Académique Documents
Professionnel Documents
Culture Documents
Learning Objectives
Following
It is an Epidemic
REACH Trial
Researchers
Controversial Definitions
Diastolic HF
Stages of Diastole
Patient Differences
HF
Body Compensatory
Mechanisms
Potential Reasons
Smoking
EtOH use
DM
HTN
Dyslipidemia
Thyroid disorder
Chemotherapy
Radiation
Cardiotoxic drugs
Fam Hx of sudden
death, CAD, conduction
problems, HCM
HIV status
Cardiovascular Medical Hx
Hx of heart failure
Angina
MI
CABG
PCI
Pacemaker/ICD
Embolic events
arrhythmias
CVA
PVD
Rheumatic Dx
Other valvular hx
Congenital
Dyspnea
PND
Orthopnea
Cough
Exercise intolerance
Edema
Fatigue
Nausea
Abdominal Fullness
Rales
S3
Pulmonary edema
JVD
Tachycardia
Cardiomegaly
Hepatojugular reflex
Peripheral Edema
Hepatomegaly
Examples
Elevated
ADHERE
ADHERE DATA
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 inhospital 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 ADHFspecific 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 <
0.001).
In-hospital mortality risk for the overall patient population was 3.6%. When
stratified by BNP level, there was a near linear relationship between BNP
quartiles and in-hospital mortality.
Overall, mortality risk varied more than three- to four-fold on the basis of
the patients initial BNP.
More Implications
Additional Signs
4. Confusion, impaired thinking
A. Changing levels of certain substances in
the blood, such as sodium, can
cause confusion..
a. memory loss and feelings of
disorientation. A caregiver or relative
may notice this first.
Physical Examination
1.
2.
3.
4.
5.
6.
7.
8.
Limitation of ADLs
Adults,
4.
Individual Patients HF
5.
6.
7.
Non-Pharmacologic Tx
Management/Treatment
Pharmacotherapy
A. Loop diuretics [furosemide (THRESHOLD
DRUG), bumentanide, torsemide] to treat
volume overload may add metolazone to any
NO EFFECT ON MORTALITY
B. Management of systolic dysfunction with an
ACE inhibitor like captopril, lisinopril
1. Main side effects cough,
hyperkalemia, angioedema, orthostasis
Management/Treatment
C.
D.
E.
F.
G.
All patients with systolic heart failure should be on ACE-I and blockers unless contraindications are present (ARBs can substitute if
there is intolerance to these drug classes, i.e.: ARBs can be used in
combination with ACE-I or with blockers).
Concerns about blood pressure may occur as these drugs are titrated
upwards limitations should relate to symptoms of low BP rather than
actual BP values (for systolic BP above 80 mm Hg) so persistence with
the titration should occur unless such symptoms occur. Concerns about
renal function may occur as these drugs are titrated upwards.
Electrolytes
Please
Role of RAS in HF
Role of ACE-I
ARBs
Angiotensin
Many
ARB Data
Val-heFT
CHARM
COMET IMPLICATIONS
The Carvedilol Or Metoprolol European Trial (COMET) study randomized more than 3,000
subjects with mild to severe heart failure (ejection fraction <35%) to either carvedilol 3.125
mg twice a day or metoprolol tartrate 5 mg twice a day. Study treatment doses were
doubled every 2 weeks until the target dose of carvedilol, 25 mg twice a day, or
metoprolol, 50 mg twice a day, was reached.
Patients were followed for 58 months for vascular endpoints including cardiovascular
death, stroke, stroke death, myocardial infarction (MI), and unstable angina. Carvedilol
reduced the likelihood of death by 20%.
Remme and colleagues also found that carvedilol resulted in improved hazard ratios
(HRs) for MI (0.71), stroke (0.79), and fatal stroke or fatal MI (0.46). This study suggests
that the full adrenergic blockade of carvedilol and its antioxidative effects may lead to
improved vascular protection relative to beta-1 blockade alone.
Tolvaptan
EVEREST
Efficacy
Tolvaptan continued
TOLVAPTAN
Device Therapy
What is an ICD
Laymens
definition:
The abbreviation for automatic internal cardiac
defibrillator, an amazing device that is often
implanted in individuals suffering from Iifethreatening disordered heart beating. The
AICD device is able to deliver a jolt of
electricity to an abnormally beating heart; the
shock restores normal orderly heart beating.
Thus, on its own, this device is able to ward
off sudden death.
Dyssynchrony
ICD Support
Evidence
Inpatient Vs Outpatient
Management
Nesiritide
Definition of Stage
Usual Therapies
Exercise regularly
Quit smoking
Treat hypertension
Treat lipid disorders
Discourage alcohol or illicit drug use
If previous heart attack or current diabetes mellitus or
hypertension angiotensin converting enzyme inhibitor
(ACE-I)
Stage
Stage A
Stage B
Stage C
Stage D
Interdisciplinary Interventions
Implementation
Protocol
Medical
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
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
Hospital Readmissions
Of
Citations
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 InHospital 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