Heart Failure in Primary, CVD Lecture PDF

Part 7: Cardiovascular Disease: Heart Failure in Primary Definition of Heart Failure A complex clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to FILL with blood or EJECT blood. (Yancy, et al., 2013) Left Ventricular Ejec...

Part 7: Cardiovascular Disease: Heart Failure in Primary Definition of Heart Failure A complex clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to FILL with blood or EJECT blood. (Yancy, et al., 2013) Left Ventricular Ejection Fraction (LVEF) A measure of how well the Heart is Pumping It is the percentage of blood volume ejected with each contraction Normal is > 55%  HFpEF vs HFrEF Diastolic Failure ~ Heart Failure with Preserved Ejection Fraction (HFpEF) result of the inability of the heart to relax and FILL with blood. (EF > 45%- 50%) Systolic Failure ~ Heart Failure with Reduced Ejection Fraction (HFrEF) result of the inability of the heart to EJECT blood. (EF≤ 40% ) Heidenreich P, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022 May, 79 (17) e263–e421.https://doi.org/10.1016/j.jacc.2021.12.012 Risk factors for HFpEF HYPERTENSION (with prevalence of 60-89%) Obesity Diabetes Atrial fibrillation Hyperlipidemia Older age OSA Risk Factors for HFrEF HTN Diabetes Metabolic syndrome Atherosclerotic disease Valve disease Dilated cardiomyopathy HF: Key Findings for Diagnosis ► Family history 1st degree relatives with heart failure ► Social history (drugs ETOH) ► PMH (who is at risk) ► SCD in family < 55 male < 65 female ► Signs and Symptoms. ► Elevated BNP ► LVEF < 40 % on Echocardiogram of MUGA scan HFrEF is LVEF ≤ 40-45% ► LVEF > 40-45% and presence of HF symptoms = HFpEF Common Symptoms of HF Dyspnea at Rest Dyspnea on Exertion Reduction in Exercise Capacity Orthopnea PND Edema Ascites Scrotal Edema Less Common Symptoms of HF Wheezing or cough Confusion/Delirium Depression/ weakness (esp in elderly Unexplained fatigue GI symptoms Early satiety Nausea and vomiting Abdominal discomfort  Symptoms of HF Dyspnea at Rest Wheezing or cough Dyspnea on Exertion Confusion/Delirium Reduction in Exercise Capacity Depression/ weakness (esp in Progressive weight gain elderly) Orthopnea Unexplained fatigue PND GI symptoms Early satiety LE Edema Nausea and vomiting Ascites Abdominal discomfort Scrotal Edema  Sorting through the Symptoms “Right Sided “Left Sided Signs and Symptoms” Symptoms” Edema DOE Early satiety PND Increased abdominal Orthopnea Dyspnea girth. Fatigue Ascites Sleep Abdominal disturbance pain (RUQ) Pleural Nausea Effusions Anorexia Abdominal Wheezing Rhonchi bloating Constipation Hepato- Congestion  Physical Exam Key components for the Heart Failure patient Vital signs (HR and B/P) Electrolytes Renal function Cardiac rhythm Neck vein assessment Pulmonary Exam Cardiac Exam Abdominal exam Extremities HF: Key Findings for Diagnosis ► Family history 1st degree relatives with heart failure ► Social history (drugs ETOH) ► PMH (who is at risk) ► SCD in family < 55 male < 65 female ► Signs and Symptoms. ► Elevated BNP ► LVEF < 40 % on Echocardiogram of MUGA scan HFrEF is LVEF ≤ 40-45% ► LVEF > 40-45% and presence of HF symptoms = HFpEF  Wet vs Dry T This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY- SA  Signs and Symptoms of HF volume excess low cardiac output HX: Decreased exercise tolerance Decreased exercise tolerance SOB- orthopnea Fatigue DOE Malaise PND Decreased appetite Edema Weight loss RUQ tenderness GI discomfort PE: Rales Cachexia Increased JVP Muscle loss Hepatojugular Cool extremities reflex/tenderness Tachycardia Edema S3 S3 Changes in body weight OBJ: Decreased peak VO2 Elevated PCWP, RA Decreased CO/CI Decreased Cardiac output Narrow pulse pressure (< 25%) Elevated BNP levels Renal dysfunction Differentials Differential Diagnoses for HF Signs and Symptoms Myocardial ischemia Pulmonary disease Sleep disordered breathing Obesity Deconditioning Malnutrition Anemia  Hepatic Failure Chronic Kidney Disease Venous Stasis Depression Anxiety and hyperventilation syndromes Hyper/Hypo thyroidism HF: Diagnostic Testing ► ECG ► 6 min hall walk ► Echocardiogram (TTE) ► Rule out ischemic disease ► Rule out OSA ► LHC~Left heart catherization ► RHC~Right heart Catherization ► Lab findings: BNP ► Routine labs ~BMP after adjustments made in diuretics, ACE/ARB, Aldosterone Antagonist ECHOCARDIOGRAM It is the single most useful diagnostic test in the evaluation of heart failure. More information is probably gained by echocardiography of the heart failure patient than any other test available. Transitioning from Hospital to Home Follow up phone call with 72 hours of hospital discharge Improves outcomes Billable via Transitional Care Management Services CPT code 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure Steven M. Hollenberg, Lynne Warner Stevenson, Tariq Ahmad, Vaibhav J. Amin, Biykem Bozkurt, Javed Butler, Leslie L. Davis, Mark H. Drazner, James N. Kirkpatrick, Pamela N. Peterson, Brent N. Reed, Christopher L. Roy, Alan B. Storrow J Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011 Image source: Hollenberg, Stevenson, Ahmad, Bozkkurt, Butler, Davis, et al. J Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011 Transitioning from Hospital to Home First post-discharge visit checklist History Exam Testing Medication Therapy Considerations Patient Education Consultations Image source: Hollenberg, Stevenson, Ahmad, Bozkkurt, Butler, Davis, et al. J Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011 Transitioning from Hospital to Home Transitional Care Management Services CPT Code 99495: Moderate Complexity Communication within 2 business days of discharge Moderate complexity medical decision making Face to face visit within 14 days of discharge CPT Code 99496: High Complexity Communication within 2 business days of discharge High complexity medical decision making Face to face visit within 7 days of discharge Getty Images / fcscafeine Co-Managing Heart Failure in Primary Care Partner with local heart specialist or cardiologist. Get to know the hospitalists team that takes care of the HF pts in local hospital. Connect with community resources such as home health, medication delivery services. Communicate any medications changes to the cardiologist or concerns for disease progression. Knowing when to refer for advanced care. Treatment of HF Guideline Directed Medical Therapy (GDMT) ACE-I or ARB or ARNI Beta blocker (metoprolol XL, carvediolol, bisoprolol) Aldosterone antagonist Hydralazine/Isosorbide (for AA and those who cannot tolerate ACE- I/ARB) These all have mortality benefit proven with Large RCTs. AND NOW SGLT2 inhibitors GDMT (cont) Loop Diuretics for volume overload Potassium supplements if needed for loop diuretics Digoxin if symptomatic helps keep out of hospital Thiazide diuretics can be added as boosters to Loop diuretics (will see this sometimes) These are all for symptomatic treatment HF: Medical Management ► Ace-I/ARB/ARNI’s: Lisinopril (any ACE-I /any ARB/Valsartan/sacubitril- valsartan **** NOT ALL THREE**** Pick one ► SGLT2i: Dapagliflozin (Farxgia) or Empagliflozin (Jardiance) ► Beta Blockers: Bisoprolol, carvedilol, Metoprolol XL ► Aldosterone antagonists: Spironolactone or Epleranone ► Hydralazine/Isosorbide: Brand__ Bidil ► Diuretics: See next slide ► Potassium supplement if needed ► Digoxin (very small dose) ► Amiodarone possibly for ant-arrhythmic HF: When to Refer ► New onset with moderate-severe symptoms ► All HFr EF would benefit from seeing a heart failure specialist as a consultation at least once for their input ► Unclear etiology ► Frequent readmissions for heart failure ► Renal impairment ► Chronic daily disease management is needed ► Not responding to treatment I-NEED-HELP (Yancy, et al., 2018) I: IV inotropes N: NYHA IIIB/IV or persistently elevated natriuretic peptides E: End-organ dysfunction E: Ejection fraction < 35% H: Hospitalized > 1 E: Edema despite escalating diuretics L: Low blood pressure, High heart rate P: Prognostic medication-progressive intolerance or down-titration of GDMT  HFpEF Clinical Pearls Management of Management of Management of Co- hypertension fluid Morbidities Labs: Assess Socioeconomic BNP NOT always Factors elevated w/ HFpEF and or Obesity  HFrEF Clinical Pearls When Dry increase When Wet increase 36 hour wash out Beta blocker ACE/ARB/ARNI changing from ACE (if HR & B/P allow) ( if B/P & Lab allow) to ARNI Higher Creatine Furosemide 80mg = Torsemide 20mg = Higher Diuretic Bumetanide 2mg Dose (Furosemide 80mg give KCL 20meq)  REFERENCES Not in alphabetical order….. N6030 Arnett, D. 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