CHF: In the trenches. David K. Orth MS RN CNS PHN UCSF, San Francisco, CA, USA

Transcription

1 CHF: In the trenches David K. Orth MS RN CNS PHN UCSF, San Francisco, CA, USA

2 No conflicts of interest to disclose Disclosures

3 Objectives Recognize significance of CHF in our patient population Differentiate between systolic and diastolic heart failure Understand focused assessments Identify common interventions Explore advanced therapies of CHF management

4 Epidemiology Heart failure as a syndrome and a progressive disorder Estimated: 6.6 million people have CHF Projected: 10 million by 2030 Mortality: approximately 50% within 5 years of CHF dx African-American men/women have highest rates at 20.4% and 19.3% Sudden Cardiac Death occurs at 6-9x rate of general population Cost: approx. $40 billion annual expenditure

5 Terminology Ejection fraction (EF) is the fraction of outbound blood pumped from the heart with each heartbeat. Stroke volume (SV) which (along with heart rate) determines cardiac output, which is the amount of blood the heart pumps per minute. Cardiac output (CO) is the volume of blood being pumped by the heart, in particular by a left or right ventricle in the time interval of one minute

6 What is Heart Failure? An impairment of the heart to fill or eject blood Systolic Diastolic Reduced EF Preserved EF

7 Systolic dysfunction (reduced EF) Chamber dilation (dilated cardiomyopathy) Eccentric remodeling Dyspnea, edema, JVD, 3 rd heart sound and hepatomegaly Ejection fraction (EF) < 50%

8 Systolic dysfunction causes Ischemic (80%) Non ischemic Hypertension Valvular disorders Viral infections Chemotherapy (Doxorubicin/Trastuzamab) Cardiomyopathies Diabetes Alcohol

9 Clinical symptoms of systolic dysfunction dyspnea fatigue paroxysmal nocturnal dyspnea orthopnea JVD peripheral edema S3 murmur

10 Diastolic dysfunction (preserved EF) Inability of ventricular chamber to receive necessary volume of blood during relaxation phase to produce stroke volume (LV filling and filling pressures) Chamber hypertrophy Concentric remodeling

11 Diastolic dysfunction causes Aging Ischemia Hypertension Hypertrophic cardiomyopathy Infiltrative disorders (amyloidosis) Valvular aortic stenosis

12 Clinical symptoms of diastolic dysfunction SOB paroxysmal nocturnal dyspnea orthopnea pulmonary edema JVD pitting edema hepatojugular reflex elevated BNP

13 Ventricular remodeling Myocardial necrosis after injury Loss of cardiac myocytes reducing ventricular function Wall thinning, scarring and/or hypertrophy Need to minimize remodeling and preserve ventricular function

14 Common chief complaints Fatigue Depression Anxiety Decreased exercise tolerance

15 Circulation Arrhythmias 3 rd and/or 4 th heart sound Peripheral edema Chest pain Pulses Increased JVD Weight gain Cardiovascular assessment

16 Respiratory Crackles Cough Tachypnea Compromised SpO2 (requiring increasing FiO2) Dyspnea on exertion, SOB at rest, orthopnea, paroxysmal nocturnal dyspnea

17 Ascites Abdomen fullness Nausea Anorexia/loss of appetite/early satiety Nocturia Hepatomegaly Right upper quadrant tenderness Decreased urine output GI/GU

18 Diagnostics Exam CXR Echocardiogram EKG Cardiac catheterization BNP (Brain-type natriuretic peptide)

19 Classifications: NYHA Classification NYHA Functional Class Class I: cardiac disease w/o limitations of physical activity. Class II: cardiac disease w/limitations of physical activity and comfortable at rest. Ordinary physical activity results in fatigue or dyspnea Class III: significant limitation of physical activity; comfortable at rest. Less than ordinary physical activity causes fatigue or dyspnea. Class IV: symptoms persist with any degree of activity and at rest

20 American College of Cardiology/American ACC/AHA Guidelines Heart Association Stages Stage A: People at high risk for HF but w/o structural heart disease or sx of HF Stage B: People w/ structural heart disease but no sx of HF Stage C: Structural abnormalities w/current or prior sx of HF Stage D: People w/ refractory HF that necessitates specialized interventions

21 Treatment goals of systolic and diastolic dysfunction Reduce afterload resistance Symptom relief Manage cardiac ischemia Rate control

22 Why ACE as First line therapy (systolic/diastolic dysfunction) Reduces symptoms Reduces ventricular size Improves ejection fraction Decreases risk of MI Prevents conversion of angiotensin I to angiotensin II Reduces vasoconstriction and fluid retention

23 ACE Inhibitor medications Captopril Lisinopril Enalapril

24 ACE Nursing considerations Blood pressure (hypotension) Serum potassium levels Renal function (creatinine <3.0 mg/dl) Patient c/o excessive coughing->switch to ARB

25 Angiotensin receptor blockers (ARBs) (Systolic and Diastolic dysfunction) Alternative to ACE inhibitors Similar benefit Combination with ACE increases renal dysfunction and hyperkalemia-> risk with no benefit. Use either ACE or ARB.

26 ARB medications Candesartan Valsartan Losartan

27 ARB Nursing Considerations Monitor K levels Renal function hypotension

28 Nitrates for systolic dysfunction Reduces systemic vascular resistance Improves cardiac output Used in acute episodes IV Resistance develops d/t loss of vascular smooth muscle sensitivity Preferred for short course tx

29 Nitrates Nitroglycerin Isosorbide Nursing Considerations: Hypotension, allergic reactions d/t patches, dizziness, falls, nausea

30 Isosorbide dinitrate/hydralazine (BiDil) Hydralazine antihypertensive Isosorbide dinitrate vasodilator Increases survival Reduces hospitalization FDA approved in 2005 for use in self identified African Americans

31 Bidil Nursing Considerations Medication taken 3x/day Hypotension Used with first line treatments

32 Reduction in mortality Reduction in symptoms Reduction in hospitalization Aldosterone Antagonists (Systolic dysfunction) Added to any person with NYHA 3 or 4 despite medical therapy

33 Aldosterone Antagonists medications Spironolactone Eplerenone

34 Aldosterone Antagonist Nursing considerations Hyperkalemia Renal dysfunction hypotension

35 Beta-Blockers (Systolic and Diastolic dysfunction) Improves systolic function Increases EF 5-10% Reduction of symptoms Reduction of excess circulating catecholamine's and decreases afterload or peripheral arterial pressure. Decreases mortality

36 Beta Blocker medications Metoprolol Carvedilol Nebivilol

37 Beta-Blocker Nursing considerations Hypotension Bradycardia Bronchospasm Do not start/stop during acute CHF exacerbation SLOW titration toward target dose Contraindicated with asthma and 2 nd and 3 rd degree AV block

38 Diuretics (Systolic and Diastolic Dysfunction) Reduces intravascular and extravascular fluid Maintain euvolemia and improve symptoms IV more potent than PO Drugs include: Thiazides (normal kidney function and can be added for synergistic effect) -HCTZ, Chlorthalidone Loop diuretics (abnormal kidney function) -Furosemide, Bumetanide, Torsemide

39 Diuretic Nursing considerations Electrolyte monitoring (Na, K, Mg)! Arrhythmia monitoring Renal function (BUN/Cr) Intake/Output Blood Pressure Weights Sulfa allergy Polypharmacy leading to renal failure (NSAIDs, loop diuretics, ACE: Triple Whammy effect )

40 When diuretics fail Ultrafiltration therapy H20 and Na removal Safe to provide therapy with 4:1 nursing ratio

41 Atrial Fibrillation (abnormal heart rhythm characterized by rapid and irregular beating)

42 Atrial Fibrillation (A-fib) Symptoms may include: heart palpitations fainting shortness of breath chest pain

43 A-Fib diagnosis 12 lead EKG lacking P wave and consisting of irregular ventricular rhythm

44 A-fib treatment goals To avoid hemodynamic instability Alleviate symptoms associated with atrial fibrillation Prevent complication of heart failure and tachycardia-mediated cardiomyopathy Improve quality of life and improve exercise capacity

45 Rate control versus Rhythm control Rate control: reduce rate to normal HR (<110bpm) w/o converting rhythm Improves hemodynamics Improves rate-related symptoms Does NOT reduce risk of thromboembolism Patient may remain symptomatic

46 Rate control versus Rhythm control Rhythm control: treat arrhythmia with medications or conversion Quality of life is improved Effective for rate and rhythm related symptoms Anti-arrhythmic drug toxicities Does not reduce risk of thromboembolism

47 Rate vs Rhythm control Studies: RACE (2002)=no significant difference except rhythm control group had more events related to anti-arrhythmics. AFFIRM (2002)= no significant difference however possible trend in lower mortality in rate control yet subgroup of CHF patients under 65 may have trended towards rhythm control.

48 A-fib treatment Anti-arrhythmics Beta Blockers rate control and preferred with CHF Digoxin may be added with Beta Blockers for rate control Calcium channel blockers used with caution in systolic dysfunction Cardioversion if hemodynamic instability and refractory to meds Ablation Anti-coagulation therapy if at risk

49 Anti-arrhythmic medications for CHF Amiodarone- can be given IV or PO Avoid in patients with decreased lung function (ILD), assess, liver function, interacts with warfarin, toxic to thyroid->check FT4 levels, reduce digoxin dose if receiving Amiodarone Dofetilide (Tikosyn) increases refractory period of atria Assess: renal function and risk for torsades de pointes

50 Digoxin Cardiac glycoside + inotropic (increased contractility) - chronotropic (decreases HR) (Rate control) Not primary treatment for CHF however used to control rate in AF and improve CHF sx Small dose: 0.125mg daily Therapeutic level (0.5-2ng/ml)

51 Digoxin Toxicity S/Sx: N/V, GI upset, headache, dizziness, confusion, delirium, vision disturbance (blurred or yellow vision), irregular heartbeat, ventricular tachycardia, ventricular fibrillation, sinoatrial block and AV block Diagnostics: Serum concentration >2ng/ml, serum potassium and renal function, serial EKGs

52 Digoxin toxicity treatment Digibind If unavailable and arrhythmias present administer Magnesium IV, Lidocaine IV and phenytoin IV, cardiac pacing

53 Anti-coagulation therapy Warfarin Ventricular thrombi Hx of atrial fibrillation Nursing Considerations: Fall Risk, Bleeding, Daily coagulation studies, Amiodarone administration (d/t potentiating effect- reduce warfarin dose based on daily coags)

54 Ensure. Pneumococcal and Influenza Avoid use of NSAIDs Medication teaching Lifestyle modification education

55 Device therapy Indication: Possible interventions may include some or all especially those with an EF<35%, advanced HF despite therapy, increased QRS: Cardiac resynchronization therapy Biventricular pacing AICD Decreases risk for sudden cardiac death Possibly beneficial to improve morbidity Symptom improvement

56 Cardiac Rehabilitation Recommended!! Improves quality of life Improves functional capacity

57 Heart Failure Management Clinics & Coordinators Research has found nurse-led heart failure clinics staffed by specially educated and experienced cardiac RNs improved survival and self care behavior in patients with heart failure and reduced the number of events, readmissions and days in hospital.

58 Palliative support Palliative care teams (symptom management, recognition of disorder progression and relationship building) Issues: Some see palliative care as End of Life/Hospice or giving up Nurses and Providers should recognize benefits of including Palliative care team as part of overall and multi-disciplinary care

59 Acute decompensated CHF interventions Require optimization of tissue perfusion Hemodynamic stabilization Oxygen administration Diuretics Vasodilators (nitroglycerin and sodium nitroprusside) Inotropic support (Milrinone and Dobutamine) Transition or initiate oral agents once stabilized

60 Pulmonary Hypertension (PH) causing Right Sided Heart Failure Abnormal elevation of pressures in the pulmonary blood vessels (increased pressured causes increased work load of right ventricle and decreased blood flow to the lungs) Pathogenesis not well understood Endothelial dysfunction Smooth muscle proliferation Inflammation

61 Causes of PH Idiopathic Congenital (Atrial or ventricular septal defects) Clinical disorders (Pulmonary embolism, ARDS) COPD w/hypoxemia Increased left heart pressures Chronic disorders (scleroderma, Raynaud s, liver disease, portal hypertension, HIV) Drugs (cocaine, methamphetamines, appetite suppressants)

62 Diagnosis of PH Similar to systolic/diastolic dysfunction and particular attention paid to: Echocardiogram EKG Pulmonary artery pressures (normal mpap=15mmhg) If >25mmHg at rest or >30mmHg during exercise confirmed from Right heart catheterization

63 Treatment of PH Treat underlying cause Decrease pulmonary vascular resistance Augment blood flow to ensure oxygen delivery to tissues Genetic testing of families

64 PH Medications Calcium channel blockers (vasodilation, decreases HR and force of cardiac contractility however only benefits 10-20% of patients) Nifedipine Diltiazem Prostacyclin's (potent vasodilators, inhibits platelets aggregation, inhibits smooth muscle proliferation) Epoprostenol (Flolan) Epoprostenol (Veletri) Treprostinil (Remodulin) Iloprost (Ventavis) Tyvaso (Remodulin)

65 Drugs used to treat PH.. Endolthelin receptor antagonist (blocks action of endothelin) Bosentan (Tracleer) Ambrisentan (Letairis) Nitric oxide (potent vasodilator of pulmonary and systemic endothelium/smooth muscle) Phosphodiesterase (PDE5) inhibitor (smooth muscle relaxation) Sildenafil (Viagra, Revatio)

66 Nursing concerns for PH Awareness of pulmonary artery pressures documented in medical history and/or recent cardiac catheterization or ICU documentation if PA catheter was in place Maintain systemic blood pressure higher than pulmonary artery pressures Arrhythmias Oxygen therapy (vasodilator and prevents hypoxemia) Trained RN staff to provide PAH infusion therapy

67 Advanced systolic dysfunction therapy Left Ventricular Assist Device Therapy for Left sided Heart Failure

68 Left Ventricular Assist Device (LVADs) The purpose of a VAD is to provide partial or complete mechanical support of the systemic circulatory system. Blood flows from the patient s heart to the VAD (a prosthetic ventricle), which then pumps blood back to the body. Used for short or long term therapy while awaiting heart transplant or symptom management

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70 Goal of LVAD therapy Provide perfusion to sustain end organ perfusion Reduce myocardial oxygen consumption Decrease myocardial work load

71 Nursing considerations of LVAD therapy Anticoagulation Infection Volume resuscitation Pulse pressures Arrhythmia management Recognition of appropriate cardiac arrest management Patient and family education/support

72 Heart Transplant How many/year? Approx. 5,000 worldwide and 2,000 in US Over 3,000 people are waiting for a heart transplant Survival? 1 year: 88.0% (males), 86.2% (females) 3 years: 79.3% (males), 77.2% (females) 5 years: 73.2% (males), 69.0% (females)

73 References Hagens, V.E., Van Gelder, I.C., Crijins, H.J. (2003). The RACE study in perspective of randomized studies on management of persistent atrial fibrillation. Cardiac Electrophysiology Review, 7(2), Schell, H.M., & Puntillo, K.A. (2006). Critical Care Nursing Secrets. St. Louis, Mosby/Elsevier. MO: Stromberg, A., Martensson, J., Fridlund, B., Levin, L-A., Karlsson, J-E., Dahlstrom, U. (2003). Nurse-led heart failure clinics improve survival and selfcare behaviour in patients with heart failure: Results from a prospective, randomised trial. European Heart Journal, 24, DOI:

74 The END! Thank you!