Heart Failure

1
Heart Failure

• Strategies for Care Providers
• Kathy Machingo RN BSN CNA-BC
• Manager of HF clinics
• Humility of Mary Health Partners
• Warren-Youngstown, Ohio

2
Incidence Prevalence of Heart Failure (HF)

• Profound public health implications an epidemic
• Almost 5 million Americans and rising
• More than 550,000 new cases each year, increasing
  with age (most 65 yr. old)
• Survival remains poor50 mortality within 5 yr.
• Costs exceed 15 Billion (twice the cost of all
  forms of cancer)
• Fixed reimbursement means hospitals rarely
  recover all costs incurred
• ( DRG days 4.5 average)
• 24 of all nursing home patients have HF
• Data Source Consensus (January 21, 1999). The
  American Journal of Cardiology.
• Recommendations for the Management of Chronic
  Heart Failure

3
Snapshot of Excess Fluid in Acute Decompensated
Heart Failure
8 pounds 8 pounds
16 pounds The average amount of
excess fluid found in acute HF patient
4
Progression of Heart Failure (Ventricular
Remodeling, then Dilatation)
(Picture courtesy of ACORN website)
5
(No Transcript)
6
Causes of Heart Failure

• Coronary artery diseaseWhen cholesterol and
  fatty deposits build up in the heart's arteries,
  less blood reaches the heart muscle. This damages
  the muscle, and the healthy heart tissue that
  remains has to work harder.
• Past heart attacks (myocardial infarction)A
  heart attack occurs when an artery that supplies
  blood to the heart gets blocked. The loss of
  oxygen and nutrients causes damage to the heart's
  muscle tissue part of it essentially "dies."
  The remaining healthy tissue has to pump even
  harder to keep up.
• High blood pressure (hypertension)Uncontrolled
  blood pressure doubles a person's risk of
  developing heart failure. When pressure within
  the blood vessels is too high, the heart has to
  pump harder than normal to keep the blood
  circulating. This takes a toll on the heart, and
  over time the chambers get larger and weaker.
• Heart defects present at birth (congenital heart
  disease)If the heart and its chambers don't form
  correctly, the healthy parts have to work

7

• Abnormal heart valvesHeart valve problems can
  result from disease, infection ( endocarditis) or
  a defect present at birth. When the valves don't
  open or close completely during each heartbeat,
  the heart muscle has to pump harder to keep the
  blood moving. If the workload becomes too great,
  heart failure results.
• Heart muscle disease ( cardiomyopathy) or
  inflammation (myocarditis)Any damage to the
  heart muscle, whether because of drug or alcohol
  use, viral infections or unknown reasons,
  increases the risk of heart failure.
• Severe lung diseaseWhen the lungs don't work as
  they should, the heart has to work harder to get
  available oxygen to the rest of the body.
• DiabetesDiabetes puts extra strain on the heart,
  increasing risk for heart failure. People with
  diabetes also tend to be overweight and have high
  blood pressure and high cholesterol all of
  which make the heart work harder.

8
Diastolic Dysfunction

• Particularly common in older women and African
  Americans
• Often caused from long term hypertension which
  enlarges the heart, ischemia from CAD
• The heart becomes stiff and harder to relax
  during diastole.
• Difficult to treat as medications for systolic
  heart failure ( ACEI /diuretics) less effective.
• Treatment includes Beta Blockers and centrally
  acting calcium channel blockers, there is a need
  to slow the heart down

9
Diastolic Dysfunction Or HF with preserved
systolic function
10
Points to Remember

• Typically these conditions cause the "wear and
  tear" that leads to heart failure. A combination
  of any of the above factors dramatically
  increases risk.
• The MI and/or CABG or HTN or Diabetic patient of
  today is the HF patient of tomorrow HF is an
  epidemic
• Those patients ( families) who do not understand
  how to manage, the syndrome will get worse are
  patients at higher risk of being readmitted to
  the hospital and/or increased morbidity/mortality
• It will take a team effort and a variety of
  treatments to make a difference ALL play a
  pivotal role in the education / management
  /treatment of patients with HF

11
Recent Approach to the Classification of Heart
Failure
Carvedilol is indicated for use in patients with
mild to severe chronic HF and in patients with
HTN. Hunt SA et al. J Am Coll Cardiol.
20013821012113.
12
New York Heart Association (NYHA) Classification
Asymptomatic LV Dysfunction No sx Class I
(asymtomatic)
A Continuum evolution of clinical changes (not
static, can change)
Compensated LV Failure Sx w/ordinary exertion
Class II ( mild)
Decompensated LV Failure Sx w/minimal exertion
Class III ( moderate)
Refractory LV Failure Sx at rest Class IV (
severe)
13
Causes of Readmission for HF Up to 50 of
hospital readmissions for heart failure may be
preventable
J Am Geriatr Soc 1990 381290-5
14
ADHERE Clinical Presentation in ED
15
AVERAGE HF Patient in ED

• 75 year old white female
• Insured, with history of HF
• Short of breath
• SBP greater than 140
• Decent renal function
• BNP 667 pg/mL

Adams KF
Am Heart Journal 2005 149209
16
Key Points in Assessment of Worsening

• All medications including new meds and especially
  OTC ( some meds worsen HF)
• Amount of fluid intake over the last 2-3 days
• What foods have been eaten over the last 2-3 days
• If they weigh daily, any change in weight ( 3
  pounds in 3 days notify physician)
• How would they rate SOB today and how does that
  compare with SOB in the past

17
Biventricular Pacemaker
Heart failure often the right and left
ventricles do not pump together. Biventricular
pacemaker keeps the right and left ventricles
pumping together by sending small electrical
impulses through the leads.
Normal heart the heart's lower chambers
(ventricles) pump at the same time and in sync
with the heart's upper chambers (atria).
18
BAD DRUGS for HF ( cause fluid retention)

• Class 1a and 1c antiarrthymics
  (norpace,quinidine, mexitil, rythmol , cordarone,
  betapace) used at times but not recommended
• Calcium channel blockers ( 1st and 2nd
  generation.
• 1st generation beta blockers (proprandolol,
  timolol)
• Lithium, Some antidepressants
• COX 2 inhibitors ( NSAIDS used in arthritis)
• Some oral DM meds ( Actos, Avandia)
• OTC Rolaids, ASA if taken more than 1 QD,
  ginseng, ginko biloba

19
Strategies to take the Congestive out of CHF

• Goal control fluid retention
• Diuretics not designed to be used alone,
  without ACE
• Thiazides prolonged
• Loop short-acting, more vigorous( Lasix,
• Demadex, Bumex)
• Potassium-sparing mild but
• Aldactone Spironolactone blocks the action of
  
• aldosterone, a hormone that may exert
  adverse
• effects on the heart muscle and peripheral
  blood
• vessels. Spironolactone not only may
  improve fluid
• balance but may also decrease the risk of
• progression of HF.
• Combination meds synergy neurohormonal benefit

20
Active Diuresis in Exacerbationits immeasurable!

• To over come worsening in acute HF, if diuresis
  is effective, we should see 500 cc urine output
  in first 4 hours.
• If the U.O. falls below 200 cc/hr and the patient
  is still symptomatic, physician needs notified to
  consider next steps
• First 24 hours is the critical time to facilitate
  diuresisrelief of feeling of suffocation is a
  top priority.

21
HF - Therapeutic Goals of TreatmentWhats the
plan?

• Reduce dyspnea and fatigue
• Improve quality of life
• Alleviate edema and fluid retention
• Reduce admissions to hospital
• HOW? ACE-I, beta-blockers, Spironolactone,
  diuretics
• Weight monitoring, I/O, low sodium/decreased
  fluid diet
• Encourage activity

22
Strategies of Best PracticeACE is the Place !

• ACE Inhibitors - studied in 30 clinical trials
• Decrease symptoms, risk of death risk of
  hospitalizations significantly
• Should be initiated at low doses, then titrated
  to appropriate target doses
• Med should be given unless patient demonstrates
  symptoms (SBP of 85-90 is usually OKAY !)
• ARB (angiotensin receptor blocker) used if ACE is
  not able to be used. ARB is similar but not equal
  w/ documented contraindication

23
Common ACE inhibitors

• Generic name of ACE ends in pril (think of
  getting your pearls at ACE hardware store)

• Captopril(Capoten)
• Quinipril(Accupril)
• Fosinopril(Monopril)
• Lisinopril(Prinivil)

• Lisinopril(Zestril)
• Trandolapril(Mavik)
• Ramipril(Altace)
• Enalapril(Vasotec)

• Please - dont call these pills your blood
  pressure medications!

24
Angiotensin-Receptor Blockers

• Angiotensin-receptor blockers (ARBs), also known
  as angiotensin II receptor antagonists, are
  similar to ACE inhibitors in their ability to
  lower blood pressure.
• They may have fewer or less-severe side effects
  than ACE inhibitors, especially coughing.
• The ARBs include valsartan (Diovan), losartan
  (Cozaar), candesartan (Atacand), telmisartan
  (Micardis), and irbesartan (Audpro).
• Although it is not clear whether they are any
  better than the less expensive ACE inhibitors,
  evidence is accumulating to indicate that they
  may reasonable alternatives to ACE inhibitors.
• At this time, valsartan is the only ARB approved
  as an alternative to ACE inhibitors for heart
  failure patients.

25
Strategies to Improve Patient CareBeta-blockers
may eventually reverse the process!

• Only 3 recommended for HF
• Carvedilol, Metoprolol XL, Bisoprolol
• Take with food separate by 2 hours if also on
  ACE inhibitor
• Do not discontinue medication abruptly (or
  symptoms will surely return)
• Monitor for orthostatic hypotension
• Shortness of breath and fatigue may become worse
  during the first month or two before patient
  feels better

26
Hydralazine and Nitrates

• The combination of isosorbide dinitrate and
  hydralazine supplies nitric oxide giving a
  vasodilator action that relaxes blood vessels and
  eases the workload of the heart.
• A-HeFT (African American HF trial tested the drug
  BiDil) showed there was a fundamental
  physiological difference between black and white
  Americans.

27
Pharmacologic Strategies Summary

• Please - dont call these pills your blood
  pressure medications!
• ACE-Inhibitors help counteract
• vasoconstriction, decrease
• mortality/morbidity, (prevent
  remodeling)
• Beta-blockers spironolactone decrease
  circulating neurohormones mortality/morbidity (
  reverse remodeling)
• Diuretics counteract fluid retention congestion
  - decreased sodium intake decreases diuretic
  resistance
• Non-pharmacological therapy
  ( preventative measures) is very effective -
  target (dry) weight assessment is important!

28
Fluid Restrictions

• 1500-2000ml Fluid Daily
• Common misconception for taking in too much fluid
  is the label on med bottles or the media saying
  drink 8 glasses a day (doesnt apply to HF pts).
• 1 cup 8 ounces (oz.) Anything that melts at
  room temperature is a fluid. Soup, gelatin, ice
  cream and watermelon count as fluid!
• Commonly recommended fluid restrictions per day
• cc (ml) Ounces
  Cups
• 1500 cc (ml) 50 ounces 6 1/4
  cups
• 1800 cc (ml) 60 ounces 7 1/2
  cups
• 2000 cc (ml) 66 2/3 ounces 8 1/3 cups

29
Dietary Restrictions(quick, call the salt
police!)

• 2000 mg Sodium Daily (1 Teaspoon of Salt)
• Most people with heart failure should eat less
  sodium (salt) and limit fluid.
• Sodium attracts water and makes the body hold
  fluid that causes worsening shortness of breath.
• Do not use salt substitutes high in potassium.
• Monitor and avoid high salt food brought in by
  family.

30
Setting the Stage for Success

• Rally champions, educate staff so they can be
  alert to changes in condition and advocate for
  the right thing to do for those with Heart
  Failure.
• Reconcile medications!!!!
• Always think HF.monitor closely fluid intake and
  sodium content of a clear liquid diet.
• IV fluid intake needs to very slow in situations
  that are out of the ordinary.

31
Typical LTC Scenario

• 75 year old female with history of hypertension
  is seen for monthly follow up by physician and RN
  in LTC. She is SOB, has some edema, and decreased
  pulse oximeter reading.
• Plan includes adding some digoxin, monitor renal
  function and potassium level, wait and see if she
  improves.

32
Implications for Care of Chronic Heart failure  

• Step 1
• Staff knowledge there is a confirmed diagnosis of
  Heart Failure
• Establish what team members are responsible for
  which aspects of care and whom they report
  changes to with an understanding of how crucial
  it is to report changes in the heart failure no
  matter how slight.

33

• Step 2
• Preventative measures in place
• Monitoring or limiting fluid intake 2000
• ml per day includes meals and meds
• Nutrition assessment and placement on 2000 mg
  sodium diet
• In LTC setting, baseline and weekly weight
  monitoring (same scale) and comparison with
  previous weight, monitor ( not measure) frequency
  of urine output

34

• Step 3
• Review medication list
• Are meds optimized (at highest tolerated
• dose) on ACEI and/or beta blocker?
• If not, do they have documented
• contraindication or can meds be increased?
• Consider they are Heart meds and not BP
• meds, not withheld unless symptoms of
• hypotension such as lightheadedness.
• What meds may be long acting and not able
• to be crushed?
• Is an oral diuretic prescribed? Do they
• require a potassium supplement?

35

• Is there an as needed order from physician for
  additional dose of oral diuretic (pending
  verification of ability to tolerate off of known
  labwork) with further fluid restriction to 1500
  ml for 2 days then reassess progress
• Appropriate drug monitoring includes If on ACEI,
  monitor renal function every four to six months
  and as needed. This will help monitor tolerance
  to dose of meds. If on Digoxin, may require every
  four month monitoring of digoxin level. If on
  diuretic, electrolytes monitored every four to
  six months and as needed for a change in
  condition.
• Avoid medications that exacerbate Heart Failure
  such as NSAIDS for pain or arthritis ( see bad
  drug list)

36

• Step 4 Appropriate Work up for HF resident in
  LTC
• On admission and if recently hospitalized having
  abnormal labs
• Chemistry Tests including electrolytes, Complete
  Blood count
• Thyroid tests
• Weekly weights or if patient deteriorates
• Chest Xray
• Echocardiogram ( annually)

37

• Symptoms
• Shortness of breath on exertion or at rest
• Need for more pillows to be able to breathe or
  inability to breathe lying down
• Unexplained cough with or without worsening to
  coughing up pink sputum
• Acute sudden onset of new state of being confused
• Abdominal symptoms (nausea, abdominal distention)
• Decreased food intake, changes in appetite
• Overall decline in status from previous baseline

• Step 5 Gather baseline info and assess changes
  in condition
•  
• Signs
• Peripheral Edema
• Abdominal bloating
• Weight gain
• Bilateral rales
• Tachycardia
• Increase jugular vein distention

38

• Step 6 In the event of apparent exacerbation
  of Heart Failure
• Complete assessment for signs/ symptoms /
  causative factors (such as family brought in high
  salt food like soup)
• Rule out medication reaction (addition of
  medication that causes fluid retention), drug
  omission, inadequate blood pressure control
• Rule in signs of fluid overload, consider
  additional dose of oral diuretic and further
  fluid restriction of 1500 ml (times 2 days).
  Monitor for relief or no resolution.
• Apply supplemental oxygen per physician order
• Evaluate the risk/benefit of hospitalization
  consistent with advanced directive

39
End of Life Issues(Palliative Care)

• HF patients can be end stage for 3 years, we
  need to understand the differences in HF vs
  Cancer.
• Provision of spiritual support.
• Find out the persons wishes for resuscitation and
  initiate DNRCC forms.
• Explore options for quality of life.
• Consider Hospice information on medication to
  alleviate air hunger.

40
Goals for Preventing or Decreasing Readmission

• Preventative Measures and Early identification
• Evaluation of potential reversible causes
• Early response to decompensation inpt outpt.
• IV diuretics
• Lab analysis
• Optimization of medical therapies - medication
  
• initiation / adjustment titration per
• guidelines Initiation titration of ACE-I
  B-blockers
• Close Follow up ( Home care hand off to CHF
  Clinic)

41
SUMMARY

• Accurate assessment, preventative measures and
  early intervention can prevent frequent
  hospitalizations.
• Quality of life for persons with HF depends on
  adequate care.
• Avoiding a disruption of a change in physical
  environment provides safe and comforting haven in
  the facility or own home.
• Every provider of care is important.

42
Questions? Comments!!!HF patients can
evolve into acute suffocating distress. Who will
champion their cause? Will you?