Tim Sutton, CardiologistCounties-Manukau DHB and Auckland Heart

Group

Exertional dyspnoea

Orthopnea

Paroxysmal nocturnal dyspnoea

Oedema

Third heart sound Elevated JVP Basal rales Swollen ankles

Temporal trend

Effort tolerance – NYHA classificationFunctional class Symptoms

I No limitation of physical activity : Ordinary physical activity does not cause undue breathlessness, fatigue or palpitations

II Slight limitation of physical activity : Comfortable at rest, but ordinary physical activity does not cause undue breathlessness, fatigue or palpitations

III Marked limitation of physical activity : Comfortable at rest, but less than ordinary physical activity does not cause undue breathlessness, fatigue or palpitations

IV Unable to carry on any physical activity without discomfort :Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased

ECG

Chest X-ray

Nt-proBNP : ◦ best done pre diuretic Rx / good renal function

“Baseline bloods”◦ FBC, U+Es, Glu, LFTs, INR, Albumen, TFTs and ferritin

1) Assess LV size and function

◦ Systolic and diastolic

◦ Regional vs global

2) Assess LV wall thickness

3) Assess valve function

4)Assess RV function

Dilated heart Normal size

Preserved EF Reduced EF

Above 50-55%

Mild 40-50%

Moderate 30-40%

Under 30% severe

Under 20% very severe

Regional Gobal

Symptoms typical of HF

Signs of typical HF

Reduced EF

Symptoms typical of HF Signs of typical of HF Normal of mildly reduced

EF and LV NOT dilated Relevant structural heart

disease (LVH / LA enlargement) and / or diastolic dysfunction

Sudden decompensation◦ Patient often euvolaemic – right amount of fluid, just in

the wrong place◦ Transient rise in left atrial pressure causing lungs to

flood with fluid (acute pulmonary oedema)

Sub-acute / chronic decompensation◦ Gradual accumulation of fluid – congestive state with

generalised fluid retention (oedema)◦ Hypervolaemia – too much fluid all over the place

Did the patient previously have a normal heart?◦ Yes….. Ischaemia

◦ No…… Ischaemia / arrhythmia / increased afterload etc

What is the cause of the heart failure?

What has triggered the presentation?◦ De novo diagnosis

◦ Decompensation secondary to:

Natural history of underlying condition

Intercurrent factor

Anaemia Infection Drugs

Diagnosis : usually a chronic disease

What is our treatment goal?

◦ “Our aim is to keep you as well as we can for as long as we can, ideally leading as normal life as possible with no restrictions on what you can do, with as few pills as possible, but as many as are needed”

Non pharmacological

Exercise

Diet – weight loss in the obese, but beware the malnourished

obese patient

Salt “restriction” – stick to the RDA!

Minimise / avoid environmental cardiotoxins

◦ Alcohol Metamephetamine Smoking

No place for fluid restriction except in exceptional situations

Is essential – regular : daily exercise improves well being and survival

Avoid extremes of dynamic exercise – only mild static exercise

Patient can engage in a formal exercise program – moderate intensity aerobic vs high intensity interval training

“A person should put aside some

part of the day for the care of his

body. He should always make sure

that he gets enough exercise

especially before a meal."

Diagnosis : usually a chronic disease

What is our treatment goal? “Our aim is to keep you as well as we can for as long as we can,

ideally leading as normal life as possible with no restrictions on what you can do, with as few pills as possible, but as many as are needed”

Non pharmacological

Pharmacological

Loop diuretics

◦ Use dose that maintains the patient oedema free

◦ Relieve dyspnoea, but usually do not need high doses

◦ Monitor for side effects

Renal dysfunction / electrolyte derangement / gout

ACE inhibitor / Angiotensin receptor blocker

◦ Any patient with impaired systolic function

◦ Optimal dose – depends on agent

Cilazapril 2.5mg (od) Quinapril 10mg (bd)

Losartan 50mg (od) Candesartan 16mg (od)

◦ Monitor renal function and electrolytes

◦ Start when euvolaemic

◦ Start low and go slow (increase every 2 weeks)

◦ Warn patient may feel slight worse for a few days

If more breathless increase diuretic dose : sx should settle

◦ Aim for maximum tolerated dose

Metoprolol CR 190mg (od) Bisoprolol 10mg (od)

Carvedilol 25mg (bd)

When is dose optimised for an individual?

◦ When maximum dose reached

◦ When heart rate in low 50s

◦ Hypotensive symptoms

Can Beta-blockers be used in airways disease?

◦ Generally yes – survival benefit offsets risk : see improvement in lung

function

◦ Not in brittle asthmatics / marked airway hyper-reactivity

Fatigue – but you can still do more than pre Rx?

Hypotensive Sx – try and cut the other meds

Erectile dysfunction – agents to assist

Who: Anyone with symptomatic heart failure due to impaired systolic function

Dose : ◦ Spironolactone (12.5mg), 25mg aim 50mg

◦ Eplerenone (25mg) 50mg aim 100mg

Monitor for side effects◦ Renal dysfunction / hyperkalaemia

Maximum tolerated doses of

◦ ACEi / ARB

◦ Beta blocker

◦ Aldosterone receptor antagonist

◦ +/- diuretic

Fluid status Weight JVP Lungs Oedema Postural BP Renal function

Hypervolaemia Climbing High Rales Present May be a rise with standing

Stable / worse

Euvolaemia Stable Stable – may be high if TR

Clear Absent No drop Stable

Hypovolaemia Falling Low Clear Absent Present Climbing

Digoxin

◦ reduces hospitalisation, but not survival

Amiodarone

◦ only for symptomatic arrhythmia, otherwise shortens life

Ivabradine (not in NZ yet)

◦ improves survival in those on optimal dose beta-blocker and HR >77bpm

at rest

Nitrate and hydralazine

◦ Very old school!

Is more common in:-◦ Elderly◦ Females◦ Obesity / diabetes / hypertension

Is the commonest cause of pulmonary hypertension in the elderly

Prognosis just as bleak as for systolic dysfunction

◦ Stiff, non compliant heart : squeezes OK, but does not fill well

◦ At rest is usually fine, but anything that increases heart rate can causes symptoms

Infection / anaemia / metabolic derrangement

Exercise

Atrial arrhythmias

Prevention is better than needing to actually treat!

No proven Rx once established◦ Low dose diuretics

◦ Negative chronotropes to slow heart

◦ Spironolactone if Nt-BNP high (>300) and symptoms

Polypharmacy with potential side effects

Takes 3-6 months to get right

◦ Drs much better with HF-ReF than HF-PeF!

Treatment is usually for life

◦ There is a risk to suddenly stopping medication

◦ There is a risk to not taking pills and then taking OMT doses

Multiple contacts with medical system

◦ Nurse / primary and secondary care

Diagnosis : usually a chronic disease

What is our treatment goal? “Our aim is to keep you as well as we can for as long as we can, ideally leading as

normal life as possible with no restrictions on what you can do, with as few pills as possible, but as many as are needed”

Non pharmacological

Pharmacological

Prognosis /general issues that may not be apparent initially

In the absence of contraindications offered to ◦ Anyone who has survived a sudden cardiac death

◦ Has poorly tolerated VT / LV impairment and syncope that is unexplained

◦ Anyone who has been on and adherent to OMT for three months and has EF of under 30% if non ischaemic CM EF of under 35% if ischaemic CM

◦ Malignant familial history / genotype

An ICD is permanent

It is not an active therapy : it will not make the patient feel

better

An ICD does not alter the natural history of the underlying

disease – one day pump failure will predominate and

consideration should be given programming shock therapy

off

Not everyone wants an ICD – they do come with risks

◦ The patient should contact / attend their ICD clinic

ICD will be read and rhythm reviewed

May be a change in ICD settings

◦ The patient cannot drive a car for 6 months

◦ There may be a period of emotional lability / depression or even post traumatic stress disorder (more common after ICD storms)

Not very common to see, but this will change over time

Improves symptoms and survival

Wairua(Spiritual health)

Whanau (Family)

Tinana(Physical Health)

Hinengaro(Mental health)

Class 1 or 6: Driving OK unless very symptomatic

Class 2,3,4,5 or P endorsement: Generally individuals will be unfit to drive – special dispensation is available

”If can mount 2 flights of stairs, reasonably quickly,

without too much problem then sex should be fine.”

Keep GTN available (not with Viagra though).

Activity is least likely to cause symptoms if engaged in

after a good night’s sleep and with the least affected

partner doing most of the work”

Viagra is safe

Patient plus website – www.patient.co.uk

Uncontrolled AF can cause heart failure ◦ AF induced tachycardiomyopathy

◦ Rate Rx vs restoration of SR

The onset of AF can cause decompensation of a previously stable cardiac condition

Anticoagulation (in the absence of contraindications) is a must◦ Warfarin NOAC: Dabigatran, Rivaroxiban, Apixiban

Good rate Rx important◦ Beta blocker◦ Digoxin◦ Amiodarone◦ Ideally avoid diltiazem◦ Interventional Rx : pulmonary vein isolation / CRT and AV nodal

ablation

Only Rx aspirin / clopidogrel if proven vascular disease

Anticoagulation with warfarin (INR 2-3) or NOAC for◦ Any proven AF◦ Any patient with impaired EF and embolic event when in

SR◦ Documented LV thrombus

Renal dysfunction is common in patients with heart failure (Cardiorenal

syndrome)

Multiple factors contribute

Renal dysfunction can improve with treatment of heart failure

Renal dysfunction in heart failure is not a contraindication for an ACEi / ARB,

but a reason for caution – can use spironolactone, but only with specialist

input due to risk of hyperkalaemia

Balance risk of a slight worsening in renal function against benefits of

cardioprotective agents

Actively treat iron deficiency◦ Oral iron replacement may not be effect

◦ Iron infusion excellent way of treating

◦ No clear role for EPO or analogues as yet – may be harmful

Commonly coexist

Central sleep apneoa common in CHF and

treatment of CHF can improve it

OSA common – cannot easily assess until on OMT

Baseline and post Rx ESS can be useful

Variable data

Reasonable to continue if one is on a statin

Start if have ACS / high CV risk

But otherwise… just another pill, especially in advanced heart failure

Address the underlying cause as best as possible – often multifactorial

Correct the reversible – especially hypoxia

Optimise Rx for left heart disease

Aries Avoid incisions in the head and face and cut no vein in the head.

Taurus Avoid incisions in the neck and throat and cut no veins there.

Gemini Avoid incisions in the shoulders, arms or hands and cut no vein.

Cancer Avoid incisions in the breasts, sides, stomach and lungs and cut

no vein that goes to the spleen.

Leo Avoid incisions of the nerves, lesions of the sides and bones,and

do not cut the back either by opening and bleeding.

Virgo Avoid opening a wound in the belly and in the internal parts.

Libra Avoid opening wounds in the umbellicus and parts of the belly

and do not open a vein in the back or do cupping.

Scorpio Avoid cutting the testicles and anus.

Sagittarius Avoid incisions in the thighs and fingers and do not cut

blemishes and growths.

Capricorn Avoid cutting the knees or the veins and sinews in these places.

Aquarius Avoid cutting the knees or the veins and veins in these places.

Pisces Avoid cutting the feet.

Address the underlying cause as best as possible – often multifactorial

Correct the reversible – especially hypoxia

Optimise Rx for left heart disease

Diuretics◦ Best taken on empty stomach, 30 minutes before food◦ Frusemide vs bumetanide◦ Oral vs IV◦ Spironolactone◦ Metolazone – use cautiously and watch electrolytes

Important to identify disease progression

Review medications – any room to push further

Acknowledge disease progression – this is not a failure of treatment, rather the natural

history of the underlying disease

Any non essential medications that could be stopped

Advanced care planning : review ICD status if present

Advanced stages of heart failure are unpredictable and patients can survive months to

years with advanced Sx / poor prognostic markers – aim is to ensure they remain well,

but not to prolong suffering

Patients with suspected heart failure – newly diagnosed

Patients with known heart failure who are◦ Deteriorating – sub-acute vs chronic

◦ Running into problems with medication side effects

◦ New onset AF

Help further establish diagnosis and cause of heart failure

Help initiate Rx and optimise Rx

Discuss diagnosis and provide education

Help establish chronic management plan

Offer support through the early phase of the disease

management

Provide follow up once on OMT – usually annual

Community ◦ Review patients in their own enviroment / clinic

Check for polypharmacy – drug inconsistencies

◦ Once stable – 3 monthly review : Check adherence to Rx and side effects

Review obs and weight chart

Lifestyle and psychosocial issues

Preventative programme : flu jab