Heart Failure 101 Heart Failure with Reduced Ejection Fraction (HFrEF) Connie M. Lewis MSN, ACNP-BC, NP-C, CCRN, CHFN 2016 Vanderbilt University Medical Center

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Objectives • Review definition of heart failure with reduced ejection fraction • Discuss ACCF/AHA stages and NYHA classes • Discuss medication titrations • Review criteria, benefits, and management of inotropic infusions • Overview of LVAD and heart transplant

Case Study 1 • Mr. S is a 43 year old gentleman with nonischemic cardiomyopathy, chronic HFrEF, diabetes, renal insufficiency, morbid obesity

What is Heart Failure? Complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood

What does that means?

♥ Heart failure actually means that the heart muscle is not pumping as well as it should. This results in less blood, nutrients, and oxygen going out to the body ♥ Heart failure does not mean that the heart has “failed” or stopped beating.

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Heart Failure with Reduced Ejection Fraction (HFrEF) ♥ Impaired contractility/ejection ♥ Ejection Fraction 8 million people over the age >18 will have HF ♥ 915,000 new cases annually ♥ Incidence of 10/1000 > 65 years of age ♥ 75% HF cases have hypertension ♥ Lifetime risk for people with BP >160/90 is double that of those with 5.0 or Cr > 2.5 Initiate/maintain at 25 mg po qd. Check renal function and K+ within 1 week of initiation and periodically

HFSA 2010 Practice Guideline RALES trial. N Engl J Med. 1999

Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators

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Diuretics

• Used to relieve fluid retention • Improve exercise tolerance • Facilitate the use of other drugs indicated for heart failure • Electrolyte depletion a frequent complication • Should not be used alone to treat heart failure • Higher doses of diuretics are associated with increased mortality • Some patients can be taught to adjust their diuretic dose based on their goal weight VanderbiltHeart.com

Diuretics and HF Patients may become unresponsive to high doses of diuretic drugs if they:

● Consume large amounts of dietary sodium2 ● Take agents that can block effects of diuretics (eg, NSAIDs, COX-2 inhibitors)1 ● Have significant impairment of renal function or perfusion1 Diuretic resistance can generally be overcome by ● IV administration of diuretics2 ● Using 2 or more diuretics in combination2 1Ravnan 2Brater

SL et al. Congest Heart Fail. 2002;8:80 DC. Drugs. 1985;30:427

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Diuretics • Agents – Thiazide: hydrochlorothiazide – Loop: Furosemide/Lasix, Torsemide/Demadex, Bumetanide/Bumex • Side Effects to monitor –  K, Na, Mg, Cl, and Ca – Low BP – Daily weight – Intake and output (inpatient) – Renal function – Hearing impairment or tinnitus VanderbiltHeart.com

Guideline-Directed Medical Therapy (GDMT) Strategies for Achieving Optimal GDMT 1. Uptitrate in small increments 2. Certain patients (e.g., the elderly, patients with chronic kidney disease) may require more frequent visits and laboratory monitoring during dose titration and more gradual dose changes. 3. Monitor vital signs closely 4. Alternate adjustments of different medication classes

5. Monitor renal function and electrolytes for rising creatinine and hyperkalemia, recognizing that an initial rise in creatinine may be expected and does not necessarily require discontinuation of therapy 6. Patients may complain of symptoms of fatigue and weakness with dosage increases 7. Discourage sudden spontaneous discontinuation of GDMT medications by the patient and/or other clinicians without discussion with managing clinicians. 8. Carefully review doses of other medications for HF symptom control (e.g., diuretics, nitrates) during uptitration 9. Consider temporary adjustments in dosages of GDMT during acute episodes of noncardiac illnesses (e.g., respiratory infections, risk of dehydration, etc.). 10. Educate patients, family members, and other clinicians about the expected benefits of achieving GDMT,

Yancy C et al. Circulation 2013;128:e240-e327 VanderbiltHeart.com

Case Study 1 • Vital signs: BP 100/64, HR 72 , weight 311, BMI 41 • Diuresed • GDMT: added lisinopril, changed carvedilol to metoprolol succinate

General Measures for Management Lifestyle Modifications ♥ Weight reduction ♥ Discontinue smoking ♥ Avoid alcohol and other cardiotoxic substances ♥ Exercise

Medical Considerations ♥ Treat hypertension, high cholesterol, diabetes, regular heart rhythms ♥ Coronary revascularization ♥ Anticoagulation ♥ Immunization ♥ Sodium restriction ♥ Daily weights ♥ Close outpatient monitoring

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Benefits of Exercise in Heart Failure ♥ Increased exercise capacity ♥ Improved exercise duration ♥ Reduces hospitalizations ♥ Improved hemodynamics ♥ Improved Quality of Life

Exercise Recommendations ♥ Start slow, increase slowly ♥ Avoid the extremes of intemperate climates – mall walking – indoor treadmills or tracks – exercise cycle indoors ♥ May not initially tolerate exercise – may see increased symptoms (2-6 weeks) ♥ Don’t be discouraged by inevitable interruptions in activity/training schedule

Treatment

Inotropic Therapy When to consider inotropes – Temporary treatment of refractory CHF – Worsening renal function in face of volume overload – Low cardiac output states (not responding to optimal medical Rx) – Cardiogenic shock – Awaiting cardiac transplant or revascularization

Inotropic Therapy: Milrinone Effects 0.125-0.75 mcg/kg/min: •  Cardiac index •  Heart rate •  SVR •  PVR Special Considerations • Renal dosing • Monitor LFTs • Monitor for ventricular arrhythmias, supraventricular arrhythmias, hypotension, chest pain/angina. 36 the Management of Heart Failure. JACC. ACCF/ AHA Guidelines for 2013

Inotropic Therapy: Dobutamine Effects 2-5 mcg/kg/min:  Cardiac index  Heart rate SVR PVR

Effects 5-20 mcg/kg/min:  Cardiac index  Heart rate SVR PVR

Special Considerations • An increase in BP is more common, but occasionally a patient may become hypotension • Headache, nausea, hypersensitivity • Monitor for chest discomfort, SOB, ST segment variation (may be indicative of ischemia); rhythm changes (especially tachycardia, ventricular arrhythmia). • Use with extreme caution in patients taking MAO inhibitors; prolong hypertension may result from concurrent use. 37 the Management of Heart Failure. JACC. ACCF/ AHA Guidelines for 2013

Low Cardiac Output Syndrome • • • • • • •

Blood pressure lower than baseline Diuretic resistance Serum creatinine greater than baseline Lethargy Anorexia Cool extremities Thready pulse

Inotropic Therapy • May improve quality of life • Long-term use may mortality • Safer in lower doses • Use only in refractory CHF • Not for use as a chronic therapy

Adverse reactions: Ventricular and atrial arrhythmias Hypotension Elevated LFT

Warnings: Monitor fluid status closely Patients may require adjustment of diuretic and electrolyte replacement therapy.

Medicare Part B Home Inotropic Therapy Diagnosis of heart failure (ICD-10 code I50) 2. Testing a. Baseline testing off inotropic therapy demonstrating CI of 2.2 L/min/m2 OR a PCWP of 20 mm Hg b. Testing on inotropic therapy demonstrating a 20% increase in CI or decrease PCWP c. Testing is done by invasive hemodynamic monitoring or by using electrical bioimpedance cardiography 3. Medications: digoxin, diuretic, ACE-I or vasodilator; must document drug, frequency, and dose OR medical; rational for not prescribing 4. Must have dyspnea at rest OR with minimal dyspnea on mild exertion upon admission (documented) AND improve clinically on inotropic therapy 5. Doses are within the following ranges (lower doses will be covered only if part of a weaning or tapering protocol from higher dose levels): a. Dobutamine - - 2.5-10 mcg/kg/min b. Milrinone - - 0.375-0.750 mcg/kg/min c. Dopamine - - less than or equal to 5 mcg/kg/min, and 6. Must have documented failure to wean in the hospital or medical rationale why weaning/tapering is not possible (i.e., BTT, required dose escalation, failed weaning from prior hospital admission) 7. Patient must be capable to go to MD for monthly outpatient evaluation 8. Patient must not need require electrocardiographic monitoring at home 1.

40

Home Inotropic Therapy Potential Adverse Events Highlights single center • Peripherally inserted central catheter (PICC)–related adverse events were assessed in heart failure patients on inotropes • 27% of the population developed a PICC-related adverse event • Median time to PICC infection was 44 days • PICCs with more than 1 lumen were associated with increased risk of infection • PICC adverse events resulted in increased hospital admission, complications, and cost 41

Devices

Implantable Cardioverter Defibrillators (ICD) • Primary prevention of sudden cardiac death (SCD) is indicated for those at greatest risk for SCD but have not had arrhythmias. Inducible, sustained VT can result in a risk of SCD of approximately 5-6% per year • Secondary prevention dictates the implantation of ICDs in HF patients who have had life threatening arrhythmias. • Poor Cardiac Output leads to increase catecholamine release thereby potentiating arrhythmia

Epstein. Circulation 2013;127:e283-e352

Primary Prevention in HFrEF • Ischemic (at least 40 days post MI) or selected with nonischemic • Do not have a prior history of arrhythmias or syncope • HFrEF  LVEF < 35%  NYHA Class II or III after 3-6 months of GDMT  Expected to live >I year - OR –  LVEF < 30% after MI  NYHA Class I  At least 40 days post-MI  Expected to live > I year

Yancy C et al. Circulation 2013;128:e240-e327

ICD Today ♥ Extended Multiprogrammable tiered therapy ♥ Longevity (> 5-7 yrs) ♥ Endocardial lead systems ♥ Smaller, thinner ♥ Pectoral implant ♥ Advanced rhythm discrimination ♥ State-of-the-art pacing therapies ♥ Powerful diagnostics

♥ Atrial therapies

Secondary Prevention ICD • VF arrest survivor - OR -

• Sustained VT - OR -

• Syncope with inducible VT/VF

Biventricular Pacing: Cardiac Resynchronization Therapy (CRT) ♥

Transvenous Approach ♥ Standard pacing lead in right atrium ♥ Standard pacing or defibrillation lead in right ventricle ♥ Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus ♥ Back-up epicardial approach

Right Atrial Lead

Left Ventricular Lead

Right Ventricular Lead

Case Study 1  ECHO: LVEF 30%  EKG: Sinus rhythm, LBBB, QRS 150 ms.  Next step?  GDMT: CRT-D

Advanced Therapies Mechanical Circulatory Support (MCS) Left Ventricular Assist Devices Heart Transplantation

Ventricular Assist Devices (VAD) Mechanical Circulatory Support: Indications for Use ♥ Bridge to Transplant – Non-reversible left heart failure – Imminent risk of death – Candidate for cardiac transplantation ♥ Destination Therapy — NYHA Class IIIB or IV heart failure — Optimal medical therapy 45 of last 60 days — Not candidate for cardiac transplantation ♥ For in-patient and out-patient use

Long Term to Destination Therapy: Miniature Ventricular Assist Devices (Mechanical Circulatory Support) Thoratec: HeartMate II

Mechanical Circulatory Support

Kirklin, J. Seventh INTERMACS annual report: 15,00 patients and counting. The Journal of Heart and Lung Transplantation 2015

Mechanical Circulatory Support

Kirklin, J. Seventh INTERMACS annual report: 15,00 patients and counting. The Journal of Heart and Lung Transplantation 2015

Transplantation  In US, 250,000 – 300,000 people have end-stage HF that could benefit from transplant or assist device  Less than 2500 transplants done per year due to donor shortage

The Organ Procurement and Transplantation Network/United Network for Organ Sharing Thoracic Committee (OPTN/SRTR) 2013 Annual Data Report: Heart

American Journal of Transplantation Volume 15, Issue S2, pages 1-28, 27 JAN 2015 DOI: 10.1111/ajt.13199 http://onlinelibrary.wiley.com/doi/10.1111/ajt.13199/full#ajt13199-fig-0014

The Organ Procurement and Transplantation Network/United Network for Organ Sharing Thoracic Committee (OPTN/SRTR) 2013 Annual Data Report: Heart

American Journal of Transplantation Volume 15, Issue S2, pages 1-28, 27 JAN 2015 DOI: 10.1111/ajt.13199 http://onlinelibrary.wiley.com/doi/10.1111/ajt.13199/full#ajt13199-fig-0005

Transplantation The benefit of transplantation is clear if a person requires continuous intravenous medications in the hospital. In unhospitalized patients, the following requirements have been recommended for consideration for cardiac transplantation: ♥ A history of repeated hospitalizations for heart failure ♥ Need for ventricular assist device or artificial heart to support circulation ♥ Increasing types, dosages, and complexity of medications ♥ A reproducible VO2 of less than 14 mL/kg per minute Patients are stratified into low, medium, and high risk of death without transplant. The final decision about listing a patient for transplant is determined by an established cardiac transplant center.

Conclusion ♥ Recognizing HF symptoms and teaching patients is the heart of what we do! ♥ Raise the surveillance of HF in your community ♥ Early identification and treatment of risk factors is one of the most significant steps in limiting the public health impact of Heart Failure ♥ Early diagnosis, stabilization, and initiation of the evidence based medical therapy are the key elements of management of heart failure patients ♥ Stay tuned for New Discoveries

Teamwork! We can make a difference!