Pearls of Heart Failure Management
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Transcript of Pearls of Heart Failure Management
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PEARLS OF HEART FAILURE MANAGEMENT
Deborah Crawford, APRN-CNS
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Speaker for Otsuka
Disclosures
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1 Identify the treatment objectives for acute heart failure vs chronic heart failure.
2. Identify the stages and classifications of Heart Failure.
3. Describe the exercise guidelines for Heart Failure patients.
4. Describe the Pharmacoligical treatment for Heart Failure.
Objectives
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Acute Decompensated Heart Failure (ADHF)
Heart Failure: Complex clinical
syndrome, Can result from any
structural or functional cardiac disorder that impairs ability of ventricle to fill with or eject blood.
Cardinal symptoms:
fatigue dyspnea
Clinical signs: fluid retention exercise
intoleranceHunt SA et al. Circulation. 2001;104:2996
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Myocardial ToxicityChange in Gene Expression
ANPBNP
Pathophysiology of ADHF
Myocardial Injury Fall in LV Performance
Activation of RAAS and SNS(endothelin, AVP, cytokines)
Peripheral Vasoconstriction Sodium/Water Retention
HF SymptomsMorbidity and Mortality
Remodeling andProgressive
Worsening ofLV Function
Shah M et al. Rev Cardiovasc Med. 2001;2(suppl 2):S2
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HFSA 2010 Practice Guideline (12.5-12.20) Overview of Treatment Options for Patients with Acute Decompensated HF
Fluid and sodium restriction Diuretics, especially loop
diuretics Ultrafiltration/renal replacement
therapy (in selected patients only)
Parenteral vasodilators (nitroglycerin, nitroprusside, nesiritide)
Inotropes * (milrinone or dobutamine)*See recommendations for stipulations and
restrictions.
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Treatment ObjectivesChronic Heart
Failure2
1. Survival2. Mortality3. Exercise capacity4. Quality of life5. Neurohormonal
changes6. Progression of CHF7. Symptoms
Acute Heart Failure1
1. Improve symptoms2. Optimize volume status3. Identify etiology4. Identify precipitating factors5. Optimize chronic oral therapy6. Minimize side effects7. Identify patients who might
benefit from revascularization
8. Educate (medications/self assessment of HF)
1 2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e.2 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.
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Class I: No limitations
Class II: Slight limitations of physical activity
Class III: Marked limitation of physical activity
Class IV: Symptoms at rest Unable to carry on any physical activity without discomfort.
Stage A: At risk for developing HF
Stage B: Structural heart disease associated with HF but asymptomatic
Stage C: Known systolic heart failure & current or prior symptoms
Stage D: Systolic heart failure and presence of advanced symptoms after receiving optimal care
Stages of Heart Failure
NYHA Functional Classifications in patients with HF
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Pharmacoligical Treatment of Heart Failure
ACE Inhibitors: Inhibit renin-angiotensin system in all HF patients with LV dysfunction
ARB: Recommended to patients with LVEF <40% intolerant of ACE
Beta Blockers: Shown effective in patients with HF with LVEF < 40% (start when euvolemic)
Aldosterone blockade: Recommended in patients with NYHA class III or IV, LVEF <35% while receiving standard therapy
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Dosing ACE/ARB
Start with low dose ie: Lisinopril/Enalapril 2.5mg BID
Stagger away from Beta Blocker dose Avoid Orthostatic Hypotension
Usually Lunch and Bedtime “Stair step” the dosing when up titrating Monitor Renal function Can use in mild, stable renal insufficiency
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Dosing Beta Blockers Carvedilol and Metoprolol Succinate are
the Beta Blockers that have an indication for Heart Failure
Start low dose and titirate up slowly Stagger away from ACE I/ARB Start or up titrate when the patient is
euvolemic “Stair step” the dosing when up titrating Titrate one drug at a time.
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Dosing Aldosterone Blockers Spironolactone, Eplerenone
Helpful in the setting of Hypertension for better BP control
Monitor Renal function : can use in mild, stable renal insufficiency
Does have mortality benefit in patients with LVEF < 35 %.
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Compensated/Decompensated ?
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Diuretic TherapyAgent Initial Daily
Dose (mg)Maximum Total Daily Dose (mg)
Duration of Action (hr)
Furosemide 20-40mg qd or bid
600mg 4-6
Bumetanide 0.5-1mg qd or bid
10mg 6-8
Torsemide 10-20mg qd 200mg 12-16
Metalozone(thiazide)
2.5mg qd 20mg 12-24
Equivalent doses: Furosemide 40mg=bumetanide 1mg=torsemide 20mg
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Dosing Thiazide DiureticMetolazone (Zaroxlyn) Usually 2.5 – 5mg
Hydrochlorothiazide Usually 25mg
Usually give 30 min prior to the Loop DiureticMore effective and increases the diuretic effect of the Loop
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Dosing Potassium and MagnesiumPotassium:Goal 4.0 – 5.0 Usually 10-20mEq /
Furosemide 40mg dose equivelent.
Usually will double the Potassium dose when you double the Loop diuretic dose
Depending on renal function of the patient
Magnesium:Goal 2.0 – 2.5 Usually 250mg BID
for 1 week then once a day
Check the Mg level in 1 month after starting Mg supplement
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CMS recommendations for Cardiac Rehab for CHF patients CMS determined
that the evidence is sufficient to expand coverage for Cardiac Rehabilitation services to beneficiaries with stable chronic heart failure.
Stable chronic HF LVEF < 35% NYHA class II-IV
despite optimal HF therapy for at least 6 weeks Stable patients No recent (< 6 wks ) or
planned (< 6 mo) major CV hospitalizations or procedures
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Exercise Guidelines for HF patients
Start slow, warm up and cool down
Start by walking 5-10 min 1-2 times a day.
Walk 3 - 5 times a week
Increase the time and frequency as tolerated
Goal is 30 min, 5 times a week
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Don’t Let this Happen to Your Patient
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Aquapheresis (Ultrafiltration)
Alternative treatment in Diuretic resisitant patients
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What Is Diuretic Resistance ? > 10 lbs or more over dry
weight
Previous hospitalizations with ineffective diuretic effect
Patient cannot achieve a goal of -2 liters at 24 hrs
No significant difference in patient’s global assessment of symptoms in 24 hrs
Non-significant symptom improvement noted after escalating to high-dosing strategy
Worsening renal function during diuretic therapy
Post-operative fluid overload
Peri-operative fluid overload
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Ultrafiltration Indicated for patients with Heart Failure not
responding to diuretic therapy 24 hour diuretic dose >80mg Furosemide or
equivalent Removes excess salt and water from patients
with fluid overload Need to monitor Renal function closely esp.
during inpatient ultrafiltration Fluid removal rate should not exceed
250ml/hr (inpatient) or 350ml/hr (outpatient for 8 hrs)
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The Aquadex System is indicated for:
Temporary (up to 8 hours) ultrafiltration treatment of patients with fluid overload who have failed diuretic therapy
AND
Extended (longer than 8 hours) ultrafiltration treatment of patients with fluid overload who have failed diuretic therapy and require hospitalization.
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Goals of Ultrafiltration Reduction in hospital readmission:
Prevent patients from being discharged when they are still “wet”
Reduction of Length of Stay: If ultrafiltration is started early (< 24 hr of
admission).
Stable renal function during treatment: Monitor BMP every 12 hours while on ultrafiltration
to prevent worsening renal function. Can reduce rate of fluid removal as needed.
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Pearls after Ultrafiltration Hold diuretic while on ultrafiltration
Restart diuretic after ultrafiltration complted usually the next day at a lower dose
May respond better to diuretics after ultrafiltration due to reduction of “gut edema”
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Patient selectionInclusion / Exclusion
Criteria for Outpatient
Ultrafiltration
Inclusion Criteria:
1. 24 hour Diuretic dose > 80mg Furosemide or equivalent * OR
2. Fluid overloaded diuretic resistanta. < 10 lbs over stable weightb. Serum Creatinine < 3.0 or
Creatinine clearence > 20ml/min or on fluid restriction or frequent hospitalizations
* 1mg Bumetanide or 20mg Torsemide = 40mg Furosemide
Exclusion Criteria:
1 Fluid overloaded and diuretic resistanta. > 10 lbs over stable
weightb. Consider hospital
admission for in patient Ultrafiltration
c. Serum Creatinine > 3.0 consider Renal consult
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Ultrafiltration
Pre-Treatment
Day of Treatment
1. Obtain IV access:a. 6Fr Dual lumen ELC venous access
catheter2. Obtain Laboratory: CMP or BMP, Mg, CBC,
PT/INR (if patient on Coumadin)3. Obtain Aquadex Flexflow pump4. Obtain UF 500 Circuit set :
a. Prime filter/tubing with Normal Saline5. 10 ml syringe6. Heparin 20,000/500ml D5W
a. Heparin infusion 1000-1200 units/hr or as need by the patient
7. Start Heparin 30min prior to starting Ultrafiltration
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Thank You !!