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CHRONIC HEART FAILURE (CHF)
2012
Jennifer Burgess
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Some Facts Fastest rising cardiovascular condition in
Canada affects 1 – 2% of the population (>350,000) 1.4 million hospital days per year Up to $2.3 billion per year Prevalence tripled over past decade
Increasing numbers of elderly Improved survival rates of cardiac and other chronic
conditions
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Some Facts Cannot be “Cured” by relieving symptoms
Often progresses without signs or symptoms Changes occur that lead to chronic debility
33% mortality within first year of diagnosis 50% mortality within five years 3:1 males:females
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Heart Failure – What is it? Inability of the heart to supply sufficient blood flow to meet
the body's needs Therefore not enough oxygen and nutrients supplied Can lead to fluid overload
Results from any heart problem that impairs ability of ventricle to fill with or eject blood Due to low cardiac output (“Congestive” HF) or increased needs
(“high output” HF) – now referred to as Heart Failure (HF) Can be acute or chronic (or acute on chronic) Can be left sided, right sided, or both (L leads to R)
It is not a heart attack, or cardiac arrest
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What is Heart Failure?
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CausesCongestive heart failure can be caused by
diseases that:cause stiffening, or weakening of, the heart
muscle e.g.. MI, HTNincrease oxygen demand by the body tissue
beyond the capability of the heart to deliver.
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Main Risk Factors Ischemic heart disease/MI (62%) Smoking (16%) Hypertension (10%) Obesity (8%) Diabetes (3%) Valvular heart disease (2%, higher in elderly)
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The heart
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Classic Indicators of CHF
Shortness of Breath
Wet sounding chest due to excess fluid in and around the lungs
Coughing
Significant swelling in lower legs or abdomen
Fatigue
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Signs And SymptomsLEFT HEART FAILURE(LOW OUTPUT/PULMONARY
CONGESTION) Dyspnea Orthopnea Paroxysmal nocturnal dyspnea
(PND) Fatigue* Reduced exercise tolerance* Cough Confusion (Especially in elderly)*
* May be earliest presentation
RIGHT HEART FAILURE(SYSTEMIC VENOUS CONGESTION)
Peripheral edema Weight gain Anorexia Abdominal discomfort Fatigue* Reduced exercise tolerance*
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Additional Signs & Symptoms RR (>20) and effort Low blood pressure (<90mmHg) Heart rate > 100 Lung crackles (+/- wheeze) Elevated JVP Heart murmur Pleural effusion Cyanosis (late sign)
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Assessing JVP and abdominal jugular reflex
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Atypical Features in Frail Elderly Delirium Falls Malnutrition Sudden functional decline Sleep disturbances Nocturia or nighttime incontinence NOTE: Dyspnea and/or crackles +/- present
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Diagnosing HF
Chest x-ray ECG Bloodwork, +/- BNP (cardiac vs pulmonary) Echocardiogram +/- angiography, nuclear imaging, MRI
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Differential Diagnosis Heart – valvular, CAD Renal failure with volume overload Lung disease Liver cirrhosis Obesity Deconditioning Anemia
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New York Heart Association Classification (NYHA) Class l (Mild)
No limitation of physical activity Class ll (Mild)
Slight limitation of physical activity Class lll (Moderate)
Marked limitation of physical activity Class lV (Severe)
Unable to carry out any physical activity without discomfort
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Medications ACE Inhibitors
Ramipril, etc. Improve hearts pumping action Prevent disease from getting worse S/E: decreased renal function, hypotension, dizziness, cough
Beta Blockers Metoprolol, etc. Reduce heart rate and work of heart Prevent and treat irregular heart beat Prevent disease from getting worse S/E: may make HF worse for first few months, bradycardia,
bronchospasm, fatigue, dizziness
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Medications Diuretics
Lasix, etc. Improve symptoms by relieving fluid overload S/E: Hypokalemia, dehydration, weakness,
muscle cramps.
Others ARB’s, Digoxin, Nitrates, anticoagulants,
Aspirin, etc.
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Management Decrease sodium
Na+ not efficiently excreted in HF We need 500 mg/day, we consume 5-6- gm/day Aim for 2 – 3 gm/day if stable 1 – 2 gm/day if advanced HF and fluid retention
Fluid restriction 1.5 – 2 L/day if fluid retention, or if renal dysfunction or
hyponatremia 1 – 1.5 L/day if severe edema
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Management Daily weight log
when Class lll/lV or med changes after emptying bladder, before eating, same clothes, same
scale Report weight when 2.5 kg increase in a week, or 2 kg in
2 days
Physical activity Consider when stable and not fluid overloaded Individualized – up to, but just short of, significant Sx’s
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Prevention BP goal <140/90
<130/80 if DM +/or chronic kiney disease Correct anemia Medications – proper use of recommended
meds can drastically reduce morbidity and mortality. E.g. ACE–I use decreases death or new HF by 29% (SOLVD Prevention study)
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Acute Decompensated HF (ADHF) Presentation:
Dyspnea - 89% Crackles - 68% Peripheral edema - 66% SBP <90 MMHG - 3%
These residents may need immediate hospitalization for I.V. diuretics, etc.
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End of Life Care Consider in residents who have advanced,
persistent HF with symptoms at rest despite optimal pharmacological and nonpharmacological therapy: Three or more hospitalizations per year Chronic poor quality of life – unable to do ADL’s Need for IV support Needing assistive devices for breathing etc.
(2006 HFSA Comprehensive HF Practice Guideline)
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The Good News We can help our residents who have Heart
Failure to have maximal quality and quantity of life by helping them to optimally manage their disease!
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ReferencesAronow, W. (2004). Evidence for the Use of Beta-blockers in
Congestive Heart Failure Treatment in Older Persons. Geriatrics & Aging. 7(2), 28-32.
Canadian Cardiovascular Society. (2009). Pocket reference card: Is it Heart Failure and What should I do? Retrieved from: http://www.hfcc.ca/downloads/educational_tools/pocket_card/pocket_card.html
Canadian Heart Failure Network. (2009). Running a Heart Failure Clinic. Retrieved from http: //www.chfn.ca/ on May 18, 2010.
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References Con’tHeart Failure Society of America. (2006). 2006 HFSA
Comprehensive Heart Failure Practice Guideline: Key Recommendations. Retrieved from: http://www.heartfailureguideline.org/index.cfm?id=150&s=1
Howlett, J.G., McKelvie, R.S., Arnold, J.M.O., et al. Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: Diagnosis and management of right sided heart failure, myocarditis, device therapy and recent important clinical trials. Can J Cardiol, 25(2), 85-105.
Kostuk, W. (2004). Initial Evaluation of the Older Patient with Suspected Heart Failure. Geriatrics & Aging, 7(2), 13-16.