: Exchange of diseaseVAD…as destination therapy
Scientific statement from AHA published 3/12
Emotion: Data demonstrates as little as 40 sec of empathetic comments can improve outcomes r/t communication (NURSE): Name the emotion, understand, respect, support the patient, explore the emotion. Depression: rates 4 fold higher in stage D vs A. Associated with impaired cognition interfering with processing. Cognition: Pts have poor understanding of medical interventions. (In pts on statin 38% did not treatment was lifelong and 83% could not id most common side effect). Cognitive decline in 25-5-% of patients. Family Dynamics: Barrier to negotiation. Culture & Religion: Be aware of the influence. Be careful assuming. Language: Subtleties and nuances can be missed with EASL. Family interpreters problematic. Time: Constraints faced by pts and clinicians. Billable visits… Resolving Conflict: Intervention desired may appear discordant with stated goals and medical reality. National culture of entitlement and denial of m/m doesn’t help.
Leading cause of inpatient admission in patients 65 and older. HF has a worse prognosis than many common cancers.
Pts tend to live variable lengths in continuous state of poor health with intermittent exacerbations.
There are many risk calculators: Seattle Heart Failure Model, Heart Failure Survival Score to define prognosis. There are significant underestimates of life expectancy in ambulatory HF.