CVD- Heart Failure Flashcards
(21 cards)
Heart failure
The physiological state in which cardiac output is insufficient for the body’s needs. Cardiomyopathy describes disease of the heart muscle.
It affects 1.5-2% of Australians, with increasing incidence and prevalence with age.
Symptoms are fatigue, loss of appetite, fluid overload, dyspnoea, decreased exercise tolerance but can be easily masked
Medical management
Limit damage by treating risk factors- statins
Modulate neurohormonal activation- B blockers, ACE inhibitors
Treat hypertension
Secondary prevention of AMI
Control diabetes and other coexisting risk factors
Recognise testable causes- myocarditis, drug induced cardiomyopathy, alcohol abuse
Surgery for valve disease, revascularisation
Treat Brady/ trachycardias
Ventricular assist device as bridge to transplant
Transplant
Dietary management
Limited rct
Epidemiological data difficult to interpret due to cofounders
The basis of dietary recommendations are based on expert consensus and hypothetical benefits
Focus on reducing malnutrition risk in vulnerable groups (elderly and advance HF)
Managing malnutrition to assist in improving outcomes
Dietary management goals
Symptomatic relief and improvement of functional capacity
Reduction in De compensation and admissions
Delayed progression of disease
Treatment of causative factors (diabetes, hypertension, hyperlipidaemia)
Prolong survival
Promote self management and monitoring strategies
Reduce complications associated with malnutrition
Reduce complications associated with immunosuppressing medications
Undertake with a multidisciplinary team wherever possible
Dietary management objectives
Limit fluid intake to <2L or <1.5L if evidence of fluid retention
Maintain low sodium diet
Aim for relevant biochemical markers within chronic disease ranges
Aim for healthy weight range, avoid malnutrition, obesity and overweight
Self management
Integral so patient can understand Underlying condition Benefits of lifestyle changes Importance of adherence to therapy Functions of their medication Possible side effects of therapy Signs of deterioration in their condition Understanding of condition by patients and caters decreases risk of poor adherence and admissions due to De compensation
Limit fluid intake to <2L or <1.5L if evidence of fluid retention
Avoid weight gain due to fluid shift
Empower patient to initiate action plan if weight increases
Fluid foods include those which are liquid at room temp such as jelly or icecream, or in some cases those which hold a large amount of water that are eaten in large amounts such as rice or pasta.
Manage fluid intake by writing down amount consumed or filling a jug with permitted amount, and emptying consumed equivalent
Use smaller cups with known volume
Time fluids when you like them most
Quench thirst with ice cubes or frozen fruit
Reduce salt intake
Self monitoring fluid
Monitor themselves for warning signs of deterioration
- rapid weight gain (>2kg in 24-48 hours)
- +/- worsening dyspnoea
- +/- increasing abdominal distension
- +/- increasing peripheral oedema
Should have action plan
Increase diuretic dose/ call hospital or GP/ present to ED
noncompliance with drugs, diet, fluid may be factor to exclude before medical factors investigated
Fluid overload medical management
Increased urine and fluid sodium eccrefion via diuretics rapidly decreases fluid overload and improves summon status
Aim for weight reduction until clinical euvolaemia is achieved with diuretic weaned thereafter if possible, kg reduction per day varies with individuals and their condition
Patients should also be monitored for hypoalkalaemia during treatment with a loop diuretic
Patients often referred to a dietitian or heart failure nurse for review of fluid / sodium intake prior to decompensation and to reiterate importance of adherence in future
Maintain low sodium diet
Critical reduction in risk of hospitalisation due to fluid overload
High salt chronically associated with hypertension
High salt intake acutely associated with fluid retention and thirst
Taste buds adjust to lower salt intakes within 4-6 weeks
Chronic fluid and sodium overload exacerbates hormonal and mechanical compensation in heart failure contributing to disease progression
Aim for intake <1600mg/d sodium
Aim for relevant biochemical markers within chronic disease ranges
Aggressive lipid management strategies should be used in the presence of prior coronas disease or IHD
Evidence of effectiveness of statins in reducing mortality and morbidity is mixed- use is continued in most centres and current
Modified fat diet should be advocated to limit risk from future coronary disease and infractions
Decrease in sat fat intake with inclusion of omega 3 fatty acids
Management of comorbidities
Diabetes sees high prevalence of heart failure and poorer outcomes
Also increases risk of ischaemia, fibrosis, hypertrophy and apoptosis, increased circulating cytokines
Poor glycaemic control leads to contraindication to transplant
The present of renal dysfunction needs to be considered with electrolyte and renal function monitored closely particular when significant changes in cardiac status of modifications to therapy occur.
Patients with renal disease often have excessive salt and water retention requiring higher doses of loop diuretics
Spironolactone carries a significant risk of hyperkalaemia
Presence of irreversible renal dysfunction contradiction for heart transplant alone
Alcohol
Alcohol is a myocardial toxin and impairs contractility
It can also lead to weight gain, increase in. Mood pressure and TG level
Patients with etoh related cardiomyopathy should abstain or maximum consumption 1-2 standard drinks within fluid restriction
Caffeine
Excessive intake may exacerbate arrhythmia and high bblood pressure
Contribute to fluid intake
May alter plasma electrolyte levels in patients taking diuretics
Limit 1-2 cups caffeinated bevs a day
Fibre
Risk of constipation is increased due to bowel hypoperfusion, fluid restriction, reduced activity and anorexia
High fibre diet of 30g/d recommended to avoid straining which may provoke angina, dyspnoea or arrhythmia
Overweightness
Increases demands on heart to pump to greater are
Increases bp- secondary risk
Case insulin resistance- secondary risk
Increase lipids- secondary risk
Increase inflammatory cytokines speeding deterioration of heart muscle.
Advise patient to lose 0.5-1kg weight per week
Exercise may be limited so need food restriction
Obesity paradox
U shaped survival - including post major surgery, transplant and VAD
Evidence is controversial-
BMI does not differentiate between lean and fat mass, often not controlled in studies
Lower BMI ranges likely to contain individuals with more severe heart failure- accelerate lean mass loss- poorer survival outcomes
Hypothesis include increases capacity of adipose tissue to clear circulating BNP reducing neurohormonal response mechanism
General consensus remains recommended healthy weight range. For advanced heart failure, heart and lung transplant have increased BMI Targets to 35 for transplant, was previously 30kg/m
Underweight
Malnutrition in heart failure patients is associated with increased LOS
Increase readmission rate
Reduced exercise tolerance, daily function and strength
Reduced immunity
Increase postoperative mortality in advance heart failure
Cardiac cachexia
Preferential loss of lean mass
Frank inadequacy of energy and protein not the sole cause; inflammatory process hastens muscle wasting
Mixed definition, most studies use malnutrition and cachexia interchangeably. Can be identified by loss of >6% of wt in 6-12
Normal BMI and obese patients may still have clinical cachexia masked by fluid
Risk factors Class IV (severe Hf) GI issues Impaired absorption Changes in Caroline and hormonal regulation - metabolic disturbances- catabolic state and increased inflammation. Reduced intake due to SOB and fatigue Anaemia
Cachexia dietary advice
Estimation of requirements, aims to maximise intake through dietary modification to increase kj intake and +/- supplements. Advise small frequent meals and snacks to avoid shunting of cardiac output to GI tract causing bloating and dyspnoea. Food fortification must take into account comorbidities
Equations- but not reliable, high variability in stress factor, Mx advances limit stress response to illness/ injury/ surgery
Indirect calorimetry- reduces risk of over or underfeedjng
Assist in evaluating management when goals are not being achieved, eg failure to gain weight
Patient selection criteria- breathing in room air, able to cooperate and follow instructions no multi resistant organisms, clear rationale/ goal for measurement
Ideal conditions- rested, fasted up to 4 hours, no recent caffeine, alcohol or strenuous exercise. Quiet room, ambient temperature, patient able to relax, supine best position
Heart transplant considerations
Meeting increased requirements immediately post ICU
Long and short term stay
Immunosuppression- food safety educator
Increased risk of chronic disease and weight gain
Funding- community referral
Interstate patients
ISHLT
