Congestive Heart Failure Philip D Houck M.D.

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Congestive Heart FailurePhilip D Houck M.D.
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Thoratec Heartmate II
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Impella 5.0
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Cardiac Transplantation
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Cardiac Transplantation
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Indications for Cardiac Transplantation Absolute
indications in appropriate patients For
hemodynamic compromise due to HF Refractory
cardiogenic shock Documented dependence on IV
inotropic support to maintain adequate organ
perfusion Peak VO2 less than 10 mL per kg per
min with achievement of anaerobic
metabolism Severe symptoms of ischemia that
consistently limit routine activity and are not
amenable to coronary artery bypass surgery or
percutaneous coronary intervention Recurrent
symptomatic ventricular arrhythmias refractory to
all therapeutic modalities
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JCAHO Quality-of-Care Indicators for HF

• HF-1 Discharge instructions
• HF-2 Assessment of LV function
• HF-3 ACEI at discharge in appropriate patients
• HF-4 Smoking cessation advice/counseling

1. Daily weights 4. What to do if Sx worsen
2. 2-gram sodium diet 5. Follow-up appointment
3. Activity Rx 6. List of medications

www.jcaho.org
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• Evaluation of the Cause of Heart Failure The
  History
• History to include inquiry regarding
• Hypertension
• Diabetes
• Dyslipidemia
• Valvular heart disease
• Coronary or peripheral vascular disease
• Myopathy
• Rheumatic fever
• Mediastinal irradiation
• History or symptoms of sleep-disordered breathing

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• Exposure to cardiotoxic agents
• Current and past alcohol consumption
• Smoking
• Collagen vascular disease
• Exposure to sexually transmitted diseases
• Thyroid disorder
• Pheochromocytoma
• Obesity

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Family history to include inquiry regarding

• Predisposition to atherosclerotic disease
• (Hx of MIs, strokes, PAD)
• Sudden cardiac death
• Myopathy
• Conduction system disease (need for pacemaker)
• Tachyarrhythmias
• Cardiomyopathy (unexplained HF)
• Skeletal myopathies

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Differential Diagnosis in Patient with HF and
Normal LVEF with Symptoms

• HF associated with high metabolic demand
  (high-output states)
• Anemia, thyrotoxicosis, arteriovenous fistulae
• Chronic pulmonary disease with right HF
• Pulmonary hypertension associated with pulmonary
  vascular disorders
• Atrial myxoma
• Diastolic dysfunction of uncertain origin

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Differential Diagnosis in Patient with HF and
Normal LVEF with Symptoms

• Incorrect diagnosis of HF
• Inaccurate measurement of LVEF
• Primary valvular disease
• Restrictive (infiltrative) cardiomyopathies
• Amyloidosis, sarcoidosis, hemochromatosis
• Pericardial constriction
• Episodic or reversible LV systolic dysfunction
• Severe hypertension, myocardial ischemia
• Obesity

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Determinants of Myocardial Performance

• Preload
• Afterload
• Contractility Inotropy
• Compliance Lusitropy
• Neuroendocrine
• Geometry Synchronization
• Properties of Blood Vessels
• Lymphatic Function Edematrope

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Neuroendocrine
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Moderators of Apoptosis

• Lipophilic Beta Blockers
• Ace Inhibitors
• Ace Blockers AT1
• Spironolactone
• Statins

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Geometry
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Cardiac Resynchronization Therapy

• Cardiac resynchronization, in association with an
  optimized AV delay, improves hemodynamic
  performance by forcing the left ventricle to
  complete contraction and begin relaxation
  earlier, allowing an increase in ventricular
  filling time.
• Coordinate activation of the ventricles and
  septum.

ECG depicting IVCD
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Ventricular Dysynchrony
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Proposed Mechanisms of Cardiac Resynchronization

• Improved Contraction Pattern
• AV Interval Optimization

Click to Start/Stop
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Proposed Mechanisms of Cardiac Resynchronization

• AV Interval Optimization
• Reduces mitral regurgitation1,2,3
• Increases diastolic filling time
• Improves LV dP/dt

Click to Start/Stop
1 Nishimura et al. J Am Coll Cardiol. 1995
25281. 2 Walker et al. Europace 2000I(suppl D)
abstract 212/5. 3 Brecker et al. Lancet.
19923401308.
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Determinants of Myocardial Performance

• Preload

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Determinants of Myocardial Performance

• Preload - The stretch of the myocardium
• How many preloads does your heart have?

2 Right and Left Heart
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Determinants of Myocardial Performance

• Preload - The stretch of the myocardium
• What is the Physical Exam finding for Right
  Heart Preload?

Jugular Venous Distention
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Determinants of Myocardial Performance

• Preload - The stretch of the myocardium
• What is the Physical Exam finding for Left Heart
  Preload?

Rales (non-specific) - S3 (Specific)
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Determinants of Myocardial Performance

• Preload - The stretch of the myocardium
• How do we decrease Preload?

Gravity Sit up, Stand up, Phlebotomy Venodilat
ors NTG Natrecor Morphine Diurectics
Lasix Machine Ultrafiltration
Dialysis
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Determinants of Myocardial Performance

• Preload - The stretch of the myocardium
• How do we increase Preload?

Volume - Blood Colloid- Albumin,
Hetastarch Crystalloid Nacl,
Ringers Which is best and why?
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Determinants of Myocardial Performance

• Afterload - The resistance to flow. The size of
  the arterioles.

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Determinants of Myocardial Performance

• Afterload - Resistance to flow
• How many afterloads does your heart have?

2 Right and Left Heart
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Determinants of Myocardial Performance

• Afterload - Resistance to flow
• What is the Physical Exam finding for Right
  Heart Afterload?

Systolic pulsation of the pulmonary artery
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Determinants of Myocardial Performance

• Afterload - The resistance to flow
• How do we decrease Right Heart Afterload?

Vasodilators Nitroprusside, Natrecor Nitrogl
ycerin Nitric oxide Phosphodiesterase
Inhibitors Calcium channel blockers Prostogl
andins Endothelilial antagonist
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Determinants of Myocardial Performance

• Afterload - Resistance to flow
• What is the Physical Exam finding for left Heart
  Afterload?

Carotid pulse, skin warmth, peripheral pulses,
urine output Cardiac Index gt2 with palpable DP or
PT
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Approach to the Cardiac Physical Exam

• Determine the State ofthe Systemic Circulation
• Carotid Exam
• Low, normal, high flow

Differential diagnosis of low and high flow
states?
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Determinants of Myocardial Performance

• Afterload - The resistance to flow. The size of
  the arterioles.
• Which patient has the highest afterload? (A)
  120/80
• (B) 220/80

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Determinants of Myocardial Performance

• Which patient has the highest afterload?
  (A) 120/80
• (B) 220/80
• (A) - EF 15 Pulmonary Edema cool skin
• (B) - 15 y/o 18 min. of Bruce ETT

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Determinants of Myocardial Performance

• Which patient has the highest afterload? (A)
  120/80
• (A) - EF 15 Pulmonary Edema cool skin cardiac
  out put is 3 l/min

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Determinants of Myocardial Performance

• Afterload SVR (Mean BP - CVP) 80/CO
• (A) - EF 15 Pulmonary Edema cool skin SVR
  (93.3-10)80/3 2222
• (B) - 15 y/o 18 min. of Bruce ETT
• SVR (126.6-5)80/20 486

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Determinants of Myocardial Performance

• Afterload SVR (Mean BP - CVP) 80/CO
• or
• Cardiac output Mean BP80/SVR
• Cardiac output in patients even with low blood
  pressure can be increased by lowering SVR
• Do not be afraid of gradually increasing ACEI

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Determinants of Myocardial Performance

• Afterload - The resistance to flow
• How do we decrease Afterload?

Vasodilators Nitroprusside, Natrecor
ACEI / ARB
Hydralazine/Nitrates Mechanical Balloon Pump
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Determinants of Myocardial Performance

• Afterload - The resistance to flow
• How do we increase Afterload?

Vasopressors Epinephrine Vasopressin
Levophed
Dopamine
Neosynephrine SQUAT
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Determinants of Myocardial Performance

• Contractility Inotropy
• The speed and shortening capacity of the
  myocardium

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Determinants of Myocardial Performance

• Contractility Inotropy
• The speed and shortening capacity of the
  myocardium
• What is the Physical Exam findings of
  contractility?

PMI - Point of Maximum Impact
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Determinants of Myocardial Performance

• Contractility Inotropy
• The speed and shortening capacity of the
  myocardium
• How is contractility increased?
• The only oral agent - Digoxin
• IV - Beta Agonist - Epinephrine Dopamine
  Levophed Dobtuamine Isuprel
• - Phosphodiesterase Inhibitors -
  Amrinone Milrinone

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Determinants of Myocardial Performance

• Contractility Inotropy
• The speed and shortening capacity of the
  myocardium
• How is contractility decreased?
• Beta blockers
• calcium channel blockers
• anti-arrhymtics

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Determinants of Myocardial Performance

• Compliance Lusitropy - the ability of the
  heart to fill

Pericardium
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Determinants of Myocardial Performance

• Compliance Lusitropy - the ability of the
  heart to fill

LVH, infiltrative excess calcium
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Diastolic Heart Failure
25
15
5
vol1
vol2
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Determinants of Myocardial Performance

• Compliance Lusitropy - the ability of the
  heart to fill.
• What is the physical exam finding for Compliance?

S4
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Determinants of Myocardial Performance

• Compliance Lusitropy - the ability of the
  heart to fill.
• How can we improve Compliance?
• Natrecor
• Spironolactone
• Ranolazine

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How do you use Natrecor?

• Decompensated volume overloaded stable patient
  with renal insufficiency (they all have CRI and
  BP is low)
• i.e. all others
• continuous infusion of 0.005 mcg/kg/min
• Initiate Lasix drip 20 mg/hr after a bolus of
  Lasix start 15 to 30 minutes after Natrecor

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What is Ranolazine and How Should it be used?

• Late sodium channel blocker (Velcro)
• No change in BP or P
• Lowers HgbA1c
• Probably an anti-arrhytmic
• Designed for angina but is great for diastolic
  dysfunction even Aortic stenosis
• 500 mg at night can increase to 1000 Bid

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Physical Exam Determinants
Determinants of Myocardial Performance

• Preload JVD (R), S3 and/or rales (L)
• Afterload Carotid pulse (L), systolic pulmonary
  artery tap (R)
• Contractility PMI (L)
• Compliance S4 (R)
• These simple physical findings should completely
  describe the hearts performance

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Equation of Life

• CO X Hgb O2 consumption / AV O2 difference
• Cardiac output X Hemoglobin
• The lower the Hemoglobin the higher the cardiac
  output
• You can compensate for lower cardiac output by
  having a higher hemoglobin

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Physical Examfor the equation of LIFE
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How do Your CHF Patients suffer as they die?

• Wide range of symptoms, which were frequently
  distressing and often lasted greater than 6
  months
• Pain was most common in 50
• Dyspnea was second most common
• Low mood, anxiety
• urinary incontinence

Living and dying with heart failure the role of
palliative care Gibbs, McCoy,Gibbs,Rogers,
Addington-Hall Heart 200288(supplII)ii36-ii39
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How do your CHF Patients die?

• Ventricular tachycardia/fibrillation
• Pulseless electrical activity after a
  defibrillator shock
• Pump failure low output
• Sepsis from GI track due to bowel ischemia
• Congestion and respiratory failure
• Infection from skin breakdown
• Liver or kidney failure
• Inadequate reserve to meet extra demand

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CHF patients can choose their mode of death

• 28 of deaths can be avoided by defibrillator
  therapy
• The mode of death changes to PEA, low out put,
  congestion or organ failure, failure to meet
  increase demands
• Defibrillators are not for everyone

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Strongest indicators of in-hospital death
Risk factor BUN (mg/dL) Systolic BP (mm Hg) Creatinine (mg/dL)
Predictive level gt43 lt115 gt2.75
The Kidney
Fonarow GC et al. JAMA 2005 293572-580.
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Cardio Renal Syndrome

• Fundamental Laws of Biology in particular
  Inflammation
• Preload is part of the afterload of the kidney
• Abdominal pressure adds to afterload
• Perfusion pressure
• Lymphatic function

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New Direction for Medical Research
Proposed Fundamental Laws of Biology
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• Biology must be consistent with the fundamental
  laws of physics and chemistry.
• Life as opposed to non-living exhibits negative
  entropy developing order out of chaos.
• (The energy to support negative entropy is
  yet to be defined.)
• 3. The cell is the fundamental unit of biology

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• The cell must be in homeostasis with its
  environment. (This property allows for
  evolution. The environment changes life.)
• There must be a distinction between self and the
  environment. (Immunity and inflammation are the
  defenses against invaders from the environment
  and responsible for repair.)
• Electromagnetic information transfer is necessary
  for development and regeneration.
• (Life, regeneration of tissue will
  not exist in a non-electromagnetic environment,
  denervation)

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Regeneration
Degneration
Inflammation
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Cardio Renal Syndrome

• Lymphatic function
• Tissue homeostasis 12 to 15 liters
• InFlammation
• Protection from the environment
• Repair
• Dysfunction explains all of the symptoms

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Etiology of Heart Failure inAfrican Americans
Patients With Coronary Artery Disease-Based HF
80
60
40
Percent
20
0
V-HeFT I
V-HeFT II
SOLVD
US Carv
BEST
MERIT-HF
Patients With Hypertension-Based HF
80
60
Percent
40
20
0
V-HeFT I
V-HeFT II
SOLVD
US Carv
BEST
MERIT-HF
AA
non-AA
The BEST Investigators. N Engl J Med.
200134416591657 Packer M et al. N Engl J Med.
199633413491355 MERIT-HF Study Group. Lancet.
199935320012007 Cohn JN et al. N Engl J Med.
198631415471552Cohn JN et al. N Engl J Med.
1991325303310 The SOLVD Investigators. N Engl
J Med. 1991325293302.
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V-HeFT I Survival Benefit in Subgroups
Non-African Americans
African Americans
80
80
Risk Ratio0.53 P.04
70
70
60
60
50
50
Cumulative Mortality
Cumulative Mortality
40
40
30
30
20
20
10
10
n480
n180
0
0
0
42
54
66
6
18
30
42
54
66
6
18
30
0
Months
Months
I/H
Placebo
75
A-HeFT 43 Relative Risk Reduction for Mortality
100
Fixed-dose I/H
95
Survival ()
90
Placebo
Hazard ratio0.57
P.01
85
0
100
200
300
400
500
600
Days Since Baseline Visit Date
Fixed-dose I/H 518 463 407 359 313 251 13 Placebo
532 466 401 340 285 232 24
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Pearls
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Pearls

• Dizziness - reduce, D/C diuretics
• Amiodarone saves lives in heart failure
• Amiodarone and a beta blocker is better
• Look for exacerbation reasons ( atrial
  arrhythmia, anemia, non-compliance)
• CHF drives salt and fluid cravings - constantly
  remind your patients -daily weight
• avoid NSAIDs
• erythropoiten is very good increases BP Stem
• Add Hydralazine/nitrates for failures consider
  ARB addition to ACE RANEXA

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How do you titrate all the medications?And what
order?
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Pearls
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Patient Flow

• Hand off between hospital and out patient therapy
• Titrate medications with compliance D/C
  Diuretic
• Educate in salt, potassium, fluid balance, and
  weight
• Not getting better Bi V Defibrillator equation
  of life
• Monitor for non compliance social/economic
  issue
• Sub Q Nesiritide to make Euvolemic H/I orARB
• Consider Geometric solutions control of ectopy
• Prometheus EECP and stem Cells Co Q 10
• Look for new endocrine failures for hypotension
• Back off - Hospice or Transplant LVAD

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Patient seems well with persistently elevated BNP
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Last Pearl

• Good is Better
• The Enemy of Good is Better
• i.e. -Watermelon Syncope

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CHF Conclusion

• Table of Cardiac Performance Parameters
• and Interventions

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