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Pharmacotherapy in Chronic Heart Failure: Pharmacotherapy in Chronic Heart Failure: Translating Evidence Based R Recommendations Into Practice d i I P i Jennifer Ballard Hernandez MSN, RN, FNP BC/GNP BC, CCRN CSC, AACC


  1. Pharmacotherapy in Chronic Heart Failure: Pharmacotherapy in Chronic Heart Failure: Translating Evidence ‐ Based R Recommendations Into Practice d i I P i Jennifer Ballard ‐ Hernandez MSN, RN, FNP ‐ BC/GNP ‐ BC, CCRN ‐ CSC, AACC Nurse Practitioner, Heart Failure Program, Hoag Heart and Vascular Institute u se act t o e , ea t a u e og a , oag ea t a d ascu a st tute Southern California Chair, Cardiac Care Associates, American College of Cardiology July 16, 2011

  2. Disclosures: Disclosures: • I have no financial disclosures I have no financial disclosures

  3. Why Focus on Heart Failure (HF)? Why Focus on Heart Failure (HF)? • United States (US) prevalence estimated around 5,800,000 1 • Leading cause of hospital admission for Leading cause of hospital admission for g g p p patients over 65 1 patients over 65 – 1,106,000 hospital discharges attributed to HF in 2006 1 – National 30 ‐ day readmission rate 24.7% 2 • Associated with approx. 283,000 deaths/year 1 • The estimated direct and indirect cost of HF in the US for 2010 is $39.2 billion 1

  4. Causes of Heart Failure Causes of Heart Failure • Ischemic Heart Disease • Hypertension • Hypertension • Idiopathic Cardiomyopathy • Infections • Infections • Viral / Bacterial myocarditis • Chagas disease (parasitic disease common in Central America) • Toxins • Alcohol or cytotoxic drugs • Valvular Disease • Prolonged Arrhythmias • Endocrine Disorders E d i Di d • Peripartum CM

  5. HF as a Progressive Model HF as a Progressive Model • HF is a complex clinical syndrome that impairs HF is a complex clinical syndrome that impairs the ability of the ventricle to fill with or eject blood 3 blood • HF is a constellation of symptoms produced by a complex circulatory and neurohormonal a complex circulatory and neurohormonal response to cardiac dysfunction – Sympathetic nervous system (SNS) S th ti t (SNS) – Renin ‐ Angiotensin ‐ Aldosterone system (RAAS)

  6. Neurohormonal Activation in Heart Failure Myocardial injury to the heart (CAD, HTN, Valvular disease) Initial fall in LV performance,  wall stress Activation of RAAS and SNS Activation of RAAS and SNS Fibrosis, apoptosis, Remodeling and progressive Remodeling and progressive Peripheral vasoconstriction Peripheral vasoconstriction hypertrophy, worsening of LV function Hemodynamic alterations cellular/ molecular alterations, myotoxicity i i Heart failure symptoms Morbidity and mortality Fatigue Arrhythmias Activity altered Pump failure p Chest congestion C est co gest o Edema Shortness of Source: AHA Get With the Guidelines Workshop breath

  7. Source: Wikipedia Commons

  8. Ventricular Remodeling and Its Prevention Ventricular Remodeling and Its Prevention • The chambers of the heart have the capacity to alter (remodel) their size and configuration in response to acute and chronic changes • Activation of the RAAS and stimulation of SNS contribute to the process • Remodeling results in physical changes in the ventricle, impacting its ability to pump and/or fill effectively • The goal of HF therapy is to minimize and possibly reverse the areas of remodeling in order to preserve ventricular function function

  9. Ventricular Remodeling Ventricular Remodeling Reproduced with permission: Jessup M, Brozena S: Heart failure. N Engl J Med, 348:2007, 2003

  10. Systolic Dysfunction Systolic Dysfunction • Inability of the left ventricle to effectively pump blood to the body effectively pump blood to the body • Weakened muscle, enlarged heart size, inability of heart to empty • The ejection fraction in systolic The ejection fraction in systolic dysfunction is less than 40%

  11. Systolic Dysfunction Systolic Dysfunction

  12. Diastolic Dysfunction (Preserved Systolic Function) (Preserved Systolic Function) • Myocardial relaxation is abnormal yoca d a e a at o s ab o a • The left ventricle is unable to fill The left ventricle is unable to fill because of the inability to relax • The EF may be normal (>50%) • Concomitant systolic and diastolic dysfunction usually co ‐ exist

  13. Diastolic Dysfunction Diastolic Dysfunction

  14. Clinical Manifestations of Heart Failure S Symptoms from Biventricular Failure t f Bi t i l F il • Fatigue/weakness • Decreased exercise tolerance • Loss of appetite • Dyspnea • Dyspnea • Inability to concentrate • Inability to concentrate • Feels cold • Feels cold Symptoms from Symptoms from LV Impairment LV Impairment RV Impairment RV Impairment • Fatigue/ • Sudden orthopnea • Fatigue/ • Abdominal weakness pain (right) weakness that awakens from sleep p • Dyspnea • Dyspnea • Bilateral leg Bil l l • Weight W i h swelling gain • Orthopnea • Abdominal • Loss of • PND bloating appetite Hunt SA et al. Circulation . 2001;104:2996-3007. Cohn NJ et al. Hurst’s The Heart . 8th ed. New York: McGraw-Hill; 1994:557-571.

  15. Evaluation of the HF Patient Evaluation of the HF Patient Three fundamental questions must be Three fundamental questions must be addressed: 1. Is the LVEF preserved or reduced? 1. Is the LVEF preserved or reduced? 2. Is the structure of the LV normal or abnormal? abnormal? 3. Are there other structural abnormalities such as valvular, pericardial, or right ventricular as valvular, pericardial, or right ventricular abnormalities that could account for the clinical presentation?

  16. Stages of Heart Failure Stages of Heart Failure Stage D Stage C Stage A Stage B Refractory HF Structural heart Structural heart disease At high risk for HF requiring specialized disease with prior but without but without structural interventions or current symptoms heart disease or structural heart of HF of HF disease or disease or symptoms of HF symptoms of HF symptoms of HF eg: Patients With: – Marked symptoms eg: Patients With: at rest despite – Hypertension maximal medical eg: Patients With: eg: Patients With: – Atherosclerotic therapy (eg, those – Previous MI – Known structural disease – LV remodeling heart disease who are recurrently – Diabetes Refractory Development Structural including LVH, and and hospitalized or – Obesity symptoms of of symptoms Heart low EF – Shortness of breath – Metabolic syndrome cannot be safely HF at rest of HF Disease – Asymptomatic and fatigue, reduced or or discharged from the discharged from the valvular disease exercise tolerance Patients hospital without – Using cardiotoxins specialized – With FHx CM interventions) THERAPY THERAPY THERAPY Goals Goals Goals Goals Goals Goals THERAPY THERAPY – Treat hypertension – All measures – All measures under Stages A – Encourage under Stage A and B Goals smoking cessation Drugs – Dietary salt restriction – All measures under – Treat lipid – ACEI or ARB in Drugs for routine use Stages A, B, and C disorders appropriate patients – Diuretics for fluid retention – Discussion re: – Encourage regular (see text) – ACEIs appropriate level of care –  -blockers in –  -blockers exercise OPTIONS – Discourage alcohol appropriate patients Drugs in selected patients – Compassionate end-of- intake, illicit drug , g – Aldosterone antagonist g life care/hospice p use – ARBs – Extraordinary measures – Control metabolic – Digitalis • Heart syndrome – Hydralazine/nitrates transplant Drugs Devices in selected patients • Chronic – ACEI or ARB in – Biventricular pacing inotropes appropriate patients – Implantable defibrillators • Permanent (see text) for mechanical vascular disease or support diabetes • Experimental surgery or drugs Table reproduced from ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

  17. NYHA Functional Class Class Patient Description Class I Asymptomatic • No limitation of physical activity • Ordinary physical activity does not cause fatigue, palpitation, or dyspnea Class II Symptomatic with Class II • Slight limitation of physical activity S g t tat o o p ys ca act ty Symptomatic with • Comfortable at rest, but ordinary physical moderate exertion activity results in fatigue, palpitation, or dyspnea Class III Symptomatic with Class III Symptomatic with • Marked limitation of physical activity Marked limitation of physical activity • Comfortable at rest, but less than ordinary minimal exertion activity causes fatigue, palpitation, or dyspnea Class IV Symptomatic at • Unable to carry out any physical activity without discomfort without discomfort rest • Symptoms include cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell et al. JAMA . 2002;287:890-897.

  18. Stages of HF and Treatment Options Stages of HF and Treatment Options Reprinted with permission: Jessup M, Brozena S: Heart failure. N Engl J Med, 348:2007, 2003

  19. AHA/ACC, HFSA Guideline Documents AHA/ACC, HFSA Guideline Documents • 2009 Focused Update: ACCF/AHA Guidelines 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: Failure in Adults: – http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.19206 4 • HFSA 2010 Comprehensive Heart Failure Practice Guidelines: – http://download.journals.elsevierhealth.com/pdfs/journals/1071 ‐ 9164/PIIS1071916410001739.pdf

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