CCS Heart Failure Guidelines: Practical Implementation October 2014
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Overview • Who is this document primarily intended to reach? What is the format? • How soon should I see a newly referred heart failure patient? • How often should my heart failure patient be seen? • Who can I discharge from my heart failure clinic? • How quickly and in what order should standard heart failure therapy be titrated for most patients? • When should I measure electrolytes, serum Creatinine and BUN? • How should I manage hyper or hypokalemia in my patients? • I know I should get a baseline measure of left ventricular ejection fraction- but should I measure it again? If so, when should it be measured? • Can heart failure medications ever be stopped? If so, then when? • How should I manage an acute episode of gout? • In what ways do I care differently for frail elderly patients with heart failure? • How do I teach self care to my patients? Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Self-care Tips Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Case Study • Mr. M. • 71 year old man with an ischemic cardiomyopathy. NYHA III, LVEF 30%. • COPD, diabetes, chronic renal failure, atrial fibrillation • Takes 12 different types of medications daily (blister pack) • Lives alone in an apartment- “lady friend nearby” • 4 admissions for heart failure in the past year Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Nobody Ever Told Me… Excerpts from patient (Mr. M)’s chart: July - ER with worsening SOB and orthopnea August - ER with increasing SOB September - 1 week follow up appointment post hospital discharge Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Self-care Maintenance Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Self-care Monitoring and Management Are my symptoms different today? Was that a good decision? Do I feel better? What should I do to relieve my symptoms? Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines I wonder why my symptoms changed? Do I need to do anything about my symptoms?
Self-care Strategies Patients define self-care not only by the actual performance of tasks but also by the emotional reactions and strategies necessary for learning how to adapt to living with HF. Self-care is a process of learning, and self-care activities are often intentional, planned, and built on previous experiences. Individualized approaches that emphasize how to self-care must be adopted for patients to develop the necessary HF self-care skills. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Harkness et al. , 2014 J. Cardiovasc Nurs
“Lay Clinical Trials”: Expert Approach One patient described her strategy to improve her tolerance to a medication based on a past experience of symptomatic hypotension that prevented her from going to work. She stopped the medication for a few days, reintroduced the medication at 1/2 the prescribed dose and then slowly titrated the medication depending on how she felt getting out of bed in the morning. At the same time, she did not report this to her physician and actually ‘‘lied to him about the dose’’ she was taking, as she was too embarrassed to disclose her own approach to titrating the medication. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca 38(p 109) Glassman KS. Older Persons’ Experience of Managing Medication: The Myth of Compliance [dissertation] 2007 in Harkness et al. , J Cardiovasc Nurs 2014 Heart Failure Guidelines
“Lay Clinical Trials”: Good Intentions • Increasing fluid intake to ‘flush out the system’ to increase diuresis and improve symptoms • Choosing Kentucky Fried Chicken rather than Swiss Chalet when dining out (Swiss Chalet worsens edema) “I thought I was doing the right thing trying to lose weight, had no idea I was making my heart problem worse” Woman trying to lose weight and switched to low fat frozen dinners - but high in sodium Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Gary R. Heart Lung. 2006; Harkness et al. , J Cardiovasc Nurs 2014
Past Experience “I don’t take my Lasix when I am going out somewhere, I can’t always get to a bathroom quick enough. I had an accident when I was out a few months ago and I was so embarrassed I could have died. ’’ “My weight just kept going up - I knew if I gained weight I would need to go back to the hospital. So I just stopped checking my weight. ” The “catch 22’. She was afraid to call for help, based on past experiences, that she would call too soon, and so tended to wait until a crisis to ask for help. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Clark et al. , Int J Nurs Studies 2012; Harkness et al. , J Cardiovasc Nurs 2014
Self-care Tips § Understand patient and caregiver beliefs about HF and its self-care, their expectations and aspirations for daily life § Harness cues in patients’ home environments and routines to increase adherence patterns § Plan ahead using a problem-solving approach that for supporting self -care when usual activities are altered § Involve caregivers - key source of support Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Strachan et al. , J Cardiac Fail, 2014; Clark et al. , BMJ, 2014
Self-care Tips § Personalize Signs and Symptoms- How do you know if you are starting to retain fluid? § Expect a large variety of vague descriptions from patients/family caregivers. § Highlight signs or symptoms that reflect HF decompensation. § Help clarify signs and symptoms that are probably not related to HF. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Self-care Tips § Try to determine the trigger with the patient/family. § Through story telling - pick out the details that seem relevant to heart failure. § Problem solving and experiential learning versus determining blame to help prevent feelings of guilt. § Watch for “unintentional non-adherence” e. g. Restaurant food, holidays, over-the-counter-medications. § Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Nobody Ever Told Me… “Teach back” technique I want to make sure I explained this in a way you could understand… Can you tell me… So when you go home to your (family)… how are you going to explain… Sometimes the information is not clear to the patient, not 'clicking' with them, ensure they understand what it is you are explaining. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines White et al. , J Cardiovasc Nurs. 2013
Difficulty with Self-care Some self-care challenges/misunderstandings are the result of minor cognitive impairment; consider administering a Mo. CA test Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Summary • Self-care is a skill and needs practice and learning over time. • Do not expect HF patients to ‘catch on’ to all the necessary instructions without repetition and reinforcement. • Teach back techniques help ensure understanding. • Involvement of family member/caregiver is often necessary. • ‘Non-adherence’ may be unintentional and represent difficulty with the level of complexity associated with self-care. • Consider formal screening for underlying depression or subtle cognitive impairment in patient who have ongoing challenges with self-care. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Summary “People don't care how much you know until they know how much you care” Theodore Roosevelt “They listen… like my input… I feel so much better. They don’t argue with me… respect me as a person. That is really, really important to me… they are interested in me” Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Currie et al. , Eur J Cardiovasc Nurs, 2014
Medications Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Objectives • To highlight the importance of evidence-based medications (EBM) in the treatment of HF • To describe issues relating to the sub-optimal use of medication in the treatment of heart failure • To describe tools that are available to help front-line practitioners manage medications in patients with HF Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
HF Management Medications Multidisciplinary team Risk factor modification Device therapy Procedures Self-care Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Incremental benefit in HF treatment Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines J Am Heart Assoc 2012; 1: 16 -26
Medications in HF: Patients “Medications don’t work in patients who don’t take them” - C. Everett Koop Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Medications in HF: Providers Medications don’t work in patients: whose Health Care Professionals don’t prescribe them whose HCP don’t prescribe them optimally whose HCP don’t prescribe them safely Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Medications in HF 50 -90% HCP Prescribes 40 -60% Patient Persistence 40 -80% Effectiveness of EBM HF Medications Patient Adherence Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines HCP Optimizes HCP Monitors 30 -70% ? Circ 2012; 122: 585 -96 Circ 2007; 116: 737 -44 Circ Heart Fail 2013; 6: 68 -75 Congest Heart Fail 2012; 18: 9 -17 Arch Intern Med 2012; 172: 1263 -65
EBM Use: Cardiology Clinics IMPROVE HF n = 34, 810 ACEI/ARB = 80% β-blocker = 86% MRA = 34. 5% Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Circ 2010; 122: 585 -96
Dose Optimization: IMPROVE HF Figure 2. Absolute (AI) and relative improvement (RI) in the percentage of treated patients with dosing recorded who received target doses of angiotensin-converting enzyme (ACE) inhibitors/angiotensin baseline and 24 months post-intervention for the 24 -month follow-up cohort. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Congest Heart Fail 2012; 18: 9 -17
EBM: Dose matters ACEI ARB Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Arch Intern Med 2012; 172: 1263 -65
EBM: Optimization Multidisciplinary heart failure clinics improve outcome in patients with HF. What components of these specialized clinics are most beneficial? Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Circ Heart Fail 2013; 6: 68 -75
Clinic Components Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
EBM: Right patient for the right drug Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Patient selection and follow-up are important Hospital admissions: hyperkalemia In-hospital deaths associated with hyperkalemia Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines 3 X 3 X N Engl J Med 2004; 351: 543 -51
It’s complicated Right drug? Right dose? Right follow-up? Right patient? Right monitoring? How do you choose? Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Practical tools App specifically focused on medications Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Case: Mrs. Tetley Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mrs. Tetley • ID: 85 yr female referred from GP for new onset HF • HPI: 3/12 progressive SOBOE, 2+bilateral pitting edema, nocturnal cough, 2 pillow orthopnea. GP started furosemide 2 weeks ago; SOBOE improved and orthopnea resolved. • PMHx: – – – HTN (x 30 years, well controlled) DM (x 15 years, diet controlled) Atrial fibrillation (x 5 years) GERD/PUD (UGIB x 3 years ago) OA Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mrs. Tetley Medications HF Furosemide 40 mg daily (started 2 weeks ago) HTN HCTZ 25 mg daily Potassium chloride 20 MEq daily Amlodipine 5 mg daily ECASA 81 mg daily DM Diet controlled Rosuvastatin 10 mg daily Atrial Fibrillation Metoprolol 25 mg BID Dabigatran 150 mg BID GERD/PUD Pantoprazole 40 mg daily OA OTC: Naproxen 220 mg daily Vitamin D 2000 IU daily, Calcium 1500 mg daily, multivitamin daily, Vitamin E 800 IU daily, Vitamin C 1000 mg daily, Vitamin B Complex 50 mcg daily Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mrs. Tetley • Investigations: – Echo: LV dilation, dilated LA, EF = 40%, diastolic dysfunction, aortic sclerosis – MIBI: normal perfusion – ECG: atrial fibrillation, HR = 68 bpm – CXR: mild pulmonary edema – Labs: Scr = 100 umol/L; K = 4. 8 mmol/L; Na = 135 mmol/L • Weight = 40 kg • BP = 114/68 mm. Hg sitting; 110/60 standing • CVS Exam = JVP 5 cm ASA; Bilateral crackles; II/IV MSM; 2+bilateral pitting edema to mid-shin Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mrs. Tetley • Plan: – Furosemide: • A) increase • B) decrease • C) maintain – Metoprolol: • • – ACEI: • A) yes • B) no – Other meds: A) increase B) decrease C) maintain D) discontinue Overall thoughts: Complex case with the opportunity to simplify her regimen outside of her HF medications Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines • • A) stop amlodipine B) stop HCTZ C) stop potassium D) stop ASA E) stop vitamins F) stop naproxen G) all the above S I M P L I F Y
Mrs. Tetley • Would your plan change with: – Baseline Scr = 40 umol/L = Cr. Cl 68 ml/min – Current Scr = 100 umol/L = Cr. Cl 27 ml/min a) b) Yes No Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mrs. Tetley • Would your plan change with: – Baseline K = 3. 2 mmol/L – Current K = 4. 8 mmol/L a) b) Yes No Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
The app will warn you if the drug you selected has a potential contraindication to therapy Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mrs. Tetley • Mrs. Tetley is followed up via telephone 1 week later – Furosemide and metoprolol were maintained and ramipril 1. 25 mg BID was started; other medications were streamlined – She reports feeling better, but still has some SOBOE and mild peripheral edema – Blood work done the day prior reveals: • SCr = 101 umol/L (was 100 umol/L) • K = 5. 5 mmol/L (was 4. 8 umol/L) • Plan: – A) Hold ACEI, repeat BW in 3 -5 days – B) Hold ACEI and give sodium polysterene (Kayexalate®), repeat BW in 2 days – C) Assess dietary intake, ensure K+ supplement was discontinued, repeat BW in 5 -7 days Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Key Points • Evidence-based medications (EBM) are a major cornerstone in HF treatment • Poor CV outcomes in HF are correlated to – Underutilization of EBM – Poor optimization of EBM – Patient non-adherence and non-persistence to EBM • Under-intensification of EBM is common and results in poorer outcomes • Clinical tools exist to help improve the application of EBM in HF to front -line practitioners. For example the app can form the underpinning of a collaborative practice arrangement between nurses/physicians/pharmacists. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Timing of Visits and Whether to Stop Medications Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
36 Year Old Female • Diagnosed with pre-ecclampsia at 24 weeks • Progressive edema • Dyspnea noted, thought to be ‘normal’ and told to ‘suck it up’ • Went into labour at 34 weeks – Pulmonary edema day 2 post natal – Nearly intubated Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mrs. Doe • ECHO: LV 57 mm (EDD), EF 18%, moderate MR • She was treated with vasodilators and diuretics • Improved • ACE and BB started – Tolerated, titrated • Clinical improvement over 12 -14 weeks Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Peripartum Cardiomyopathy Incidence • Varies widely geographically, ranging – United States : 1/2289 -1/4000 live births, – to 1/300 live births in Haiti 99. We are seeing a lot more cases like Mrs. Doe, than true incidences of peripartum cardiomyopathy due to: more non-Caucasians, more obesity, and increased hypertension in pregnancy Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
How soon should I see HF patients? Triage category Access target Emergent < 24 hours Clinical scenarios Acute severe myocarditis Cardiogenic shock Transplant and device evaluation of unstable patients Post hospitalization or ER visit for HF HF with severe valvular heart disease New diagnosis of HF, stable, compensated NYHA III, AHA/ACC stage C Chronic HF disease management, NYHA II <6 weeks Post myocardial infarction HF Scheduled New progression to NYHA IV, AHA/ACC stage D < 4 weeks New diagnosis of HF, unstable, decompensated Semi urgent Progressive HF / decompensated HF < 2 weeks Urgent New-onset acute pulmonary edema NYHA I, AHA/ACC stage B <12 weeks Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
How often should my HF patient be seen? Risk group Low risk Features defining risk of group NYHA Class I or II; No hospitalizations in past year; No recent changes in medications; On all optimal medical HF therapies Intermediate No clear features of high or low risk. High risk NYHA IIIb or IV symptoms, frequent symptomatic hypotension, more than 1 HF admission (or need for outpatient intravenous therapy) in past year, recent HF hospitalization esp. in past month, rising creatinine, especially e. GFR < 30 ml/min, Non-adherence to therapy for any reason; During titration of HF medications (ACEi/BB/ARB/MRA); New onset heart failure; Complication of HF therapy; Need to downtitrate or discontinue beta-blockers or ACE/ARB ; Concomitant and active illness (i. e. high grade angina, severe COPD, frailty); frequent ICD firings (1 month) Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Suggested frequency of follow-up* At least yearly (90% suggested within 12 months, 50% within 6 months) In certain cases, may consider discharge of patient from clinic to specialist office (in addition to primary care). 1 -6 months Minimum 1 -2 visit per month In some cases, there may be weekly assessments or even more frequent- especially if patient willing to undergo multiple visits to potentially avoid a hospitalization.
When should I get another EF Measurement? Clinical Scenario Timing of measurement New Onset Heart Failure Immediately or within 2 weeks for baseline assessment Modality of Measurement ECHO (preferred when available); or MUGA or CMRI Comments 70% request ECHO and 30% MUGA, report should include numeric EF or small range of EF as well as diastolic function evaluation Following titration of 3 months after completion ECHO or MUGA or CMR LVEF following optimal triple therapy for HFr. EF, of titration (preferably the same medical therapy may or consideration of modality and lab as initial obviate device therapy. ICD/CRT implantation test) Stable Heart Failure Approximately every 2 -3 ECHO or MUGA or CMRI Rationale is to screen for years, especially if EF is those who may cross above 40% from HFr. EF to HFp. EF and vice versa, which may change therapeutic goals Following significant Within 30 days, during ECHO or MUGA or CMRI, Frequently helpful clinical event (i. e. hospitalization if possible. cardiac catheterization in information such as EF, hospitalization for HF) context of ACS degree of valvular dysfunction and RVSP. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Ejection fractions do not remain the same foreverthey will change over time, thus should be checked periodically (or at least thought about) as there is no predefined schedule for EF measurement Circ Heart Fail. 2012; 5: 720 -726 Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mrs. Doe Follow Up • Now asymptomatic • Diuretic stopped due to hypovolemia • Repeat ECHO EF 54% – LV EDD 48 mm – No MR – Normal RVSP est but only trivial TR Because she is asymptomatic, she starts ‘playing’ with her drugs, and questions whether she could go off them completely. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Now she wants to stop her HF meds • Yes or no? • If so, which ones? If EF goes above 40, good prognosis. Thus, for certain conditions you may be able to stop/discontinue medications if EF returns to normal, or above 40% (refer to following 2 slides). Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Maternal Complications Associated With Subsequent Pregnancy* % 44% % 31% % 25% 21% 19% % 14% % 0% % *including aborted pregnancies A B HF Symptoms Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca A B >20% Decreased LVEF Heart Failure Guidelines A B >20% Decreased LVEF at F/U A B Maternal Mortality
Contractile Reserve in Patients With Peripartum Cardiomyopathy and Recovered Left Ventricular Function Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Lampert et al. AM J Ob Gyn 1997; 176: 189
Who can I discharge from my HF clinic? • Stable NYHA I or II for 6 -12 months • On optimal devices and pharmacological therapies • Stable adherence to optimal HF therapy • No hospitalizations for > 1 year • LVEF > 35% (consistently shown if more than one recent EF measurement) • Reversible causes of HF Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Case • 74 yo male with 10 year hx DCM (normal coronaries), followed in HF clinic • ICD inserted 6 years ago • Has done very well since you have seen him Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Case • Perindopril 8 mg OD • Digoxin 0. 125 mg OD • Carvedilol 25 mg BID • Spironolactone 25 mg OD • Lasix 40 mg OD- patient has not been taking it Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Case • BP 120/70, HR 60 reg • JVP ASA, - AJR • HS: S 1, S 2, no murmurs, no rub • 1+ pretibial edema bilaterally • No palpable organomegaly • Chest: clear • NT-pro. BNP 810, reasonably well controlled Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Case • Hb 128, WBC 6. 5 (n diff) • Na 139, K 4. 7, creat 100 • LVEF 54% and LVID 55 mm – Had been 23% and 64 mm 3 years ago Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Would you stop his medications? • Yes • No • It depends Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Would you replace his ICD? • • Yes No Leave it to EP Depends Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Can HF Meds be stopped? Clinical Presentation Conditions to justify withdrawal of TT after 6 -12 months of therapy Tachycardia 1) Normal EF related 2) NYHA FC I cardiomyopathy 3) Underlying tachycardia controlled Alcoholic 1) Normal EF Cardiomyopathy: 2) NYHA FC I 3) Abstinence ETOH Chemotherapy related CM Peripartum Cardiomyopathy Valve replacement surgery 1) Normal EF 2) NYHA FC I 3) No further drug exposure 1) 2) 3) Normal EF NYHA FC I Normalization of EF NYHA FC I Normally functioning valve Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines Comments Usually due to atrial fibrillation/flutter with increase HR, may rarely occur due to PVCs. May need BB for rate control Nutritional deficiency may coexist. May need control of obesity and obstructive sleep apnea Certain types of chemo (trastuzamab - high rate of improvement one it is stopped) are more likely to reverse than others (anthracyclines for which therapy should be continued). Long-term surveillance strongly recommended Repeat pregnancy may be possible for some(REF 2009); (silversides). Consultation at high-risk maternal centre should be undertaken. Less consensus on regurgitant lesions with ongoing dilation of LV
What is the evidence for drug withdrawal in HF? • Almost nil for ACE (however symptoms may return in majority of cases) • Few studies of BB (show development of symptoms, and recurrence of phenotypic HF syndrome) – Several case series of up to 60 patients – No controls – No ‘denominator’ • Largest Trial Waagstein 24 pts withdrawal – 66% deteriorated, 4 died • Morimoto- Japan- 13 patients – 7 deteriorated, 4 died • Swedberg, initial paper in 15 DCM – 40% worsened • When deterioration occurred, it did so within a few months Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Consort Diagram Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Withdrawal of agents • ACE inhibitors – Clinical worsening in 70% – Minor change in EF – Exception seems to be in renal dysfunction • Beta Blockers – In both NICM and ICM – Odds ratio of return of HF 26 in one study if BB stopped – About 70% chance of lower EF, often with symptoms • MRA: – No real data • Diuretics – Increased likelihood of return of symptoms • PPCM – Low incidence of HF if EF returned to normal Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
39 year old male • Seen last year with A Flutter and LVEF 22% – Was drinking heavily at time and was hypertensive • Cardioverted and in NSR since then • Now LVEF on ACE and BB and OAC is 60% • Asymptomatic Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Do you stop his medications? • Yes • No • Depends Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Tachycardia-Induced Cardiomyopathy • Caused by persistent supraventricular or ventricular arrhythmias, especially atrial fibrillation, atrial flutter, atrial tachycardia, junctional tachycardia, ventricular tachycardia • May occur at any age • Should be suspected when LV dysfunction (with or without typical HF signs/symptoms) occurs with a persistent, inappropriate tachycardia or tachyarrhythmia, without another identified cause • Important to exclude inadequately treated HF and other conditions that may produce a persistent tachycardia Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008; 24(1): 21 -40. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Follow up • Patient still drinking 2 drinks per day (what he admits to) • Patient has gained 30 lbs (salesman, travel) and BP is elevated 150/94 • Patients has developed diabetes during the past year Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Alcohol-Induced Cardiomyopathy • Alcohol consumption is a major risk factor for dilated cardiomyopathy Recommendation • Permanent abstention from alcohol must be recommended and reinforced (refer to a counselling program if necessary) in patients diagnosed with an alcohol-related cardiomyopathy (Class I, Level C) Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008; 24(1): 21 -40. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mrs. PP • 60 year old female presented 1 year ago with breat cancer, HER + • Underwent FAC and Trastuzamab therapy for 6 months • 9 month EF showed EF 60 to 44% • Trastuzamab stopped • Progressive heart failure 3 months later • Placed on Ace and BB and diuretic and Trastuzamab stopped Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Questions (Y or N) • Would you stop trastuzamab for good? • When would you re-check LVEF? Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Further Follow-up • 3 months later LVEF is 55% on therapy • Do you stop therapy? – Why or why not? • How long would you follow if EF stayed normal? Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Chemotherapy-Induced Cardiomyopathy • Most common and severe with anthracyclines and herceptin Recommendations • Patients receiving known cardiotoxic agents for cancer should be carefully monitored during and after therapy. If LV function deteriorates, they should be aggressively treated with beta-blockers and other standard therapies for HF (Class IIa, Level B) • In patients with a history of chemotherapy-induced cardiomyopathy or HF, other cancer treatment options should be considered (Class IIa, Level B) Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008; 24(1): 21 -40. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Additional Case Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Case study: Mr. CC • 62 year old man- presents to ER: 4 week history of increasing SOB, 3 pillow orthopnea, PND. • PMHx- viral cardiomyopathy (8 years ago). • EF 35%, NYHA class I symptoms (until recently) • Hypertension, family history CAD, non-smoker, rare ETOH, no diabetes, lipids normal. • Normal coronaries – coronary angiogram 8 years ago • Medications: Ramipril 12. 5 mg daily, metoprolol 25 mg BID (not taking these for a few months- they make him “itchy and give him a cough”) Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mr. CC: findings • Weight: 103. 7 Kg • bp 159/96 mm Hg • ECG: Sinus rhythm- 80 bpm (narrow QRS) • Lab: Creatinine 110 umol/L, urea 9. 2 mmol/L, K+4. 3 mmol/L, Na+140 mmol/L • CXR: mild pulmonary edema • Echo: global hypokinesis, EF 15%, no significant valvular abnormalities, RVSP 54 mm Hg. Dilated LA, RA, LV. 1. 2. 3. 4. How would you optimize the pharmacological management for this patient? Does he need to be followed in a heart function clinic? How do you work through adherence issues? Does he need an ICD? Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Mr. CC: 2 years later Progress over next 2 years: Followed in HFC- optimization No hospitalizations NYHA Class I within 6 months Medications Atacand 32 mg OD Coreg 37. 5 mg BID Lasix 40 mg prn- rarely uses • Optimized medications Norvasc 2. 5 mg OD • Working through challenges with adherence Pradaxa 110 mg BID * trust, negotiation • Sleep clinic assessment • Developed atrial fibrillation • No ICD Weight: 100 Kg. BP 124/82 mm Hg, ECG- Afib 72 bpm. Echo: global HK- EF 35 -40%. No valvular abnormalities, RVSP <35 mm. Hg RNA- EF 34% Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Case Summary • 78 year old lady with a history of mildly obstructive cardiomyopathy for the past 30 years • Very stable on diltiazem 180 mg daily • Lives with husband used to walk everyday • No history of CAD • Over the past 2 years, developed shortness of breath on exertion and palpitations, also presents occasional dizziness • Referred for evaluation at CHF clinic • PEx: JVP 15, irregular HR 80/ min, loud systolic murmur of aortic stenosis, no S 3, mild hepatomegaly and no pedal edema. • ECG Afib and LVH • Echo small LV with asymmetric hypertrophy and normal LVEF • Severe calcified aortic stenosis Grad 80/45 with very small LVOT, very calcified mitral annulus with 20/10 gradients and severe LA dilatation • No significant MR • Moderate TR with PA pressure 50 mm. Hg +JVP Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
What is your plan? A. Anticoagulation and cardioversion B. Diuretics C. Change cardizem for B blocker D. Cardiac cath with intended surgery E. Keep in CHF clinic Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
Looking for best practices in heart failure diagnosis and management? To access this tool, and to view all of our guideline resources, please visit www. ccs. ca. Moe GW, Ezekowitz JA et al. , Can J Cardiol www. ccs. ca Heart Failure Guidelines
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