Heart Failure
Amanda Ryan, D.O.
Cardiology Fellow
February 14th, 2008
Learning Objectives
Following this presentation, the
participant should be able to:
1. Recognize the magnitude of heart failure epidemic and its public
health implications
2. Distinguish the different classifications and stages of heart failure
3. Review underlying pathophysiology of heart failure
4. Discuss signs and symptoms of heart failure exacerbation
5. Identify current practice guidelines for treatment of acute
decompensated heart failure
What is Heart Failure
Heart failure occurs when the heart cannot
pump enough blood fast enough to meet the
metabolic needs of the body.
No longer use the term “congestive” because
all heart failure does not result in clinically
apparent volume overload
It is an Epidemic
Estimated that over 5 million Americans have heart
failure
Estimated 500,000 new cases per year
Within 5 years, half of those diagnosed will be dead
Over 1 million hospitalizations per year with HF as
primary diagnosis
Most common reason for hospitalization in those >65
years old
85% of HF cases are in adults 65 and older
Heart failure is 4th in a list of quality of care initiatives in
vulnerable older adults
Costs of Heart Failure
It is the leading cause of hospitalization in patients older than 65 years
of age and is a primary hospital discharge diagnosis in 1.1 million
people of all ages each year.
It is one medical condition for which mortality continues to increase.
From 1994 to 2004, the overall death rate declined 2.0% in the United
States, but deaths from HF increased 28% in the same time period.
According to the National Heart, Lung, and Blood Institute, the
estimated direct and indirect costs associated with HF care in the US is
$33.2 billion yearly.
The majority of the costs – approximately two-thirds – are attributable
to the management of episodes of acute HF decompensation (i.e.,
hospitalization).
REACH Trial
Researchers at Henry Ford Heart and
Vascular Institute found that the annual
number of heart failure cases more than
doubled for Henry Ford Health System in
Detroit from 1989-1997. Over that nine-year
period, 26,442 cases were identified.
Strikingly, the annual prevalence rose from 9
to 20 cases per 1000 health system patients .
Our Aging Population
Different Ways to Define HF
Dilated (congestive) cardiomyopathy is a group of heart muscle
disorders in which the ventricles enlarge but are not able to pump
enough blood for the body's needs, resulting in heart failure.
(Example - CAD, myocarditis, EtOH, HIV)
Hypertrophic cardiomyopathy includes a group of heart disorders
in which the walls of the ventricles thicken (hypertrophy) and
become stiff, even though the workload of the heart is not
increased. (Example – congenital HOCM, or acquired)
Restrictive (infiltrative) cardiomyopathy includes a group of heart
disorders in which the walls of the ventricles become stiff, but not
necessarily thickened, and resist normal filling with blood
between heartbeats. (Example – radiation, amyloidosis)
Different Ways to Define HF
Diastolic Versus Systolic Heart Failure
A. Systolic cardiac (heart) dysfunction (or systolic
heart failure) occurs when the heart muscle doesn't
contract with enough force, so there is not enough
oxygen-rich blood to be pumped throughout the
body.
B. Diastolic cardiac dysfunction (or diastolic heart
failure) occurs when the heart contracts normally,
but the ventricle doesn't relax properly so less
blood can enter the heart.
Different Ways to Define HF
Clinically, patients are classified as having
HF of ischemic or nonischemic etiology
based on a history of myocardial infarction
(MI) or based on objective evidence of
coronary artery disease (CAD) such as
angiography or functional testing.
Controversial Definitions
Staging of Heart Failure
New York Heart Association
Class I: No obvious symptoms, no limitations on patient
physical activity (35 percent).
Class II: Some symptoms during or after normal activity,
mild physical activity limitations (35 percent).
Class III: Symptoms with mild exertion, moderate to
significant physical activity limitations (25 percent).
Class IV: Significant symptoms at rest, severe to total
physical activity limitations (5 percent).
Causes of Heart Failure
Coronary artery disease
Problems with the heart muscle itself [known as
cardiomyopathy (myocarditis, etc)]
Hypertension
Problems with any of the heart valves
Abnormal heart rhythms (also called arrhythmias)
Toxic substances (EtOH, cocaine)
Congenital heart disease
Diabetes
Thyroid problems
HIV
Diastolic HF
Diastolic heart failure is defined as a condition caused by increased resistance
to the filling of one or both ventricles; this leads to symptoms of congestion from
the inappropriate upward shift of the diastolic pressure-volume relation.
k 40% of patients
k Increasing incidence with age
k More common in women
k HTN and cardiac ischemia are most common causes
k Common precipitating factors include volume overload; tachycardia; exercise;
hypertension; ischemia; systemic stressors (e.g., anemia, fever, infection,
thyrotoxicosis); arrhythmia (e.g., atrial fibrillation, atrioventricular nodal block);
increased salt intake; and use of nonsteroidal anti-inflammatory drugs.
More About Diastolic
Dysfunction
Alterations involve relaxation and/or
filling and/or distensibility.
Arterial hypertension associated to LV
concentric remodelling is the main
determinant of DD but several other
cardiac diseases, including myocardial
ischemia, and extra-cardiac pathologies
also possible.
Stages of Diastole
1. Isovolumetric relaxation, period occurring between the end
of LV systolic ejection (= aortic valve closure) and the opening of
the mitral valve, when LV pressure keeps going its rapid fall while
LV volume remains constant.
2. LV rapid filling, which begins when LV pressure falls below
left atrial pressure and the mitral valve opens. During this period
the blood has an acceleration which achieves a maximal velocity,
direct related to the magnitude of atrio-ventricular pressure, and
stops when this gradient ends.
3. diastasis, when left atrial and LV pressures are almost equal
and LV filling is essentially maintained by the flow coming from
pulmonary veins – with left atrium representing a passive conduit
– with an amount depending of LV pressure, function of LV
"compliance".
4. atrial systole, which corresponds to left atrial contraction and
ends at the mitral valve closure. This period is mainly influenced
by LV compliance, but depends also by the pericardial resistance,
by the atrial force and by the atrio-ventricular synchronicity (=
ECG PR interval).
Patient Differences
HF is a hemodynamic disorder but there is a
poor relationship between measures of
cardiac performance and patient symptoms
For example, pts with very low EF may be
asymptomatic while someone with preserved
EF may be severely disabled with symptoms
Body Compensatory
Mechanisms
Epinephrine and norepinephrine release which increases heart rate
and contractility which increased myocardial work load
Decrease salt and water excretion from kidneys which helps maintain
BP by increasing blood volume, this leads to stretching of heart’s
chambers which can impair ability to contract
Hypertrophy and thickening of heart muscle which initially increases
contractility but over time leads to stiff chambers and can impair
contractility
HF patients have higher levels of epinephrine, norepinephrine,
aldosterone, angiotensin II, endothelin, inflammatory cytokines, and
vasopressin which contribute to heart remodeling, progression of HF,
and higher levels are associated with increased mortality
Potential Reasons
Alternation in ventricular distensibility
Valvular regurgitation
Pericardial restraint
Cardiac rhythm
Conduction abnormalities
RV function
Also several non-cardiac factors including peripheral
vascular fxn, reflex autonomic activity, renal sodium
handling, etc.
HF Risk Factors - History
o Smoking o Cardiotoxic drugs
o EtOH use o Fam Hx of sudden
o DM death, CAD, conduction
o HTN problems, HCM
o Dyslipidemia o HIV status
o Thyroid disorder
o Chemotherapy
o Radiation
Cardiovascular Medical Hx
p Hx of heart failure p Embolic events
p Angina p arrhythmias
p MI p CVA
p CABG p PVD
p PCI p Rheumatic Dx
p Pacemaker/ICD p Other valvular hx
p Congenital
Signs and Symptoms of HF
Dyspnea Rales
PND S3
Orthopnea Pulmonary edema
Cough JVD
Exercise intolerance Tachycardia
Edema Cardiomegaly
Fatigue Hepatojugular reflex
Nausea Peripheral Edema
Abdominal Fullness Hepatomegaly
HF Diagnosis and Assessment
Remains primarily a clinical diagnosis but
additional information via other diagnostics
can be beneficial
Evaluation depends on if this is first
presentation, change in clinical symptoms,
certainty of diagnosis, etc
Examples
Elevated BNP levels have been associated
with reduced LVEF, LVH, elevated LV filling
pressures, and acute MI
Evidence supports baseline levels for acute
exacerbations at this time
Evaluation with coronary angiography on
initial dx or presentation is recommended
TTE Recommendations in Heart
Failure
ADHERE
The Acute Decompensated Heart Failure National Registry
(ADHERE) is the largest clinical database of patients with acute
decompensated heart failure (ADHF). It provides a cross-
sectional evaluation of the HF population in the United States
and provides insights into how patients with ADHF are managed
during hospitalization.
ADHERE DATA
The data gathered for this registry include demographic
information, medical history, baseline clinical characteristics,
initial evaluation, treatment received, procedures performed,
hospital course, and patient disposition.
Importantly, registry participation does not require any alteration
of treatment or hospital care, and entry of data into the registry is
not contingent on the use of any particular therapeutic agent or
treatment regimen
Lessons From ADHERE
Prior studies on chronic systolic HF have demonstrated that body mass index
(BMI) is inversely associated with mortality, the so-called obesity paradox.
ADHERE investigators sought to determine whether BMI influences the mortality
risk in ADHF, a subject not previously studied. In the large ADHERE cohort of
hospitalized patients with HF, higher BMI was associated with significantly lower
in-hospital mortality risk. The authors noted that the relationship between BMI
and adverse outcomes in HF appears to be complex and deserving of further
study.
Since most ADHF patients present for hospital care via the emergency
department (ED), the ADHERE investigators studied the impact of early ED
initiation of ADHF-specific therapy, as indicated by nesiritide use, on subsequent
outcomes. Nesiritide was started in the ED in 1,613 patients (EDN group) and
after admission to an in-patient unit in 2,687 patients (INN group). Nesiritide was
initiated a median of 2.8 and 15.5 hours after presentation in EDN and INN
patients, respectively (p 120 ms. This electrocardiographic representation
of abnormal cardiac conduction has been used to identify patients with
dyssynchronous ventricular contraction. While imperfect, the ACC/AHA
guidelines acknowledge that no other consensus definition of cardiac
dyssynchrony exists as yet, although several echocardiographic measures
appear promising.
The mechanical consequences of dyssynchrony include suboptimal ventricular
filling, a reduction in LV dP/dt (rate of rise of ventricular contractile force or
pressure), prolonged duration (and therefore greater severity) of mitral
regurgitation, and paradoxical septal wall motion. Ventricular dyssynchrony is
associated with increased mortality in HF patients.
Evidence for CRT
In a meta-analysis of several CRT trials, HF
hospitalizations were reduced by 32% and
all-cause mortality by 25%. The effect on
mortality in this meta-analysis became
apparent after approximately 3 months of
therapy.
Guidelines for CRT
ICD Support
Evidence that ICDs save lives comes from
trials such as MADIT II, DEFINITE, and SCD-
HeFT
Ventricular Assist Devices
A VAD is a temporary life-sustaining device. VADs
can replace the left ventricle (LVAD), the right
ventricle (RVAD), or both ventricles (BIVAD). They
are used when the heart muscle is damaged and
needs to rest in order to heal or when blood flow
from the heart is inadequate. VADs can also be
used as a bridge in patients awaiting heart
transplantation or in patients who have rejected a
transplanted heart.
Inpatient Vs Outpatient
Management
Nesiritide is a new drug that is a synthetic
BNP that vasodilates vessels and serves as a
potent diuretic agent
Inotropic agents (dobutamine, milrinone) –
often used inpt, potent inotropic agents used
to increase cardiac output – use is
controversial in outpt settings, may improve
morbidity, definite use in hospice setting,
increase risk of arrhythmias which is
important in those with AICD’s
Definition of Stage Usual Therapies
Stage
Stage A Those at high risk for developing heart
failure. Includes people with:
•Hypertension •Exercise regularly
•Diabetes mellitus •Quit smoking
•Coronary artery disease (including heart •Treat hypertension
attack) •Treat lipid disorders
•History of cardiotoxic drug therapy •Discourage alcohol or illicit drug use
•History of alcohol abuse •If previous heart attack or current diabetes mellitus or
•History of rheumatic fever hypertension angiotensin converting enzyme inhibitor
•Family history of cardiomyopathy. (ACE-I)
Stage B Those diagnosed with “systolic” heart
failure but have never had symptoms of
heart failure (usually by finding an ejection •Care measures in Stage A +
fraction of less than 40% on •All patients should be on ACE-I
echocardiogram). •Beta-blockers should be added
•Surgical consultation for coronary artery revascularization
and valve repair/replacement (as appropriate)
Stage C Patients with known heart failure with In this group, care measures from Stage A apply, ACE-I and
current or prior symptoms. beta-blockers should be used +
Symptoms include: •Diuretics (water pills)
•Shortness of breath •Digoxin
•Fatigue •Dietary sodium (salt) restriction
•Reduced exercise intolerance. •Weight monitoring
•Fluid restriction (as appropriate)
•Withdrawal of drugs that worsen the condition
•Spironolactone when symptoms remain severe with other
therapies
Stage D Presence of advanced symptoms, after All therapies under Stages A, B and C + evaluation for:
assuring optimized medical care •Cardiac transplantation
•Ventricular assist devices
•Surgical options
•Research therapies
•Continuous intravenous inotropic infusions
•End-of-life care
Major Outcome Measurements
1. Accuracy of diagnostic instruments
2. Survival
3. Quality of life
4. Symptoms of heart failure
5. Exercise tolerance and functional capacity
6. Effects of medications to treat systolic HF on
morbidity and mortality
7. Adverse effects of drugs
8. LVEF per echo or radionuclide
9. Hospitalization rate
Health System HF Intervention
Goals
Ensure medical management for HF is
consistent with national guidelines
Provide residents with essential information
for self-care
Prevent avoidable hospital readmissions
Reduce financial burden to health care
system through clinically appropriate
utilization of resources and length of stay
Administer preventive vaccinations
Interdisciplinary Interventions
Implementation of protocol for heart failure in
the long-term care setting has been proven to
standardize management and strengthen the
continuum of care
Nursing facility in Michigan which consisted
of 150 nursing home beds designed such a
program
Protocol
Medical director, director of nursing, key
nursing unit leaders developed
Nursing staff then received education
regarding specifics of protocol
Admission personnel play an important role
by early recognition and requesting certain
documentation from d/c hospitals
Recent weight and immunization hx obtained
Protocol continued
Diagnosis verification by reviewing records,
admission Chest X-ray, echo reports, medication
review.
Pharmacists were utilized when appropriate
Weight monitoring program established (three times
weekly) and if more than 2 lb gain, a standard
nursing assessment
a. Included physical exam and history is possible
focusing on shortness of breath, fatigue, night
cough, LE edema, cough, change in vital signs
More Protocol
Preventive vaccination policy
Patient education – heart failure booklet,
family counseling when appropriate, input
from dietary and nursing staff
Quality Assurance via CMS HF
Standards
Current echo report
Use of ACE-I where appropriate
Standardized nursing assessments
Effective tx for heart failure symptoms
90% immunization rate
Education for resident and families for HF
Results – Echo documented
Ejection Fractions
More Results – Symptom
Management
Results – ACE-I utilization
Hospital Readmissions
Of 22 noted clinical deteriorations at 5
months, only one resulted in a hospital
readmission in this study.
The other declines or changes in status were
managed in the facility with early, aggressive
interventions
Required several training sessions with
nurses, educating attending physicians, and
the involvement of facility administrator
End of Life Care
Realization that heart failure is often a terminal
disease and while we have made great strides in
treatment, there often comes a point where the
focus of care changes to a palliative focus
May include shutting off defibrillator
Symptom relief, psychosocial and spiritual
considerations are of key importance
End-of-life predominating symptoms are often
dyspnea, dry mouth, nausea, fatigue, pain,
restlessness, and apprehension.
Final Reminder – Continue to
Break Barriers
Nursing staff, mid-level practitioners,
physicians, dietary staff, therapist, patients &
families, and other ancillary staff must realize
that together we can make the greatest
difference in treating heart failure
HF is an epidemic with primary care staff
having the greatest potential impact by early
realization of decline and appropriate
intervention &/or referral
Citations
Douglas et al. Appropriateness criteria for echocardiography. J Am Coll Cardiol 2007
Poole-Wilson PA, Swedberg K, Cleland JGF, et al. Comparison of carvedilol and metoprolol on clinical
outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET):
randomized controlled trial. Lancet 2003;362:7-13.
Remme WJ, Torp-Pedersen C, Cleland JGF, et al. Carvedilol protects better against vascular events than
metoprolol in heart failure – Results from COMET. J Am Coll Cardiol 2007;49:963-71.
Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics--2007 update: a report from
the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation
2007;115:e69-171.
Adams Jr. KF, Fonarow GC, Emerman CL, et al. Characteristics and outcomes of patients hospitalized
for heart failure in the United Statesrationale, design, and preliminary observations from the first 100,000
cases in the Acute Decompensated Failure National Registry (ADHERE). Am Heart J 2005;149:209-216.
Higgins SL, Hummel JD, Niazi IK, et al. Cardiac resynchronization therapy for the treatment of heart
failure in patients with intraventricular conduction delay and malignant ventricular tachyarrhythmias.
JACC 2003;42:1454-1459
Citations Continued
Peacock WF 4th, Fonarow GC, Emerman CL, Mills RM, Wynne J; ADHERE Scientific Advisory
Committee and Investigators; Adhere Study Group. Impact of early initiation of intravenous therapy for
acute decompensated heart failure on outcomes in ADHERE. Cardiology 2007;107:44-51.
Galvao M, Kalman J, DeMarco T, et al. Gender differences in in-hospital management and outcomes in
patients with decompensated heart failure: analysis from the Acute Decompensated Heart Failure
National Registry (ADHERE). J Card Fail 2006;12:100-7.
Fonarow GC, Peacock WF, Phillips CO, et al. Admission B-Type Natriuretic Peptide Levels and In-
Hospital Mortality in Acute Decompensated Heart Failure. J Am Coll Cardiol 2007;49:1943-50
Hunt SA American College of Cardiology; American Heart Association Task Force on Practice Guidelines
(Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure).
ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult:
a report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of
Heart Failure). JACC 2005;46:e1-e82
Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J
Med 2002;346:1845-1853