Mechanisms Venous Congestion CVP RAP CO IVS to LV side Renal vein pressure Filtration fraction Perfusion GFR Heart Failure Guidelines
Increased CVP, renal function and mortality Heart Failure Guidelines Dammen W, et al. J Am Coll Cardiol. 2009;53:582 – 88
Impact of Venous Congestion on Glomerular Net Filtration Pressure Heart Failure Guidelines Jessup M, et al. J Am Coll Cardiol 2009; 53:597-9
Case: Resolution • Increased dose of metolazone, furosemide infusion started for 2 days • JVP declined, wt. 6 kg, no more crackles, minimal peripheral edema • Labs: – Cr decreased from 313 to 198 mol/L – NT-proBNP decreased from 9458 to 4600 pg/mL Heart Failure Guidelines
Cardiorenal Syndrome Recommendation We recommend that patients with the CRS should be managed by a multispecialty team with experience and expertise. (Strong Recommendation, Low-Quality Evidence). Heart Failure Guidelines
Cardiorenal Syndrome Practical tip Careful assessment of all clinical indicators of fluid status is mandatory as changes in body weight may relate to changes in concurrent changes in fluid status or to muscle or fat content. When evaluating patients, attention should be paid to the evolution of symptoms, renal function, body weight, and fluid status to aid management. Overaggressive fluid removal should be avoided, especially in advanced biventricular HF and severe chronic kidney disease. Heart Failure Guidelines
What is the reason for the rising serum creatinine during Rx for HF following admission? 1. Low cardiac output, cardiogenic shock? “Over diuresis”, dehydration? 2. CVP and intra-abdominal pressure? 3. Heart Failure Guidelines
Case # 4 Heart Failure Guidelines
Case: Refractory Heart Failure • 49 year old male – Stage ‘D’ HF PMH: • DM, previous MI’s • Recurrent admissions for decompensating HF Meds: – low dose of hydralazine/nitrates, bisoprolol, high doses of diuretics, CRT-D in place • Deemed not suitable for cardiac transplant Heart Failure Guidelines
Case: Refractory Heart Failure Labs: – Cr = 300 – 400 mol/L – NT-proBNP = 15,000 to 20,000 pg/mL • Increasing congestion and edema, 5 kg in 5 days, no precipitants identified – Did not respond to higher doses of furosemide and metolazone – Admitted, – Limited diuretic response to repeated high bolus dose and 15 mg/hr dose of IV furosemide Heart Failure Guidelines
Question • In patients with decompensated HF who are resistant to IV diuretics with hyponatremia, what are the therapeutic options? Heart Failure Guidelines
Question Therapeutic Options? 1. Still higher doses of diuretics? 2. IV Nitroglycerin? 3. IV Nesiritide? 4. Tolvaptan? 5. Ultrafiltration? Heart Failure Guidelines
Fluid Removal by Ultrafiltration Interstitial UFT removes fluid from the Space (Edema) blood at the same rate that fluid can be “naturally” Na P H 2 O recruited from the tissue Na K UF The transient removal of K blood elicits a compensatory PR mechanism, called plasma or intravascular refill (PR), aimed at minimizing this P reduction in intravascular volume Vascular Na Space Vascular Na Space 1. Lauer et al. Arch Intern Med . 1983;99:455-460. Heart Failure Guidelines 2. Marenzi et al. J Am Coll Cardiol . 2001;38:4.
Costanzo MR et al . J Am Coll Cardiol 2007;49:675-83 . Heart Failure Guidelines
Costanzo MR et al . J Am Coll Cardiol 2007;49:675-83. Heart Failure Guidelines
Role of Ultrafiltration HF Recommendation We suggest that in patients with acute decompensated heart failure (ADHF) and diuretic resistance, UF may be considered for volume management and to be performed in centers by clinicians with experience and expertise in its use. (Weak recommendation, low quality of evidence) Heart Failure Guidelines
CCS HF guideline Practical Tip • Careful assessment of all clinical indicators of fluid status is mandatory as changes in body weight may relate to changes in concurrent changes in fluid status or to muscle or fat content. • When evaluating patients, attention should be paid to the evolution of symptoms, renal function, body weight, and fluid status to aid management. • Overaggressive fluid removal should be avoided, especially • in advanced biventricular HF and severe chronic kidney disease. Heart Failure Guidelines
CASE # 5 Heart Failure Guidelines
Case - 69 yo male with ischemic CMP • Referred 2009 for cardiac transplantation evaluation. • CAD & CABG (1998); chronic AF; Diabetes; • Primary prev. ICD (turned down for CRT); • s/p multiple hospital admissions for ADHF, including a recent one with cardio-renal syndrome requiring CVVH and milrinone. • Seen at the HF clinic for deterioration. – NYHA ¾ with mainly symptoms of fatigue and gained 5Kg. – Meds: needed to be reduce because of symptoms • ACE, BB, Furosemide 160 die, metolazone, spironolactone 25, atorvastatin, ASA, Heart Failure Guidelines
Case - 69 yo male with ischemic CMP (2) • Physical Examination – Looks older & cachexia, HR 60, paced, BP 79/55 – JVP angle of jaw – Parasternal lift +, ↑/displaced apex – 2/6 SEM, mid systolic; increased P2; S3+ – decreased BS @ bases – 3+ LLE, • Labs: – Na 129 - K 4.5 - Tropo: 0.05 - NT-proBNP: 15 850 – Creatinine 192 (125 at discharge) • CXR: – Cardiomegaly, pacemaker dual lead and sternal wires Heart Failure Guidelines
Case - 69 yo male with ischemic CMP (3) • Recent Echocardiogram : – LVEDD 78 mm, LVEF about 15-20% – RVSP 60, RV normal, biatrial enlargement – moderate TR moderate MR (2/4) • Recent cath: – Grafts all open (Lima- LAD and SVGX 3) • Pressures: – RA 15, RV 64/18, PA 66/28 -42, PCWP v= 45, mean 32 – CO 4.0 l/min PVR: 2.5 No constriction Heart Failure Guidelines
69 year old male • Second hospitalization for heart failure in 6 months • Long history of AF, CAD and previous CABG • No other comorbidities • Presented with exertional dyspnea, orthopnea, PND • Excellent response to diuretics • Angiogram: grafts patent -> medical management • Discharged home: NYHA II-III Heart Failure Guidelines
69 year old male: investigations • Echocardiogram: EF 30% • ECG: LVH, RBBB QRS 136 msec • Labs (all stable): – creatinine 87 – Na 137 – K 4.4 • Meds: optimized ACE, BB, Furosemide 20 mg/day, spironolactone 12.5 mg daily, atorvastatin, ASA, Heart Failure Guidelines
Question Does this man require palliative care? 1. Yes 2. No 3. Need more information Heart Failure Guidelines
WHAT WHAT IS IS PALLIATIVE PALLIATIVE CARE? CARE? Heart Failure Guidelines
Palliative care is a patient-centred and family-centred approach that improves the quality of life of patients and their families facing the problems associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. It is applicable early, as well as later, in the course of illness, in conjunction with other therapies that are intended to prolong life, including but not limited to in the setting of heart failure, oral pharmacotherapy, surgery, implantable device therapy, hemofiltration or dialysis, the use of intravenous inotropic agents, and Ventricular Assist Devices. Adapted from the WHO definition for palliative care, http://www.who.int/cancer/palliative/definition/en Heart Failure Guidelines
Palliative care in Canada • In Canada: – 30% die from Cancer – cancer patients represent 90% of hospice palliative care recipients • Why? – Multiple reasons including illness trajectory Heart Failure Guidelines
End-of-life trajectories • Cancer trajectory – Relatively easy to predict life-expectancy once advanced – Admission criteria for palliative care based on known limited life expectancy Heart Failure Guidelines
The course of Heart Failure From: Goodlin, JACC 2009;54:386 Heart Failure Guidelines
The problem with HF (and many chronic non-malignant diseases) • Existing palliative services developed based on cancer model • Difficult to predict timing of death for individuals – often denied palliative care • Focus on prognosis often at the expense of assessing symptoms which can be present for months or years before death • Prognostic uncertainty leads to hesitancy around discussing advance care plans Heart Failure Guidelines
Recommendation We recommend that the provision of palliative care to patients with HF should be based on a thorough assessment of needs and symptoms, rather than on individual estimate of remaining life expectancy. (Strong recommendation, low quality of evidence) Heart Failure Guidelines
What are the symptoms of HF? Symptom class Examples Physical Dyspnea, chest pain, edema, fatigue, exercise intolerance; Gout, pruritus, muscle cramps, pain, anorexia, nausea, constipation; Social / Falls, incontinence, trouble walking, loss of functional independence in performing activities of daily living Psychological Panic attacks, anxiety, depression, cognitive impairment, insomnia, loss of confidence, feelings of uselessness or hopelessness Heart Failure Guidelines
Heart Failure specific symptom assessment tools Tool Name Description Minnesota Living with Heart Failure 21 item, Likert scale, self-administered, overall Questionnaire (MLHFQ) rating, physical (8) and emotional (5) Kansas City Cardiomyopathy 23 item, Likert scale, self-administered, physical Questionnaire (KCCQ) function (6), symptoms (8) social function (4), self- efficacy (2) and quality of life (3) Quality of Life Questionnaire for 26 item, visual analogue scale and Likert scale, self- Severe Heart Failure (QLQ-SHF) administered, psychological (7), physical function (7), life-dissatisfaction (5), somatic symptoms (7) Chronic Heart Failure 16 item, Likert scale, interviewer administered, Questionnaire (CHFQ) dyspnea (5), fatigue (4), emotional (7) Left Ventricular Dysfunction 36 item, dichotomous (true/false), self (LVD-36) administered, physical domain Memorial Symptom Assessment 32 items reflecting symptoms in last 7 days, each Scale (modified for HF) rated according to frequency, severity, and associated distress; domains assessed include HF symptoms, other physical symptoms and psychological symptoms Heart Failure Guidelines
ADVANCE CARE ADVANCE CARE PLANNING PLANNING Heart Failure Guidelines
Question Advanced care directives allow you to 1. Identify a substitute decision maker 2. Direct your care when you are no longer mentally capable of doing so 3. Enhance communication between you, your family and your healthcare provider 4. Have a Level 1 Grade C recommendation 5. All of the above Heart Failure Guidelines
Advance care planning (ACP) is a process whereby a patient, in conversation and reflection with family members, important others and health care providers, makes decisions about future health care. ACP is a process of reflection on and communication of a person ’ s goals, values and preferences for future healthcare, to be used should they become incapable of giving informed consent. ACP can encompass rich conversations, which go beyond "to resuscitate or not to resuscitate" and may include meanings and fears around illness and dying, preferences for after death rituals and spirituality. Heart Failure Guidelines
When should these be discussed? • Difficult decision but need to consider that mortality from HF is high in the first year after diagnosis • Ontario data: – 33% at one year – Over 60% if comorbidity (Jong et alArch Int Med 04) Heart Failure Guidelines
How should discussions about end-of-life planning and palliative care be conducted? Recommendation • We recommend that clinicians looking after HF patients should initiate and facilitate regular discussions with patients and family regarding advance care planning. (Strong recommendation, low quality of evidence) Practical tips • The timing of discussions should strongly consider the high mortality rate in the year following a first HF hospitalization; • A surrogate decision-maker should be identified early and regularly participate in these discussions; Heart Failure Guidelines
How should we approach the topic of ACP? • Balance hope with honesty • Assess readiness: many patients willing to talk about it but expect physicians to initiate conversation • If ready – Identify surrogate decision-maker early – Clarify and articulate patients ’ values over time – Establish leeway in surrogate decision making Heart Failure Guidelines
Practical tips • Triggers for initiating discussions include: – a new HF diagnosis; – an important clinical event (e.g. Hospitalization) – identification that a patient is at high risk of adverse outcomes according to one of several prognostic tools – when considering an invasive intervention; – if patient requests and expectations are at variance with clinical judgement. Heart Failure Guidelines
More practical tips • Topics to address include: – uncertainty of the HF trajectory and prognosis; – patients ’ values and preferences for advance care planning (ACP) and treatment goals including comorbidities and frailty in determining prognosis – acknowledging that decisions are made in the context of a process that will evolve as the clinical state and wishes of the patient change. Heart Failure Guidelines
Examples of “ opening lines ” • “ You have developed heart failure. Heart failure is a very serious disease, from which many patients ultimately die. Thankfully we have some extremely good treatments to manage heart failure and to make you feel much better and for longer. ” • “ If you were to get very sick, is there anyone you trust to make medical decisions for you, and have you talked with this person about what is important to you? Can we talk about this today? ” • Lots more in the paper! Heart Failure Guidelines
Back to the case • He is now 70 years old – Followed in a HF clinic for frequent admissions, IV lasix in ER – Optimal ACEi, Beta-blocker, Spironolactone, Digoxin, Furosemide 120 mg od, prn metolazone – Not revascularization candidate – EF 20%, creatinine 185, sodium 133 Heart Failure Guidelines
Question What does he require? 1. Referral to HF specialist? 2. Referral to Palliative care specialist? 3. Referral to a Geriatrician? 4. Closer involvement of the family doctor? 5. All of the above? Heart Failure Guidelines
Recommendation We recommend that the presence of persistent advanced HF symptoms (NYHA III-IV) despite optimal therapy be confirmed, ideally by an inter-disciplinary team with expertise in HF management, to ensure appropriate HF management strategies have been considered and optimized, in the context of patient goals and co- morbidities. (Strong recommendation, low quality of evidence) Heart Failure Guidelines
How should the care of patients with HF be organized? Recommendation We recommend an inter-disciplinary chronic care model (CCM) for the organization and delivery of palliative care to patients with advanced HF. (Strong recommendation, low quality of evidence) Heart Failure Guidelines
Practical tips • At minimum, the care model should include the primary care team and access to providers with specialty knowledge of HF and palliative care; • Other providers could include allied health (occupational therapy, speech therapy, and physiotherapy, pharmacy, home care, social work, spiritual care), and specialists in psychiatry, geriatric or internal medicine; • Formal and integrated protocols promoting seamless communication among various providers are required to ensure optimal patient care Heart Failure Guidelines
Advance HF: Preference for Life vs. Symptoms Don’t want 90 to trade 80 time 70 Don’t want 60 risk of 50 dying Life Utility Score 40 30 Would trade almost all 20 time to feel better 10 Would take any risk to 0 feel better FC II FC III FC IV Heart Failure Guidelines Lewis et al, JHLT, 2001
Question What options are available for this patient ? 1. Cardiac Transplantation 2. Palliative Care 3. Mechanical Circulatory support 4. Moving to Banff in a log cabin 5. All of the above Heart Failure Guidelines
Do the Math! • 5% of 500,000 Canadians with HF Stage D • 25,000 patients with advanced heart failure ~ 180 Transplants/year ~ 80 VAD’s per year 48,740 pts with advanced HF and no life saving therapeutic option • Majority elderly i.e. >70 Heart Failure Guidelines Hunt et al Circ 2009; Kirklin et al, JHLT 2010 ; 29:1-10; www.unos.org
Heart Failure Guidelines www.thecarenet.ca
Question Health Canada should fund Destination Therapy in Canada because 1. We are all getting older and will need it 2. We have lots of money left over from the oil sands 3. Evidence supports better outcomes for DT therapy versus medical therapy in selected patients 4. You have stock in HeartWare and Thoratec H. Ross Heart Failure Guidelines
ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by Age Group (Transplants: 1/1982-6/2008) 100 18-29 (N=4,957) 30-39 (N= 6,968) 40-49 (N=15,772) 50-59 (N=27,900) 60-69 (N=15,269) 70+ (N=453) 80 Survival (%) 60 All pair-wise comparisons are statistically significant at p < 0.04 40 except for 18-29 vs 30-39 p=0.1856 20 HALF-LIFE 18-29: 11.5 years; 30-39: 11.5 years; 40-49: 10.8 years; 50-59: 9.7 years; 60-69: 8.8 years; 70+: 7.1 years 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Years ISHLT 2010 Heart Failure Guidelines J Heart Lung Transplant. 2010 Oct; 29 (10): 1083-1141
June 2006 – September 2010: Adult Primary LVADs, Destination Therapy: n=389 100 90 80 Age < 70 years, n=273, deaths=69 70 60 % Survival 70+ years, n=116, deaths=25 50 40 By Age 30 Groups overall p = .68 20 10 Event: Death (censored at transplant or explant due to 0 recovery) 0 3 6 9 12 15 18 21 24 Months after Implant Heart Failure Guidelines Courtesy of Dr. D. Naftel and J. Kirklin; INTERMACS
Case - 67 yo male with ischemic CMP the sequel • Referred 2009 for cardiac transplantation evaluation. • CAD & CABG (1998); chronic AF; Diabetes; • Primary prev. ICD (turned down for CRT); • s/p multiple hospital admissions for ADHF, including a recent one with cardio-renal syndrome requiring CVVH and milrinone. • Seen at the HF clinic for deterioration. – NYHA ¾ with mainly symptoms of fatigue and gained 5Kg. – Meds: needed to be reduce because of symptoms • ACE, BB, Furosemide 160 die, metolazone, spironolactone 25, atorvastatin, ASA, Heart Failure Guidelines
Case - 67 yo male with ischemic CMP (2) • Physical Examination – Looks older & cachexia, HR 60, paced, BP 79/55 – JVP angle of jaw – Parasternal lift +, ↑/displaced apex – 2/6 SEM, mid systolic; increased P2; S3+ – decreased BS @ bases – 3+ LLE, • Labs: – Na 129 - K 4.5 - Tropo: 0.05 - NT-proBNP: 15 850 – Creatinine 192 (125 at discharge) • CXR: – Cardiomegaly, pacemaker dual lead and sternal wires Heart Failure Guidelines
Case - 67 yo male with ischemic CMP (3) • Recent Echocardiogram : – LVEDD 78 mm, LVEF about 15-20% – RVSP 60, RV normal, biatrial enlargement – moderate TR moderate MR (2/4) • Recent cath: – Grafts all open (Lima- LAD and SVGX 3) • Pressures: – RA 15, RV 64/18, PA 66/28 -42, PCWP v= 45, mean 32 – CO 4.0 l/min PVR: 2.5 No constriction Heart Failure Guidelines
69 year old male • Second hospitalization for heart failure in 6 months • Long history of AF, CAD and previous CABG • No other comorbidities • Presented with exertional dyspnea, orthopnea, PND • Excellent response to diuretics • Angiogram: grafts patent -> medical management • Discharged home: NYHA II-III Heart Failure Guidelines
69 year old male: investigations • Echocardiogram: EF 30% • ECG: LVH, RBBB QRS 136 msec • Labs (all stable): – creatinine 87 – Na 137 – K 4.4 • Meds: optimized ACE, BB, Furosemide 20 mg/day, spironolactone 12.5 mg daily, atorvastatin, ASA, Heart Failure Guidelines
Patient with refractory heart failure • Consideration of ICD, CRT, cardiac Tx, • After an initial response MCS to UFT, one week later, • Seen by Hepatology who suggested end the patient retained fluid stage liver disease secondary to HF again, and continued to • Respirology did not find active deteriorate and went pulmonary issues into low output state • RAP 24, PAP 64/25, PCWP 28, CO 3.8 • Cr climbed up to 320 • Put on dobutamine with slight mol/L, NT-proBNP to improvement in creatinine, volume status, electrolytes, abdominal girth, 24,500 pg/mL weight and exercise capacity Heart Failure Guidelines
Question What are the Clues to the Presence of Truly Intractable Heart Failure 1. Hyponatremia (Na <135 mmol/l) 2. Relative hypotension (<100 mmHg) 3. Age > 75 Years 4. Renal Insufficiency (>2.5 mg/ml) 5. Intolerance to ACEI and BB 6. Continuing Functional Class IV 7. Inotropes dependence 8. All of the above And it is OK to consult for options Heart Failure Guidelines
Question Should the patient be referred for consideration of a VAD (ventricular assist device)? 1. Yes 2. No Heart Failure Guidelines
What is destination therapy? Destination therapy with a left ventricular assist device (LVAD) has the potential to effectively treat a large number of patients with advanced heart failure who are not eligible for heart transplantation With the advent of continuous-flow LVADs, safe and effective long-term circulatory support is available for properly identified candidates Destination therapy with left ventricular assist devices: patient selection and outcomes Slaughter, Mark Sa; Meyer, Anna La; Birks, Emma Jb, Current Opinion in Cardiology: May 2011 - Volume 26 Heart Failure Guidelines
Mortality in REMATCH Heart Failure Guidelines
Heart Failure Guidelines
Destination therapy with a left ventricular assist device (LVAD) HeartMate II HeartWare Heart Failure Guidelines
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