Heart Failure Continuum of Care Flashcards Preview

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Flashcards in Heart Failure Continuum of Care Deck (100):
1

Co-morbidities with Heart Failure in WOMEN

HTN
Valvular disease
Thyroid function
Less obstructive CAD
DM
LVH (increased mortality)

2

Define Heart Failure

Complex, heterogeneous & progressive syndrome characterized by structural and/or functional abnormalities in cardiac contraction, consequent adverse euro-hormonal adaptations & remodeling & co-morbidities that collectively alter myocardial function, fluid regulation, respiration, & perfusion & overall hemodynamic stability

3

Unusual Causes of Cardiomyopathy

Hypertrophic obstructive cardiomyopathy (HCM)
AL amyloid cardiomyopathy
Myocarditis
Tachycardia-induced cardiomyopathy (TIC)
Takotsubo cardiomyopathy (TTC)
Peripartum cardiomyopathy (PPCM)

4

Co-Morbid Conditions in Heart Failure

Anemia: of chronic disease
Gout: thiazides contribute
HTN
Renal dysfunction: murderous marriage with the heart
Lung disease; sleep-disordered breathing
Rapid or irregular dysrhythmias
DM
Thyroid disorders

5

Types of Remodeling in Heart Failure

Hypertrophy (preserved EF HF)
Dilation (reduced EF HF)

6

Clinical Features of Heart Failure with Preserved Ejection Fraction

Volume overload
Decreased activity tolerance
QOL similar to low EF patients

7

Heart failure with preserved ejection fraction is associated with what kind of dysfunction?

Diastolic dysfunction

8

Signs/Symptoms of Diastolic Dysfunction

Increased LV wall stiffness
Decreased compliance/impaired relaxation
Decreased cardiac output

9

3 Stages of Diastole

Isovolemic (active) relaxation & rapid early filling
Diastasis (passive) filling
Active filling during atrial contraction

10

Define Grade 1 Diastolic Heart Failure

Impaired relaxation

11

Define Grade 2 Diastolic Heart Failure

Pseudonormal
Concomitant LA enlargement, LV hypertrophy and/or decreased LV ejection fraction

12

Define Grade 3 Diastolic Heart Failure

Restrictive/constrictive
Difference is reversibility
Impaired LV relaxation
Increased LV stiffness
Increased LA pressures

13

Define Dilation

Compensate for poor cardiac output, ventricle dilates, becomes thinned & weakened

14

Heart failure with reduced ejection fraction is associated with what kind of dysfunction?

Systolic dysfunction

15

Clinical Features of Reduced Ejection Fraction Heart Failure

Impairment of LV contraction
EF less than 40%
Decreased stroke volume
Decreased cardiac output
Engorgement of systemic veins
Decreased perfusion to vital organs

16

Atrial Fibrillation in Heart Failure

Lead to an acute decompensated state

17

Common Symptoms of A-fib in Heart Failure

Fatigue
Dyspnea
Especially in preserved HF

18

Factors that Contribute to HF

Cardiac chamber enlargement
Conduction system & anatomical heart abnormalities
Adaptations of SNS
Adverse responses to medications
Electrolyte abnormalities

19

Functional Classification of HF

Class 1 (Minimal): no limitations
Class 2 (Mild): no strenuous activity
Class 3 (Moderate): activity limited to ADLs
Class 4 (Severe): symptoms with any physical activity

20

2 Parts of a Cardiovascular Assessment

Wet or dry: assessing fluid status & congestion
Warm or cold: assessing indicators of perfusion

21

No Low Perfusion or Congestion at Rest

Warm & dry

22

Congestion at Rest but No Low Perfusion at Rest

Warm & wet

23

Low Perfusion at Rest & No Congestion at Rest

Cold & dry

24

Lower Perfusion & Congestion at Rest

Cold & wet

25

Possible Evidence of Low Perfusion

Narrow pulse pressure
Sleepy/obtunded
Low serum sodium
Cool extremities
Hypotension with ACE inhibitor
Renal dysfunction

26

Signs/Symptoms of Congestion

Orthopnea/PND
JV distension
Ascites
Edema
Rales (rare)
S3
Hepato-jugular reflex

27

Follow Up Questions with SOB

Occurring at rest or with exertion
Awaken patient from sleep
Occur when walking on a flat surface; worse with stairs/carrying items
Increasing with daily activities now as opposed to 1 & 6 months ago
Ask family if patient looks more SOB than normal

28

Follow Up Questions with Cough

Productive, non-productive, blood tinged sputum
Worse with exertion or when lying down
Patient taking any new medication

29

Follow Up Questions with Chest Pain

Description
Accompanied by diaphoresis, SOB, N/V
Alleviating or aggravation factors
With or without exertion
Awaken patient from sleep

30

Follow Up Questions with Palpitations

Circumstances when symptoms occur
Duration & description
Accompanied by dizziness, loss of consciousness, shock from ICD

31

Follow Up Questions with Dizziness, Lightheadedness, Syncope

Occur with position changes, while bending over
Accompanied by palpitations
Loss of consciousness (alone or witnessed)

32

Follow Up Questions with Abdominal Fullness

Weight change in the past week, month
Presence of nausea, early satiety, abdominal bloating
Clothes feel tight (pants, belt)
Experiencing RUQ tenderness, feelings of pressure in abdomen

33

Follow Up Questions with Dietary Habits

Table salt added while cooking or eating
Consuming frozen processed meals, canned foods, eating in restaurants
Foods high in fat/cholesterol

34

Follow Up Questions with Edema

Presence in feet, ankles, calf, knees, back
Resolve overnight
Skin painful or seeping

35

Follow Up Questions with Sleep

Awaken during the night with SOB
Able to lay flat, sleep propped up in bed, on a sofa, recliner, or sit at the edge of the bed

36

Follow Up Questions with Mentation

Difficulty thinking, staying awake, concentrating or understanding written/verbal communication
Does family notice whether patient's mind drifts or not paying attention
Falling asleep while talking to someone in person or on the phone

37

Follow Up Questions with Substance Abuse

Smoking
Illicit drugs
Alcohol

38

Follow Up Questions with Past Disease/Treatment

Recent infections
Symptoms
Treatment
Rheumatic fever
Chemo: type & year

39

Clues for Identifying Patients with Advanced HF

Repeated hospitalizations or ED visits for HF in past year
Progressive deterioration in renal function
Weight loss without other cause
Intolerance to ACE inhibitors due to hypotension and/or worsening renal function
Intolerance to beta blockers due to worsening HF or hypotension
Frequent systolic blood pressure

40

Diagnostic Testing for HF

CXR
Lab: include biomarkers
ECG
ECHO, MUGA, MRI
Risk stratification for CAD
Risk stratification for HF

41

Non-invasive Imaging for Risk Stratification for CAD

Nuclear stress test
Stress echo

42

Invasive Imaging for Risk Stratification for CAD

Cardiac cath

43

Initial Lab Testing & as Indicated

CBC without diff
CMP
A1C
BNP
TSH
Lipid panal
UA: proteinuria, RBCs
Uric acid
CXR (new/suspected HF)

44

Diuretic Guidelines

Used in symptomatic patients to reduce fluid
Increase initial dose as necessary to relieve congestion
Torsemide & bumetanide can be effective in patients with poor absorption of oral meds or erratic diuretic effect, esp. RHF
IV diuretics may be pessary to relieve congestion
Avoid chlorthiadone or metolazone when high-dose loop diuretic therapy not effective
Education to adjust daily dose of diuretic in response to weight gain from fluid overload
Diuretic refractoriness may represent patient non-adherence
Observe for SE

45

SE of Diuretic Therapy

Electrolyte abnormalities
Symptomatic hypotension
Renal dysfunction
Worsening renal function

46

MOA of ACE Inhibitors

Inhibits conversion of angiotensin I to II
Dilates blood vessels
Decreases systemic vascular resistance & blood pressure

47

Effect of ACE Inhibitors

Reduces morbidity & mortality
Improves cardiac function, symptoms, & clinical status

48

Contraindications for ACE Inhibitors or ARBs

Hx of intolerance
Pregnancy
Serum K+ >5 mEq/L
Symptomatic hypotension
Caution: patients with Cr >3.0 mg/dL

49

Surveillance with ACE Inhibitors & ARBs

BP
Renal function
Potassium

50

ACE Inhibitors in HF

Captopril
Enalapril
Lisinopril
Ramipril

51

Beta-blockers in HF

Metoprolol XL
Carvedilol
Bisoprolol

52

When to start beta-blockers?

When patient is NOT significantly congested

53

Beta-Blocker Effects

Increased LVEF
Global symptom improvement
Decreased hospitalizations & mortality
Decreased sympathetic stimulation
Stable HF & LVEF less than 40%
Beneficial in DM2 or CAD
Ok with COPD, PAD

54

Managing Vasodilator SE of Beta-Blocker Up-Titration

Temporary
Separate dosing of Beta-blocker & ACEI
Persistent: reduce vasodilators

55

Managing Fluid Retention in Beta-Blocker Up-Titration

Increase diuretic to restore baseline weight
Delay up-titrating until weight is at baseline

56

Managing Bradycardia/AV Block in Beta-Blocker Up-Titration

Check digoxin level
Persistent: cardiac pacing

57

Patient Selection for Aldosterone Antagonists

On ACEI/ARB & beta-blocker therapy
K+ less than 5.0
Creatinine less than 2.5 in men & 2.0 in women

58

When is an aldosterone antagonist not recommended?

Absence of a concomitant loop diuretic

59

New HF Drugs

Entresto (Sacubitril/valsartan)
Corlanor (Ivabradine)

60

MOA of Entresto (Sacubitril/valsartan)

Sacubitril: inhibits breakdown of vasoactive peptides including BNP, bradykinin; results in natriuresis & diuresis
Valsartan: ARB, antagonizes angiotensin II at ATI receptor; decreases AT II dependent aldosterone release, increases vasodilation

61

Monitoring with Entresto (Sacubitril/valsartan)

BP
Volume status
BUN/Cr
K+
BNP: may impact

62

SE of Entresto (Sacubitrli/valsartan)

Decreased BP
Hyperkalemia
Cough
Dizziness
Acute renal failure
Angioedema

63

MOA of Corlanor (Ivabradine)

Reduces the slow diastolic depolarization phase

64

Indications for Corlanor (Ivabradine)

Reduce risk of hospitalization for worsening HFrEF
Slow releasing with HR resting >70 bp on maximum beta-blocker or contraindicated for beta-blocker use

65

Contraindications for Corlanor (Ivabradine)

Acute decompensated heart failure
BP less than 90/50
Sick sinus syndrome
SA block
Complete heart block
Resting heart rate less than 60 bpm
Severe hepatic impairment
Pacemaker dependent

66

Relative Contraindications for Corlanor (Ivabradine)

Negative chronotropes (amiodarone, digoxin)
Increased bradycardia

67

SE of Corlanor (Ivabradine)

Bradycardia
HTN
Dizziness
Fatigue
Complete heart block
A-fib

68

Interactions with Corlanor (Ivabradine)

Not for patients with a demand pacemaker set to a rate of >60 bpm
Delayed absorption with food
Increased plasma exposure

69

Monitoring Parameters

HR (50-60 bpm)
Signs/symptoms of improvement in HF
Cardiac rhythm
BP
HR

70

Other Medical Treatments for HF

Vasodilators: nesiritide, nitroglycerine, nipride)
Inotrope infusion: dobutamine, dopamine
Milrinone (Primacor) "inodilator)
Anticoagulation
Dysrhythmics
Lipid management
Screen for sleep disordered breathing

71

MOA of Dobutamine

Stimulates beta-adrenergic receptors
Can not be used with beta-blockers

72

MOA of Dopamine

Norepinephrine release
Promotes diuresis

73

MOA of Milrinone (Primacor) "inodilator"

Decreases systemic vascular resistance & peripheral vascular resistance
Increase cardiac output
Can be used with beta-blockers

74

Treatment Strategies for HF preserved EF`

Manage comorbidities: BP, a-fib, myocardial ischemia, DM
Block neuro-hormonal activation
Improve left ventricle relaxation
Screen for/treat sleep disordered breathing
Sodium restriction

75

Treatment Strategies for Right Sided HF

Oxygen therapy
Inhalers, CPAP if indicated
Digoxin: rhythm problems
Diuretics
Pulmonary HTN
Accompanied with preserved LV HF

76

Medications that May Hurt a HF Patient

Most CCBs
Amlodipine
Felodipine
Anti-arrhythmic drugs
Megestrol acetate
NSAIDs
Corticosteroids

77

Surgeries & Medical Devices to Treat HF

CABG
TAVR
Cardiac tranplantation
CRT: cardiac resynchronization therapy (bi-ventricular pacing)
ICD
LVAD

78

Indications for ICD Placement

LVEF less than 35%
QRS >120 ms
NYFC III-IV

79

Ventricular Assistive Devices (VADs)

Type of mechanical circulatory support device sufficient to replace/assist pumping function of the LV
Durable
Expensive: $75K-125K
Narrowed/no pulse pressure
No valves: constant flow

80

VADs & Emergencies

Do not interfere with ICD/pacemaker
Can exercise like everyone else
Patient responsive?
LVAD pumping?
Get LVAD running?
CPR only if LVAD not running
Defibrillation can be done

81

Complications of LVADs

Arrhythmias: stable vs. unstable
Right heart failure
Hypovolemia
Bleeding
Infection (drive line)
Thrombus/stroke (embolic/hemorrhagic)

82

Non-Pharmacologic Recommendations for Heart Failure Patients

Sodium restrictions
Fluids
Sleep disordered breathing
Weight
Exercise
Education/self-care

83

Risk Factors for OSA

Obesity
Male
Post-menopausal women
Men neck >16"
Women neck >15"

84

Risks with having OSA

Exacerbate myocardial ischemia
Increased risk for arrhythmias
Fatigue
Excessive daytime sleepiness
Mood disturbance
Decrease QOL

85

Benefits of CPAP

Improve heart function & functional status in HF patients
Decreased apnea-hypopnea index
Increased nocturnal O2
Increased LVEF
Decreased norepinephrine levels
Increased 6 minute walk distance

86

Weight Management & HF

BMI: 18-30 ideal
Cachexia

87

Cachexia & HF

Predicts worse prognosis
Weight loss >5% in 12 months or BMI

88

Exercise & HF

Recommended as safe/effective for patients who are able to improve functional status
Cardiac rehab can improve functional capacity, exercise duration, QOL, & mortality

89

When should a HF patient stop exercise?

Rapid pulse
CP/pressure
Unusual SOB
Irregular or slow HR
Weakness
Faintness or dizziness
Extreme fatigue

90

Define Self-Care

Process whereby individuals and/or their caregivers perform the daily activities that serve to maintain health, well-being, prevent illness, manage chronic illness or restore health

91

Mechanisms Through Which HF Self-Care Influences Health outcomes

Neuro-hormonal deactivations
Limited inflammation
Avoidance of pharmacology
Limited myocardial hibernation

92

Self-Care Activities in HF

Medications: take as prescribed
Follow a lower sodium diet
Monitoring symptoms of worsening HF
Daily weighing
Physical activity
Alcohol, smoking, fluid intake

93

Hospitalization Requirements for HF Patients

Worsened congestion without dyspnea
S/S of pulmonary or systemic congestion even in absence of weight gain
Major electrolyte disturbance
Associated co-morbid conditions
Symptoms suggestive of TIA or stroke
Repeated ICD firings
Previously undiagnosed HF with S/S of systemic or pulmonary congestion

94

Guiding the HF Patient out the Door

Near optimal volume
Stable after transition from IV to oral diuretics for 24 hours
Exacerbating factors addressed
LV EF documented
Near-optimal medical therapy
Patient & family education initiated
FU clinic visit scheduled within 7 days

95

Risk Factors for Highest Risk of Readmission

Advanced age
Co-morbidities: renal disease, DM2, COPD, HF severity, psychiatric disease, frailty
Low education/literacy levels
Prior admission for HF
Patient behaviors: lacking self-care skills, adherence issues, substance abuse
Not ready for discharge
Absence of family, friend, religious, social, & financial support & access to transportation

96

3 Phases of Progressive HF

Chronic disease management
Supportive & palliative care phase
Terminal care phase

97

Parts of Chronic Disease Management

Diagnosis
Focus on extended survival
Concurrent palliation of symptoms
Promoting self care

98

Parts of Supportive & Palliative Care Phase

Appropriate when patients require recurrent hospitalizations
Focus on promoting comfort & QOL
Palliation of symptoms & advanced care planning

99

Barriers to the Use of Palliative Care

Traditional model of medicine: cure & comfort are mutually exclusive
Proposed integrated model of palliative care

100

Define Hospice Care

A deploy of a team of doctors, nurses, chaplains, & social workers to help people with fatal illness to have the fullest possible lives now