Managing patients admitted with…. Heart Failure
Transcript of Managing patients admitted with…. Heart Failure
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Managing patients admitted with….
Heart Failure
Vass Vassiliou
Royal Brompton and West Suffolk Hospitals
Imperial College London
RCP, 10th October 2016
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Objectives
• Understand the principles of Heart Failure
• Epidemiology
• Aetiology
• Pathophysiology
• Review the ESC 2016 guidelines for management of Heart Failure
• Discuss clinical scenarios
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Eugene Braunwald
“A clinical syndrome caused by the
inability of the heart to supply blood to the tissues
sufficient to meet their metabolic needs,
or achieved at the expense of elevated filling pressures.”
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• Inability of the heart to keep up with demand
• Inadequate perfusion of organs such as : • brain, liver and kidneys
• Congestion in lungs and legs
• Collection of signs and symptoms
HEART FAILURE
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• Typical symptoms
• Breathlessness, ankle swelling and fatigue
•Accompanying signs
• Elevated JVP, pulmonary crackles and peripheral oedema
•Caused by…
• Structural or functional cardiac abnormality
↓cardiac output
↑intracardiac pressures
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CARDIOMEGALY
UPPER LOBE DIVERSION
?PLEURAL EFFUSIONS
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Symptoms
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Epidemiology
•Heart failure is common
• 1-2% of all the adult population
• 10% in those over the age of 70
• 1 million patients in the UK
• Most common cause of hospital admission in those aged >65 in high income countries
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Let’s test the keypads!
There are almost one million patients with heart failure in UK.
Which city has a population of approximately one million?
A. Birmingham
B. Edinburgh
C. London
D. Swansea
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Let’s test the keypads!
There are almost one million patients with heart failure in UK.
Which city has a population of approximately one million?
A. Birmingham
B. Edinburgh
C. London
D. Swansea
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The Starling equilibrium St
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WET and COLD DRY and COLD
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CONGESTION NO CONGESTION
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DRY and WARM
CONGESTION NO CONGESTION
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WET and WARM
CONGESTION NO CONGESTION
WEL
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H
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Preload
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What causes heart failure?
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• Associated with high mortality- 30% will die with in one year
• 2-3% of healthcare spending
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ESC 2016 Heart failure Guidelines
Ponikowski et al Eur Heart J 2016
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Systolic HF EF <40%
Diastolic HF= HFpEF EF ≥40%
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BNP
• Brain natriuretic peptide
• Secreted by ventricles in response to excessive stretch
• Acts to decrease systemic vascular resistance
• Increases natriuresis
• Excellent Negative Predictive Value
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Investigations – is there HF?
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ACE I
Beta blockers
MR antagonist
ARNI
CRT
Ivabradine
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WET and WARM
Vasodilators and Diuretics
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Cases
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Case 1
An 84 year old woman presents to the acute medical unit with a 6 week history of SOB and peripheral oedema.
PMHx
• MI
• PMR
• Hypertension
Medication
• Aspirin 75mg od
• Simvastatin 20mg od
• Prednisolone 4 mg od
• Diltiazem 60mg tds
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O/E
• BP = 187/94mmHg
• Pulse = 98 bpm SR
• Elevated JVP +5 cm
• Normal HS
• Bilateral crackles
• Moderate peripheral oedema
• ECG • LBBB
• CXR • Pulmonary oedema
• FBC and U+E normal
• Troponin normal
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Acute Heart Failure
• Which is the single most appropriate next step in her management?
A. Intravenous furosemide
B. Intravenous GTN
C. Intravenous heparin
D. Intravenous metoprolol
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Acute Heart Failure
• What is the next most appropriate step?
A. Intravenous furosemide
B. Intravenous GTN
C. Intravenous heparin
D. Intravenous metoprolol
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Which medication should be discontinued?
A. Aspirin 75mg od
B. Diltiazem 60mg tds
C. Prednisolone 4 mg od
D. Simvastatin 20mg od
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Which medication should be discontinued?
A. Aspirin 75mg od
B. Diltiazem 60mg tds
C. Prednisolone 4 mg od
D. Simvastatin 20mg od
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An echocardiogram is requested
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According to the 2016 ESC HF Guidelines what is the diagnosis?
A. Heart failure with reduced Ejection Fraction
B. Heart failure with mildly reduced Ejection Fraction
C. Heart failure with preserved Ejection Fraction
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According to the 2016 ESC HF Guidelines what is the diagnosis?
A. Heart failure with reduced Ejection Fraction, EF< 40%
B. Heart failure with mildly reduced Ejection Fraction, EF 40-49%
C. Heart failure with preserved Ejection Fraction, EF ≥ 50%
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According to the 2016 ESC HF Guidelines what is the diagnosis?
A. Heart failure with reduced Ejection Fraction, EF< 40%
B. Heart failure with mildly reduced Ejection Fraction, EF 40-49%
C. Heart failure with preserved Ejection Fraction, EF ≥ 50%
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What other medication should be initiated early on during the admission? A. Amlodipine 5mg od
B. Atorvastatin 40mg od
C. Bisoprolol 2.5mg od
D. Ramipril 2.5mg od
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What other medication should be initiated early on during the admission? A. Amlodipine 5mg od
B. Atorvastatin 40mg od
C. Bisoprolol 2.5mg od
D. Ramipril 2.5mg od
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Medication to initiate during admission...
As EF<35% if still symptomatic
spironolactone or eplerenone
Ivabradine if HR >70 bpm in SR
ARNI Sacubitril/ valsartan if ACE I tolerated well
Consider CRT if QRS >130ms and LBBB or QRS >150 and RBBB
If still symptomatic…
ACE Inhibitor
Beta blocker bisoprolol or
carvedilol; NOT atenolol or
metoprolol
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Very importantly…
• Accurate daily weight
• In/ out fluid balance chart
• Fluid restrict
• Salt restrict
• Low molecular weight heparin
• Frequent blood monitoring- daily if on iv diuretics
• Look for signs of depression
• Correct iron deficiency
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What is the role of Digoxin?
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Is there a role for hydralazine and ISDN?
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What else should be arranged prior to discharge?
A. Enrolment in a disease management programme
B. Hospital appointment within 2 weeks of discharge
C. Review by their general practitioner within 1 week of discharge
D. All of the above
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What else should be arranged prior to discharge?
A. Enrolment in a disease management program
B. Hospital appointment within 2 weeks of discharge
C. Review by their general practitioner within 1 week of discharge
D. All of the above
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Case 2
O/E
• Elevated JVP
• Bilateral crackles
• Mild peripheral oedema
Investigations
• Admission troponin 400 ng/L
(normal <40)
• 12 hour troponin 1200 ng/L
A 36 year old man presents to the acute medical unit with breathlessness and chest pain on and off for two days.
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ECG on admission
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What is the provisional diagnosis?
A. Myocarditis
B. NSTEMI
C. Pulmonary embolus
D. STEMI
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What is the provisional diagnosis?
A. Myocarditis
B. NSTEMI
C. Pulmonary embolus
D. STEMI
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Investigations
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He still has ongoing chest pain…
What is the single most appropriate investigation to confirm the diagnosis?
A. Cardiovascular Magnetic Resonance
B. Coronary angiography
C. Exercise test
D. Transthoracic echocardiography
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He still has ongoing chest pain…
What is the single most appropriate investigation to confirm the diagnosis?
A. Cardiovascular Magnetic Resonance
B. Coronary angiography
C. Exercise test
D. Transthoracic echocardiography
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Management
• Aspirin and Clopidogrel- he is troponin positive…
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Management
• Aspirin and Clopidogrel- she is troponin positive…
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Causes of acute heart failure
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Myocarditis
What are the concerns?
• Heart failure
• Arrhythmias
• Brady
• Tachy
• Death
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Management
• Heart failure management • Transfer to referral centre if signs of severe HF • Consideration for LVAD and transplantation
• Monitor rhythm • Treat heart failure
• Frusemide • GTN • ACE I • B blockers • Inotropes
• Colchicine • High Dose NSAIDS
AVOID STEROIDS
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Case 3
A 47 year old man presents with breathlessness for a week and this morning he collapsed at work. He has pleuritic chest pain.
• BP 95/66mmHg
• HR 120bpm
• HS normal
• Chest clear
• JVP +5cm
• Moderate peripheral oedema
• BNP raised (600 pg/ mL) • Troponin raised (320 ng/ L)
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A portable echo was done…
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More images…
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What would you do next?
A. Intravenous furosemide
B. Intravenous heparin
C. Intravenous alteplase
D. Intravenous GTN
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What would you do next?
A. Intravenous furosemide
B. Intravenous heparin
C. Intravenous alteplase
D. Intravenous GTN
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www.heart.org
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Learning points
• Three categories of heart failure
• Look for the aetiology of heart failure
• Appropriate Investigations
• Multidisciplinary work
• Acute management • Diuresis and nitrates • Inotropes
• Chronic management • Diuretics • ACE I • B blocker • Mineralocorticoid antagonists
• Ivabradine • ARNI- sacubitril/valsartan • CRT
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Conclusion
Reviewed pathophysiology of heart failure
Discussed recent ESC HF guidelines
Evaluated the management of clinical cases
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References
• Material used available from the following sources: • www.studyblue.com
• www.heart.org
• www.patient.info
• www.findingmedicalsolutions.com
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Case 4
O/E
• Elevated JVP
• Bilateral crackles in lower bases
• Mild peripheral oedema
• Systolic murmur
Investigations
• Admission troponin 33 ng/L
(normal <40)
• 12 hour troponin 567 ng/L
A 22 year old woman presents to the acute medical unit with breathlessness, palpitations and episodes of dizziness.
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• Soon after the admission she had multiple NSVT on telemetry and an urgent echo was organised
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What is the diagnosis?
• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Ischaemic cardiomyopathy
• Takotsubo cardiomyopathy
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What is the diagnosis?
• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Ischaemic cardiomyopathy
• Takotsubo cardiomyopathy
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