getting to the heart of the matter - webinars, webcasts,...

6/17/2013

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Getting to the

Heart of the Matter

Albert Riddle, MD, CMD

Riddle Medical Group

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CARDIAC ANATOMY

Getting to the Heart of the Matter

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Cardiac Anatomy

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Cardiac Anatomy

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PHYSIOLOGY


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Normal Electrical Conduction

• Initiated in SA node.

• Impulse travels to LA and RA

leading to contraction in both.

• Impulse travels to the AV node.

• Bundle of His.

• Right and Left Bundle Branches.

• Purkinje System.

• Ventricular Contraction.

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Normal Heartbeat

• P wave: atrial depolarization.

• PR interval: Time for impulse to

travel from SA node to AV node.

• QRS interval: Time it takes for

ventricles to depolarize.

• T wave: Ventricular

repolarization.

• QT interval: Time needed for the

ventricles to repolarize.

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CARDIOVASCULAR CHANGES WITH

PHYSIOLOGIC AGING VERSES DISEASE


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Functional Areas of Concern

• Heart Rate

• Cardiac Rhythm

• Systolic Function

• Diastolic Function

• Valvular Changes

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Rate• Resting heart rate is not affected by aging

– Daytime bradycardia with heart rates < 40 bpm and sinus

pauses of over 3 seconds are not seen with healthy aging.

• Decreased heart rate in response to exercise and

stress is characteristic of healthy aging.

• Consequences

– Maximum heart rate on a treadmill is decreased.

– Heart rate response to fever, hypovolemia, and postural

stress is decreased with healthy aging.10

Rhythm

• Time for conduction through the AV node is increased

with healthy aging (P-R interval increases with healthy

aging).

• 2nd and 3rd degree AV block are not normal

consequences of aging.

• Isolated RBBB has not been linked to increased risk for

advanced conduction abnormalities.

• Isolated Left Anterior Hemiblock is not a predictor of

cardiovascular morbidity or mortality.11

Rhythm

• Left fascicular hemiblock in combination with

RBBB is associated with cardiovascular

disease in 75% of older patients.

• Isolated LBBB is not associated with normal

aging and is associated with increased risk for

cardiac events.

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Rhythm

• Atrial premature contractions increase with

age and are frequent in 95% of older healthy

people at rest and during exercise.

• Atrial Fibrillation is usually associated with

coronary, hypertensive, valvular, sinus node

disease, or thyrotoxicosis but can occur in the

absence of detectable cardiac disease.13

Rhythm

• Prevalence of atrial fibrillation presence in

absence of detectable cardiac disease:

– Older Males: 1/5

– Older Females: 1/20

• Isolated and/or multiform ventricular ectopy has

been reported in up to 80% of older men and

women without detectable cardiac disease. 14

Systolic Function

• Resting left ventricular systolic function

(ejection fraction and/or stroke volume) is not

altered by aging.

• A few studies report declines of stroke volume

with sedentary older populations.

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Systolic Function

• Cardiac output may be reduced with exercise due

to decrease in maximum heart rate and limited

ability for the heart to increase contractility.

• Result = an age-related decline in exercise

capacity.

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Cardiac Output = Stroke Volume X Heart Rate

Diastolic Function

• During Diastole the heart relaxes and gives the

ventricles time to fill.

• This time is prolonged with normal aging.

– Reasons: increased ventricular mass, collagen

infiltration, altered myocardial calcium metabolism.

– Result: Prolonged filling times may limit cardiac

output with increased heart rates, but does not lead

to congestive failure.17

Valvular Changes

• Degenerative calcification leading to sclerosis

that is normal with aging.

– Effect: Aortic and Mitral Regurgitation

• Primary valve changes that occur with

congenital and rheumatic disease are not a

normal part of aging.

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Change Comparison

Age-Related Changes Cardiovascular Disease

Decreased heart rate response Sinus Pauses

Longer P-R intervals 2nd and 3rd degree AV block

Right Bundle Branch Block Left Bundle Branch Block

Increased Atrial Ectopy Atrial Fibrillation

Increased Ventricular Ectopy Sustained Ventricular Tachycardia

Altered Diastolic Function Decreased Systolic Function

(Ejection Fraction)

Aortic Sclerosis Aortic Stenosis, Aortic Regurgitation

Annular Mitral Calcification Mitral regurgitation, Stenosis Systolic

Hypertension, Diastolic Hypertension

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BASIC CARDIAC EXAM OF THE

ELDERLY PATIENT


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Skin Exam

• Look for maculopapular

skin lesions on the

upper extremities as

these are a signal of

end stage heart failure

known as Robertson’s

Sign.

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Neck Veins• Always examine from the

right side (gives a more

accurate estimate than the

left: straight shot from the

right jugular veins to the

right superior vena cava

and right atria).

• Have patient turn head

slightly to the left.

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Neck Veins Estimating Central Venous Pressure

• Estimate height of column

of blood in the internal and

external jugular (use the

most distended one to

calculate).

• More than 3 cm above the

clavicle with the patient at

45 degrees is abnormal.

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Interpretation of Increased JVD

• Look at changes in JVP with respiration

– Veins should collapse with inspiration.

– Veins distend with inspiration if there is a problem with right

atrial filling (Kussmaul’s sign).

– Causes

• Constrictive pericarditis

• Right Ventricular Infarction

• There should be 2 downward motions for each upward

motion representing right atrial filling (1st) and right

ventricular filling (2nd).24

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Apical Impulse

• Look for the Point of

Maximum Impulse

(PMI)

• Mid-clavicular line at 5th

intercostal space.

• Displaced down and/or

left with LVH.

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AUSCULTATION


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Normal Heart Sounds

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S1: Turbulence caused by closure of the Mitral and Tricuspid valves at the start of systole.

S2: Closure of the Aortic and Pulmonic valves at the end of systole..

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Aortic RegurgitationAKA Aortic Insufficiency

• Leaky aortic valve.

• As the ventricles rest in

diastole, blood flows

backward from the

aorta into the left

ventricle.

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Symptoms• Dyspnea on exertion• Orthopnea• Angina Pectoris• Congestive failureTreatment• Surgical Correction• Medical management with

ACE or ARB and Nifedipinewith or without history of hypertension

• Vasodilators such as hydralazine if the patient also has hypertension.

Aortic Stenosis

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Early

Late

Opening of the valve is narrowed.• Usually no symptoms with mild to moderate disease.• Initial presentation is usually shortness of breath on

exertion.• Patients respond by reducing activity, thus, masking

symptoms.• Subsequent symptoms of syncope, chest pain, and

sudden death.• Nitrates, ACE inhibitors, and vasodilators such as

hydralazine may worsen condition.• No treatment indicated if patient is asymptomatic.• Valve replacement has been most effective

intervention to date.• Poor response to medical interventions.

Mitral StenosisAlmost all cases due to Rheumatic Heart Disease

• Symptoms

– Heart failure

– Palpitations

– Chest Pain

– Hemoptysis

– Thromboembolism

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Treatment is not indicated in

asymptomatic patients.

Good results seen with

valvuloplasty by balloon catheter or with surgical valve

replacement.

Medical management according

to symptoms or other conditions.

• Angina: Vasodilators, B-blockers, or Calcium channel

blockers.

• Heart Failure: Lanoxin, Diuretics, Vasodilators, or ACE

inhibitors

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Pulmonic Stenosis

• Obstruction of blood flow from the right ventricle to

the pulmonary artery.

• Usually congenital.

• Can cause symptoms of right ventricular failure and

systemic cyanosis.

• Treatment: Percutaneous balloon valvuloplasty.

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S3 Gallop

• Rare extra heart sound

• Associated with congestive heart failure due to

conditions that are associated with

– Rapid ventricular filling (Mitral regurgitation)

– Poor left ventricular function (Post MI or Dilated

Cardiomyopathy)

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S4 Gallop

• Rare extra heart sound

• Caused by a forced contraction of the atria to

overcome an abnormally stiff hypertrophied

ventricle.

• Does not require treatment.

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Abnormal Breath SoundsRales

(Crackles)Rhonchi Wheezing Stridor

Small clicking,

popping, bubbling, or rattling sounds in

the lungs.

Sounds that

resemble snoring.

High pitched

sounds produced by narrowed

airways. They are heard when a

person breaths out.

Wheeze-like sound

heard when a person inhales and

exhales.

Occurs when air

opens closed air spaces. They can be

further described as moist, dry, fine, and

course.

Occur when air is

blocked or when air passage through

the large airways becomes rough.

Sign of a partially

obstructed airway.

Usually due to a

blockage of airflow in the trachea or in

the back of the throat.

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Absence of breath sounds where sounds are expected may indicate an effusion,

consolidation (as can be seen with pneumonia), or compression of the lung.Pleural rub occurs with friction between the pleural membranes due to inflammation.

THE HEART OF THE MATTER

Q&A Session #1

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ATRIAL FIBRILLATION

The Heart of the Matter

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Atrial Fibrillation

• 0.4% prevalence in those aged less than 65.

• 10% prevalence in those greater than 75.

• Prevalence projected to rise two to three fold

by the year 2050, largely due to increased life

expectancy.

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Atrial Fibrillation

• Present in 9.4% of patients with CVD and

1.6% of patients without CVD.

• Condition associated with valvular heart

disease, hypertension, heart failure, and

advancing age.

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PATHOPHYSIOLOGY

Atrial Fibrillation

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Atrial Fibrillation

• Rapid and disorganized

electrical activity in the atria.

• Areas other than the SA node

in the atria depolarize rapidly

and irregularly resulting in

chaotic atrial activity.

• The AV node attempts to

block as much choatic activity

as possible to slow down

ventricular rate.40

Atrial Fibrillation

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Remodeling with Atrial Fibrillation

• Atria gradually dilate and stretch.

– The hypertrophied atria then becomes more

vulnerable to abnormal electrical impulses.

• Progressive loss of ability of the AV node to block

impulses .

– More ventricular beats in response to ectopic signals

from the atria.

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A resident who is on Lanoxin 0.125 mg daily is

comfortable and in no distress. She has a heart rate of 82 per minute and her pulse is irregularly

irregular.

A lab report shows that her digoxin level is

slightly below normal.

What would you do next?

Types of Atrial Fibrillation

Type Ventricular Rate

Rapid Ventricular Response > 120 BPM

Controlled Ventricular Response 60 – 110 BPM

Slow Ventricular Response < 60 BPM

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Digoxin

• Indications

– CHF: 0.125 – 0.5 mg PO QD

– Atrial Fibrillation/Flutter: 0.125 – 0.5 mg PO QD

– PSVT conversion: 0.125 – 0.5 mg PO QD

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Digoxin

Serious Reactions

• AV block

• Severe bradycardia

• Thrombocytopenia

• Hallucinations

• Intestinal Ischemia

• Ventricular Arrhythmias

• Hemorrhagic intestinal

necrosis

Common Reactions

• Nausea/ vomiting

• Abdominal pain

• Weakness

• Bradycardia or Tachycardia

• Anorexia

• Confusion

• Depression/ Anxiety

• Mental disturbance46

IMPACT ON ADL’S

Atrial Fibrillation

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Impact on ADL’s

• Can cause a 5% - 40% drop in cardiac output

• Can lead to Cardiomyopathy that is reversible

if heart rate is controlled

• Stasis of blood in the atria increases risk of

thrombus formation that can lead to CVAs

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ASSESSMENT AND

MANAGEMENT

Atrial Fibrillation

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Causes of Atrial Fibrillation

• 3 main categories

– Primary arrhythmia in the absence of structural heart

disease or other precipitating cause.

– Secondary arrhythmia associated with a variety of

cardiovascular diseases.

– Secondary arrhythmia where there is no heart

disease but there is a condition that precipitates the

arrhythmia.50

Primary Causes of Atrial Fibrillation

• Isolated condition with no known

precipitating cause.

– Seen most commonly in patients < 65 years old

– Characterized by paroxysmal onset and

termination

– Frequently recurs

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Secondary Causes of Atrial Fibrillation

Cardiac Causes

• Hypertension

• Rheumatic heart disease

• Mitral valve disease

• Cardiomyopathy

• CHF

• Sick Sinus Syndrome

• Pericarditis

• Cardiac Surgery

Non-Cardiac Causes

• Hyperthyroidism

• Non-Cardiac surgery

• Non-cardiac diagnostic

procedure

• COPD

• Pulmonary Embolism

• Herbs (ephedra/ ginseng)

• Alcohol and drug use

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Assessment of Patient

• Symptoms

– Palpitations

– Hypotension

– Fatigue

– Dizziness

– Reduced exercise

tolerance

– Shortness of breath

– Worsening CHF

– Chest pain

– Syncope

– Near Syncope

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• Paroxysmal Atrial fibrillation may lead to

unpredictable patterns that cause:

– Loss of feeling of control

– Fright

– Curtail usual activity to prevent recurrence

– Depression and a sense of helplessness

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• Physical Assessment

– Blood Pressure

• Variable pulse pressure (due to variable ventricular filling

caused by irregular conduction)

• Hypotension

• Blood pressure can vary widely whether or not ventricular

rate is controlled (may need to take several blood pressure

and take an average to get a true sense of blood pressure

level)55



– Heart Sounds

• Rapid

• Irregularly irregular

• Variable loudness of S1

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– Other Findings

• Signs of CHF

– Decreased oxygen saturation

– Rales or crackles in lung fields

• Signs of poor peripheral perfusion

– Diminished distal pulses

– Impaired capillary filling

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Testing Capillary Filling Time

• Compress nail bed for 5

seconds.

• Upon release the blood

flow to the area should

be restored within 3

seconds.

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Lab & Diagnostic Testing

• Serial Cardiac Enzymes to assess for possible

acute MI

• Arterial Blood Gas to assess for hypoxia

• Thyroid Function Tests to rule out

hypothyroidism

• Electrolytes and Magnesium Level

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• Chest X-Ray to rule out CHF, Pulmonary

Disease, or Pneumonia

• Echocardiogram to assess cardiac valve

function and determine LV function

• Trans-esophageal Echo to assess for presence

of clots in the atria

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• 12 lead ECG

• Continuous ambulatory ECG may be

indicated if there are symptoms of atrial

fibrillation but the ECG is normal

• Nuclear medicine cardiac studies may be

indicated

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GOALS OF THERAPY

Atrial Fibrillation

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Appropriate Goals of Therapy

• Paroxysmal Atrial Fibrillation

– Use of antiarrhythmic therapy may not be needed

for patients that are asymptomatic.

– Antiarrhythmic therapy is indicated for those that

experience severe symptoms.

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• Recurrence after electrical or pharmacologic

cardioversion

– Long term rate control

– Ablation may be required for severely

symptomatic patients

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• Persistent (Permanent) Atrial Fibrillation

– Long term rate control

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• Persistent Signs of Decreased Cardiac Output

during episodes of atrial fibrillation

– Restoration of normal sinus rhythm

–Maintenance of normal sinus rhythm is the goal

for persons who spontaneously convert from

atrial fibrillation to sinus rhythm

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MANAGEMENT

Atrial Fibrillation

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Pharmacologic Therapy

Antiarrhythmics

Class Actions Agents

Ia Slows conduction velocity Quinidine

ProcainamideDisopyramide

Ib Used only for Ventricular arrhythmias Lidocaine

Mexiletine

Ic Slows conduction velocity Flecainide

Propafenone

II Slows AV node conduction

Slows sinus rateDecreases myocardial oxygen consumption

Metoprolol

AcebutololPropranolol

Esmolol

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Pharmacologic Therapy

Antiarrhythmics

Class Actions Agents

IV Blocks outward movement of potassium

Prolongs cardiac refractory period

Amiodorone

SotalolDofetilide

Ibutilide

V Blocks calcium channels

Slows conduction through SA and AV NodesProlongs AV node refractory period

Verapamil

Diltiazem

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Acute Rate Control

Agent Action Route Time

Diltiazem Calcium Channel

Blocker

IV bolus Onset in 3 – 7

minutes

Verapamil Calcium Channel

Blocker

IV Loading

dose

Onset in 3 to 5

minutes

Esmolol B-Blocker IV Infusion

Metoprolol B-Blocker IV Loading

dose

Onset in 5 minutes

Digoxin Slows conduction

through SA and AV node

IV or oral

loading odse

Onset in 2 hours

70

Oral treatment is possible with Digoxin, however, onset of action is 2 hours after administration of oral loading dose. More rapid onset of medication action would require IV therapy.

Long Term Rate Control

Agent Action Route ER Formulation

Diltiazem Calcium Channel

Blocker

120 – 360 mg per

day (divided doses)

SR: 60 – 120 BID

ER: 120 – 240 QD

Verapamil Calcium Channel

Blocker

120 – 360 mg per

day (divided doses)

ER 120 – 360 QD

IR 240 – 480 TID or QID

Lanoxin Slows SA/AV

conduction

0.125 – 0.375 mg

daily

Metoprolol B-Blocker 25 – 100 mg daily in

divided doses

Daily ER formulations

Propranolol B-Blocker 120 – 240 mg daily

in divided doses

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PREVENTING STROKE

Atrial Fibrillation

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Atrial Fibrillation & Stroke Risk

• Results from Framingham study in the 1970’s

provided the first population data to show a

fivefold increased risk of stroke with AF.

• The typical natural history is to go from

paroxysmal to persistent to permanent

usually over the course of many years.

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Atrial Fibrillation & Stroke Risk

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Percentage of stroke attributed to Atrial Fibrillation is 15% for all age groups and increases with advancing age.

Atrial Fibrillation & Stroke Risk• Increased risk for stroke with chronic, persistent, or

frequent episodes of atrial fibrillation.

• Reasons

– Heart’s atria doesn’t squeeze effectively

– Blood pools in the atria

– The pooled blood forms clots

– Clots eventually can break loose

– Loose clots can travel to the arteries to the brain

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CHADS2 Score

• Increased risk for stroke is

dependent upon age, and

on other medical conditions

that are present.

• CHADS2 assigns a number

from 0-6 to help decide

whether anticoagulation

therapy is warranted.

Medical Condition Points

Prior Stroke 2

CHF 1

Hypertension 1

Diabetes 1

Age 75 or older 1

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Developed by researchers from the Washington University School of Medicine in St. Louis, Missouri

Stroke Estimates Using CHADS2

• The CHADS2 model was

developed by studying

records of 1,733 Medicare

Beneficiaries aged 65 to 95.

• Cautions: not a proven

predictor for patients < 65

years old and not found to

be a valid predictor in

patients with mitral

stenosis.

CHADS Score

Yearly Stroke Risk

0 1.9%

1 2.8%

2 4.0%

3 5.9%

4 8.5%

5 12.5%

6 18.2%

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CHADS2VASc ScoreRisk Factors for Stroke and Thromboembolism in non-valvular AF

Major Risk Factors Clinically Relevant non-major Risk

Factors

Previous stroke, TIA, Systemic Embolism,

and Age > 75.

Heart failure or moderate to severe LV

dysfunction (LVEF < 40%), Hypertension, Diabetes, Female, Age 65 – 74, and

Vascular Disease

Point Based Scoring System

Congestive Failure or LV Dysfunction 1

Hypertension 1

Age 75 or greater 2

Diabetes Mellitus 1

Stroke, TIA, thromb0-embolism 2

Vascular disease 1

Age 65-74 1

Sex category (i.e. female sex) 1

Maximum score 9 78

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Plan of Care Using CHADS2VAScRisk Category CHADS2VASc

Score

Recommended Antithrombotic

Therapy

One major risk factor or 2

or more clinically relevantnon-major risk factors

2 or more Oral anticoagulation therapy (OAC)

One clinically relevant risk

factor

1 Either OAC or Aspirin 75 – 325 mg daily

Preferred: OAC rather than aspirin

No risk factors 0 Either aspirin 75 – 325 mg daily or no

antithrombotic therapy.

Preferred = No antithrombotic therapy rather than aspirin.

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Major : Previous stroke, TIA, Systemic Embolism, and Age > 75.

Non-Major: Heart failure or moderate to severe LV dysfunction (LVEF < 40%),

Hypertension, Diabetes, Female, Age 65 – 74, and Vascular Disease.

HAS BLED Bleeding Risk Score

Letter Clinical Characteristics Points Awarded

H Hypertension 1

A Abnormal renal and liver function (1 point each) 1 0r 2

S Stroke 1

B Bleeding 1

L Labile INR’s 1

E Elderly (> 65 years of age) 1

D Drugs or alcohol (1 point each) 1 or 2

Maximum 9 Pts

80

High Risk: Score > 3

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Atrial Fibrillation Summary

• Atrial Fibrillation is a prevalent condition in the elderly that

can negatively impact ADL’s and quality of life.

• A. Fib can result from a large number of other chronic

medical conditions.

• Patients with atrial fibrillation are at increased risk fro

ischemic stroke.

• Appropriate management of anticoagulation is important.

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Q&A Session #2

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CONGESTIVE HEART FAILURE

The Heart of the Matter

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Heart Failure Zones

• Everyday

– Weight before breakfast

– Take prescribed

medications

– Check for swelling in

ankles, feet, legs, and

stomach

– Low salt food

– Balance activity with rest

periods86

Heart Failure Zones

• All Clear: Green Zone

– No shortness of breath

– No weight gain more

than 2 pounds

– No edema

– No chest pain

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Heart Failure Zones

• Caution

– Weight gain of 3 pounds

over a day or 5 pounds

over a week


– More edema

– More tired/ no energy

– Dry/ Hacky Cough

– Dizziness

– SOB when lying down88

Heart Failure Zones

• Emergency

– Struggling to breath


while sitting still

– Chest pain

– Having confusion or

difficulty thinking clearly

89

Weight (If 8 ounce glasses)?

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Weight (If 8 ounce glasses)?

Answer = 1 Pound

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Weight QOD: 2 Days Later

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1 Quart

Weekly Weights8 pounds (1 Gallon) a Week Later

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Visualizing Daily Weights

1 gallon of water weighs 8.34 pounds

1 pound of water = 0.119 gallons

8 ounces of water is 1/16th of a gallon

8 ounces of water = 0.0625 gallons

16 ounces of water = 1 pound

2 glasses of water = 1 pound

30 cc in one ounce94

STAGES IN THE EVOLUTION OF

HEART FAILURE


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Stages in the Evolution of HF

Category Stage Characteristics

At Risk for Heart Failure

A • No structural heart disease.• No symptoms of Heart Failure.

At Risk for Heart Failure

B • Structural heart disease• No symptoms of heart failure

Heart Failure

C • Structural heart disease• Prior or current symptoms of HF

Heart Failure

D • Refractory heart failure requiring specialized interventions

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Stage A

• Definition: High risk for

heart failure but without

structural heart disease or

symptoms of HF.

• Examples: patients with

HTN, ASHD, DM, Obesity,

Metabolic syndrome, or

using cardiotoxins.

• Therapy Goals

– Optimal control of DM, HTN,

and lipid disorders

– Smoke cessation

– Regular exercise

– Discontinue excessive alcohol

intake or elicit drug use

• Treatment: ACE/ARB in

appropriate patients for DM,

HTN.

97

Stage B

• Definition: Structural heart

disease without symptoms

of heart failure.


Previous MI, LV remodeling

other than LVH, or

asymptomatic valvular

disease.

• Therapy Goals (Same as A)

– Optimal control of DM, HTN,

and lipid disorders

– Smoke cessation

– Regular exercise

– Discontinue excessive alcohol

intake or elicit drug use

• Treatment:

– ACE/ARB in appropriate

patients for DM, HTN

– B-blockers

98

Stage C

• Definition: Structural heart

disease with prior or current

symptoms of heart failure.


known structural heart

disease and shortness of

breath, fatigue, and reduced

exercise tolerance.


– Same as under A & B

– Dietary salt restriction

• Treatment:

– Diuretics for fluid retention

– ACE/ARB where appropriate

– B-blockers

– Hydralazine/ Nitrates

– Digitalis where appropriate

• Devices

– Pacemaker

– Implantable difibrillator99

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Stage D

• Definition: Refractory heart failure

requiring specialized interventions.

• Examples: Patients with marked

symptoms at rest despite

maximum medical therapy

(recurrent hospitalizations or

cannot be safely discharged from

the hospital without specialized

interventions)


– Same as under A , B, and C

• Options:

– Compassionate end of life care

– Hospice

• Extraordinary Measures

– Heart transplant

– Chronic inotropes

– Permanent mechanical support

– Experimental drugs

– Experimental surgery 100

Management of Chronic CHF

• General Measures

– Control systolic and diastolic blood pressure

– Treat lipid disorders

– Control blood sugar

– Treat thyroid disorders

– Use or consider ASA 50 – 325 mg daily

– Assess Left Ventricular Function101

If LVEF > 40%

• Goal: Preserve function

• Treat volume overload with short term loop

diuretics until signs of overload resolve.

• Aggressively treat underlying disease such as

myocardial ischemia, hypertension, or atrial

fibrillation.

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If LVEF at or under 40%

• No signs or symptoms of congestion

– Initiate treatment with ACE followed by initiation

and titration of a B-blocker to target dose.

– Continue to monitor for onset of signs or

symptoms of congestion

• At onset add loop diuretic followed by digoxin then

aldosterone receptor antagonist and finally

spironolactone.103

If LVEF at or under 40%

• With signs or symptoms of congestion

– Initiate ACE with a loop diuretic

– Titrate ACE to target dose

• Once symptoms resolve

– Initiate and titrate B-blocker

– If symptoms develop

• Titrate diuretic and consider addition of Zaroxolyn104

BRAIN NATRIURETIC PEPTIDE


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BNP

• Brain Natriuretic Peptide Hormone.

• Made in the heart.

• Normally only a small amount if found in blood.

• If the heart has to work harder than usual over a long

period of time (heart failure) it releases more BNP.

• With response to treatment for heart failure the BNP

levels fall.

106

BNP

• Function

– Regulates Circulation

• Dilate blood vessels

• Stimulate the kidneys to excrete more salt and water

• Lower blood pressure

• Reduce the workload and stress on the heart

107

BNP

• Information obtained from the test

– Confirms presence of heart failure in those with

symptoms (example: trouble breathing, edema)

– Indicates how severe heart failure is

–Measures the response to treatment for heart

failure

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BNP

• Interpretation of Results

– < 100 pg/mL rules out heart failure

– 100 – 400 warrant further diagnostic investigation

– > 400 pg/mL indicates a 95% likelihood of heart

failure

– The higher the BNP, the more severe the heart failure

with levels sometimes reaching into the thousands

109PG = Picograms

110

A 76-year-old female, Doris Smith, is admitted to your facility after a 4 day hospitalization for decompensated congestive heart failure. She was treated aggressively with diuretics and stabilized in the hospital but is not strong enough to go home. You are accepting her to provide a brief course of rehabilitation so that she can eventually return to her home. She weighs 124 pounds.

History: Diabetes, Hypertension, and CHF

MedicationsLasix 40 mg daily with potassium supplementationLanoxin o.125 mg dailyInsulin (Long and Short Acting with SSI Coverage

ECG: Old anterior wall MI and PVC’s

She ambulates about 100 feet without SOB, eats meals without assistance, and is able to toilet herself without assistance.

CHF Care Plan

• Goals

– Body weight will remain stable

– Sodium restricted diet

– Maintain optimal level of physical activity

– Staff will monitor for early signs of fluid overload

– Maintain optimal cardiac output

– Maintain optimal fluid volume

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CHF Care Plan

• Interventions

–Weight resident in the same clothing type and at

the same time of day in the morning.

–Maintain a record of weights.

– Teach resident and family about maintaining a

daily weight log.

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CHF Care Plan

• Interventions

– Provide sodium restricted diet along with other

appropriate dietary restrictions.

– Teach the resident about restricting sodium.

– Teach family about appropriate food and snacks.

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CHF Care Plan

• Interventions

– Establish the baseline level of physical activity (the level at

time of hospital discharge).

– Increase activity gradually.

– Utilize measurements (V.S., “Talk Test) and coordinate

with Physical Therapy.

– Observe for complications (dyspnea, fatigue, and pain)

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CHF Care Plan

• Interventions

– Observe for the following

• Edema of extremities

• Coughing

• # of pillows used or resident wanting to sleep in chair

• Shortness of breath with usual acitivity

• Increasing weight

– Provide emotional support

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CHF Care Plan

• Interventions

– Check vital signs, breath sounds, and breathing

patterns

– Observe for s/s of decreased cardiac output

• Chest pain, dyspnea, edema, JVD, or change in mental

status

– Check lab values as ordered

– Monitor pacemaker and other related devices116

CHF Care Plan

• Interventions

– Administer cardiac medications, anticoagulants, and

diuretics as per medical orders.

– Administer oxygen as needed.

– Elevate head of bed as needed.

– Monitor I’s and O’s.

– Check appetite and monitor for s/s of malnutrition.117

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118

During her second night in the facility Mrs. Smith asked to C.N.A. if she could have an additional pillow to sleep on. It was provided, but as the C.N.A. was helping her get comfortable, she noticed that Mrs. Smith had a cough that she did not hear the previous night.

During the next morning, Mrs. Smith appetite was poor and she seemed slightly confused. She had not been confused at all one day earlier.

She also seemed to be having more difficulty getting to the toilet, about 30 feet away from her bed, without assistance. While being assisted, she was having difficulty speaking clearly.

The C.N.A. reported her findings to the nurse manager of the unit.

Stop and Watch Early Warning Tool

S Seems different than usual

T Talks or communicates less

O Overall needs more help

P Pain – New or worsening (Less participation in activities)

A Ate less

N No bowel movement in 3 days; or diarrhea

D Drank less

W Weight change

A Agitated or nervous more than usual

T Tired, weak, confused, or drowsy

C Change in skin color or condition

H Help with walking, transferring or toileting more than usual119

120

The nurse manager assessed Mrs. Smith to have the following

findings:

1. She had gained 3 pounds since admission.

2. She needed to sit upright to breath comfortably.

3. She was having difficulty talking.

4. Her nail-beds were dusky.

5. Blood pressure 145/92

6. Pulse 102

7. Respirations 26

8. Bilateral ankle edema

9. Oxygen saturation 95% on 2 liters oxygen by N/C

10. Skin cool and moist (no fever)

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SBAR – CHF

Situation• I am calling about Mrs. Smith. He/she has CHF and;

– Unrelieved or new shortness of breath at rest (no)

– Unrelieved new chest pain (no)

– Wheezing or chest tightness at rest (no)

– Inability to sleep without sitting up (Asked for another pillow)

– Inability to stand without severe dizziness or light headedness (no)

– Weight gain of > 5 pounds in 3 days (3 pounds in 2 days)

– Markedly increased edema (some edema)

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SBAR – CHF

Background• Primary diagnosis: CHF, Diabetes, Hypertension

• Medication changes during the last week: None

• Findings include

– Temp Afebrile

– Heart rate 102

– Respirations 26

– Blood Pressure 145/92

– Oxygen saturation 95% ON 2 liters per minute

– Glucose (if applicable) fingerstick 88

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SBAR – CHF

Assessment

I think the resident has signs and symptoms of

new or worsening CHF. They Do/ Do not meet

the care path criteria for management of signs

and symptoms in the nursing home.

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SBAR – CHF

Recommendations

• Manage in the nursing home

• Consider CBC, BMP, CXR

• Initiate or increase diuretic dose if indicated

• Oxygen supplementation if indicated

• Monitor VS (pulse and apical heart rate) Q4H for 24 –

72 hours

• Transfer to acute care facility

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CAREPATH for CHF

Initial Assessment Observation

Unrelieved shortness of breath or new shortness of breath.

Yes

Unrelieved new chest pain. No

Wheezing or chest tightness at rest. No

Inability to sleep without sitting up. Yes

Inability to stand without severe dizziness or light headedness.

No

Weight gain of > 5 pounds in a week. No

Worsening edema. Yes

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CAREPATH for CHF

Vital Signs Observation

Temperature > 100.5 No

Apical heart rate > 100 or < 50 Yes

Respiratory rate > 28/min or < 10/min No

BP < 90 or > 200 systolic No

Oxygen saturation < 90% No

Finger stick glucose < 70 or > 300 No

New or worsening chest pain No

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CAREPATH for CHF• Initiate Work-Up

– STAT Portable Chest X-Ray

– STAT Complete Blood Count with Differential

– STAT Basic Metabolic Panel

– EKG

– BNP level

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CAREPATH for CHF

• What to look for

– CHF or pneumonia on CXR

– Critical lab values

– EKG shows new changes suggestive of acute MI

or arrhythmia

–Worsening clinical condition

128

CAREPATH for CHF• Plan of Care: Manage at Facility

–Monitor vital signs, fluid intake, and urine output

every 4 to 8 hours.

– Supplemental Oxygen.

– Initiate or increase diuretic dose.

– Initiate or modify other cardiovascular

medications.

–Monitor electrolytes and kidney function.129

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CAREPATH for CHF

• Monitoring

– Vital Signs

• Keep temperature at 100.5 or less

• Maintain apical heart rate between 50 - 99

• Maintain respiration between 10 - 28

–Worsening condition

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CHF Summary

• CHF is a serious condition that demands careful

monitoring and early recognition of signs and symptoms of

decompensation.

• A comprehensive care plan is vital.

• Aggressive monitoring of weight change is crucial.

• BNP is a powerful monitoring tool.

• Use of Interact III tools can improve care and reduce

potential risk of hospitalization.

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Q&A Session #3

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