Post on 23-Dec-2015
Pharmacological Therapy of Heart Failure: Case presentations
Steven W. Harris MHS, PA-C
Heart Failure
Complex diagnosis that results from structural or functional disorder(s) which impair the ability of the ventricle to fill with or eject blood. – ACC 2005
Epidemiology Prevalence
Affects 5+ million Americans currently, >600,000 new cases diagnosed each year. 23 million people worldwide.
Estimates are based only on symptomatic HF.
Cost Annual direct cost is >10 billion dollars
Frequency It is the most common inpatient
diagnosis in the US for patients over 65 years of age
In 2004, there were over one million hospitalizations in the US with a first listed discharge diagnosis of HF
Major Determinants of Cardiac Function
Ventricular systolic function Ventricular diastolic function Ventricular preload Ventricular afterload Cardiac rate and conduction Myocardial blood flow
Ventricular Systolic Function
Systolic dysfunction accounts for 60-70% of all cases of HF
Ejection fraction decreased 55-65% normal 40-50% mild 30-40% moderate <30% severe systolic dysfunction
NYHA Classification
Class I - symptoms only at activity levels that would limit normal individuals
Class II – symptoms with ordinary exertion (moderate exertion)
Class III - symptoms with less than ordinary exertion (minimal exertion)
Class IV - symptoms at rest
Heart Failure Stages
Stage A — High risk for HF, without structural heart disease or symptoms
Stage B — Heart disease with asymptomatic left ventricular dysfunction
Stage C — Prior or current symptoms of HF
Stage D — Advanced heart disease and severely symptomatic or refractory HF
Classification of HF severity
1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.
2New York Heart Association/Little Brown and Company, 1964.
Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.
ACC/AHA HF Stage1 NYHA Functional Class2
A At high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)
B Structural heart disease but withoutsymptoms of heart failure
C Structural heart disease with prior orcurrent symptoms of heart failure
D Refractory heart failure requiringspecialized interventions
I Asymptomatic
II Symptomatic with moderate exertion
IV Symptomatic at rest
III Symptomatic with minimal exertion
None
Treatment Objectives
Decrease Symptoms Improve tissue perfusion Increase exercise tolerance Quality of/Prolong Life /Survival Correct aggravating/precipitating factors:
Arrhythmias Pregnancy Infections Hyperthyroidism Thromboembolism
Endocarditis Obesity Hypertension Physical activity Dietary excess Medications
Preload Afterload Ionotropy Optimize
chonotropy
Neurohormonal activity
Vicious CycleChronic HF
SOB, Wt gain
Providers office
PO Lasix
ER
IV Lasix +/-admit
Home
Case 1
76 y/o moderately obese male with a history of CAD with associated CABG x 4, presents to your clinic c/o dyspnea on exertion, 2 pillow orthopnea, bilateral lower extremity edema.
Case 1 Meds:
Simvastatin 80mg po qhs
Synthroid 125 mcg po qd
Lisinopril 5 mg po qd Metoprolol 50 mg po qd ASA 81 mg 2 tabs po qd
PMH ??
Physical exam: Vitals
BP: 146/78 HR: 78 regular RR: 12 bpm T: 98.6 F SPO2: 95% on
RA JVD at 5 cm
above sternal angle
Bilateral rales to mid lung fields
1+ bilat pedal edema
Case 1
Plan: Diagnostics: Treatment: Patient
Education: Follow-up/
Referrals:
Echocardiogram BMP BNP Lasix 20 mg po
qd KCL 10 meq po
qd f/u in 1 wk
Case 2
65 y/o female who is 6 months s/p AWMI c/o 10 lb weight gain over 72 hours. Associtated sx include orthopnea, pnd, dyspnea at rest and abdominal “fullness”. At the time of discharge 6 months prior she had an ischemic cardiomyopathy with an EF of 50%
Case 2 Meds:
Quit meds ASA 81 mg 1 tab po qd
PMH DM HTN Dyslipidemia
Physical exam: Vitals
BP: 130/78 HR: 100 regular RR: 18 bpm T: 98.7 F SPO2: 90% on
RA JVD at 10 cm above
sternal angle Hepato-Jugular
reflux to angle of mandible
Bilateral rales 2/3 up 1+ bilat pedal
edema
Case 2
Plan: Diagnostics: Treatment: Patient
Education: Follow-up/
Referrals:
Admit to hospital Echocardiogram CMP, BNP, CBC… Lasix 40 mg IV x
1 Then 40 mg po
BID Enalapril 2.5 mg
BID Simvastatin 20
mg qhs Morning labs
Case 2
Morning Results: Diuresed 3 liters Feeling much
better EF 45% BNP 550 Vitals:
BP 122/76 HR 78 RR 12 T 98.6 SPO2 98 % on 2
L Plan
Plan: Wean O2 Carvedilol 3.125
mg BID Continue
Furosemide dose Morning labs
Beta blockers
Case 3
65 y/o male with known history of prior MI and CABG, ischemic cardiomyopathy with an EF of 30% presents to the ER with dyspnea at rest. He states that over the last week he has gained “at least 10 lbs” and has been sleeping in his armchair.
Case 3 Meds:
Carveidolol 12.5 mg BID Lisinopril 5 mg qd Atorvastatin 40 mg qhs Furosemide 80 mg qAM ASA 81 mg 1 tab po qd
PMH HTN, Dyslipidemia ??
Physical exam: Vitals
BP: 110/78 HR: 110 regular RR: 22 bpm T: 98.7 F SPO2: 88% on
RA Sitting upright JVD above angle of
the mandible Hepato-Jugular
reflux to angle of mandible
Diffuse bilateral rales
2+ bilat pedal edema
Case 3
Plan: Diagnostics: Treatment: Patient
Education: Follow-up/
Referrals:
Admit to hospital Echocardiogram CMP, BNP, CBC… Bumetanide 1
mg IV then 0.5 gtt
KCL repletion 2 gm sodium
diet
Case 3 Results
Diuresed 4 liters Weaned from IV
to PO Furosemide 80 mg po qd
Cr 1.5 Slowly gaining
H2O weight What can you
do? Sequential
nephron blockade.
Addition of aldosterone antagonist
Sequential nephron blockade with: Metolazone 2.5
mg po qd Aldosterone
antagonist Spironolactone
25 mg daily f/u labs
K+ in 3 days and one week.
Increased Risk of hyperkalemia if Cr >1.6
Case 3 Consideration of positive inotropes
Dobutamine 2-20 mcg/kg/min IV Indications: insufficient cardiac output Effect: Increase Cardiac output and stroke
volume Comment: Tachycardia, hypertension,
hypotension Dopamine. 2-20 mcg/kg/min IV
Indications: Insufficient cardiac output, hypotension, reduced renal perfusion
Effect: Increase cardiac output, stroke volume, and renal blood flow
Digoxin
Digoxin
Mildly positive inotropic effects Associated with symptomatic
improvement, increase exercise tolerance, and clinical stability
Pts taking digoxin are less likely to be hospitalized (25% reduction) due to CHF.
Additive benefits to Diuretic, ACE, Beta blocker therapy
Case 4
60 y/o male with known history of CAD and prior MI presents to your clinic to establish care. He states that over the last month he has had to double his water pill to keep his legs thin and breathe well at night. His most recent EF was 50% one year ago. Currently he is feeling fine, but has SOB with riding his road bike.
Case 4 Meds:
Enalapril 20 mg qd Cardizem CD 180 mg qd Atorvastatin 40 mg qhs HCTZ 25 mg 2 tabs po
qd ASA 81 mg 1 tab po qd Naproxen 220 mg qd
PMH HTN, Dyslipidemia ??
Physical exam: Vitals
BP: 118/78 HR: 64 regular RR: 12 bpm T: 98.7 F SPO2: 97% on
RA JVD 3 cm above
sternal angle Clear lung fields Trace bilateral pedal
edema
Case 4
Plan: Diagnostics: Treatment: Patient
Education: Follow-up/
Referrals:
DC Cardizem Start:
Carvedilol 6.25 mg BID and uptitrate to 12.5 mg BID in two weeks
DC Naproxen Consider
acetaminophen BMP to eval K+ Echocardiogram F/u 2 weeks
Case 5
80 y/o female c/o of 1 week h/o palpitations and 3 days of SOB and orthopnea
Considerations
African Americans CRF ACE intolerant