ACUTE DECOMPENSATED HEART FAILURE Robert E. Hobbs, MD
CLEVELAND CLINIC
EPIDEMIOLOGY OF HEART FAILURE Patients in US (millions)
10.0 10 8 6 4
• 5 million Americans have HF; likely 10 million in 2037 • 550,000 new cases annually
4.8 3.5
• 1.1 million hospitalizations
2 0
1991
2001
2037
• Mortality is high
• Sudden cardiac death is 6 to 9 times higher than normal American Heart Association. Heart Disease and Stroke Statistics 2010 Update. Circulation 2010;121:e1-170 Year
.
HOSPITAL DISCHARGES FOR HEART FAILURE BY SEX Discharges in Thousands 700 600
Males Females
500 400 300 200 100 0
1979
1980
1985
1990 Years
1995
2000
2006
(United States: 1979-2006). Source: NHDS/NCHS and NHLBI. Note: Hospital discharges include people discharged alive, dead and status unknown.
HF HOSPITALIZATIONS • Incidence: 1.1 million/year • Costs: $8,000 +/• Outcomes: poor longterm • Mortality: 4-22% • 30 day mortality: 10-22% • 30 day readmission: 25%
HOSPITALIZATIONS ARE INCREASING • Aging population (“Baby Boomers”) • Rising incidence of chronic heart failure • Improved outcomes: MI, CABS, stenting • Inevitable progression of heart disease • Inadequate CHF treatment in hospital • Suboptimal education and followup • Noncompliance with diet and drugs
HEART FAILURE COSTS
60.6% Inpatient care (n=1.1 M)
38.6% Outpatient care (3.4 visits/year /patient) (n=3.4 M) 0.7% Transplants LVADs (n=3 k)
DISTRIBUTION OF HOSPITAL COSTS DRG 127
Non-ICU Bed (35%)
Pharmacy (9%) Laboratory (8%) Supplies (6%) Other Therapy (5%) Radiology (3%) Other (3%)
Medpar Data for Heart Failure
ICU Bed (31%)
2008 NATIONAL AVERAGE PER CASE FOR DRG 127 • Hospital costs……………..$8250 • Amount reimbursed………$4989 • Net financial loss……….... $3261
CMS Discharge Database (MEDPAR)
HOSPITALIZATION
INITIAL POINT OF CARE Physician’s office 22%
Emergency Dept 78%
Approximately 80% of ED visits for HF result in hospitalizations
ADHERE 2006
EMERGENCY DEPARTMENT VISITS FOR HEART FAILURE Initial Episode 21%
Repeat Visits 79%
Aghababian RV. Rev Cardiovasc Med. 2002;3(suppl 4):S3–S9.
DEMOGRAPHIC PROFILE • Mean age: 75 years • 52% female • 72% hypertension • 57% coronary disease • 44% diabetes mellitus • Smoked 48%; active 13% ADHERE 2006
PRESENTATION OF ADHF • Heart failure with congestion • Heart failure with hypertension • Acute pulmonary edema • Low output failure, shock • High output heart failure • Right sided heart failure
HEART FAILURE PATIENTS GROUP 1
ABNORMALITY Diastolic
Systolic
AGE Elderly
Older
GENDER Female
Male
BP High
Normal
GROUP 2
HF HOSPITALIZATIONS
• Prior heart failure…………… 76% • Hospitalized < 6 months…...33% • LVEF < 40%………..………… 47% ADHERE Registry 2006
DIAGNOSIS
CLINICAL INDECISION IN THE ED Physician Report on Clinical Probability of CHF 350
Number of Cases
300 250 200 150 100 50 0
0
10
20
30
40
50
60
70
Pretest Probability of CHF (%) McCullough PA et al. Circulation. 2002;106:416–422.
80
90
100
DIFFERENTIAL DIAGNOSIS • Pulmonary infection • Decompensated COPD • Asthma exacerbation • Acute coronary syndrome • Pulmonary embolism • Pneumothorax • Obesity, anxiety, drugs
BNP LEVELS OF PATIENTS DIAGNOSED WITHOUT CHF, WITH BASELINE LEFT VENTRICULAR DYSFUNCTION, AND WITH CHF P < 0.001
Mean BNP Concentration (pg/ml)
1400
1076 ± 138
1200 1000 800 600 400 200 0
141 ± 31 38 ± 4 No CHF (n=139)
Asymptomatic LV Dysfunction (n=14)
Maisel A. et al. J Am Coll Cardiol 2001;37(2):379-85
CHF (n=97)
RAPID ASSESSMENT OF CHF Congestion at Rest No
Yes
Signs/symptoms of congestion
Low Perfusion at Rest
No
Warm & Dry
Warm & Wet
Yes
Cold & Dry
Cold & Wet
Possible evidence of low perfusion • Narrow pulse pressure • Sleepy / obtunded • Low serum sodium
• Cool extremities • Hypotension • Renal dysfunction (one cause)
Stevenson LW. Eur J Heart Fail. 1999;1:251–257.
• • • • •
Orthopnea/PND JV distension Ascites Edema Rales (rare in chronic)
ACUTE HF HOSPITALIZATION ED LOS……………….. hours
5
Hosp LOS……………. days
4.3
ICU Admit……………. ……20% ADHERE 2006
ICU LOS………………
2.5
ACUTE HF HOSPITALIZATION Mortality…………………..4.1 % PA catheter……………….4.0% Ventilator………………… 4.8% Dialysis…………………… ADHERE 2006 5.3%
PREDICTORS OF DEATH ADHERE REGISTRY • Elevated BUN (>43 mg/dL) • Elevated creatinine (2.75 mg/dL) • Low blood pressure (SBP<115)
Fonarow. JAMA 2005;293:572-80
MANAGEMENT
JACC 2009;53:1343
Crit Pathways Cardiol 2008;7:83-121
PROBLEMS • Only 15% of ADHF guidelines are supported by randomized clinical trials • Nearly all drug trials in ADHF failed • No drug given for ADHF has ever been shown to improve longterm outcomes • Readmissions and mortality are high
IV DIURETICS
Furosemide 83%
Bumetanide 8% Torsemide 3% None 6%
ADHERE 2006
DIURETICS • “First-line” agents for HF • IV loop diuretic • Rapidly control fluid • Relieve congestion • Diuresis / natriuresis
DIURETICS • Bolus therapy when dose is low (<160 mg daily) • Continuous infusion when daily dose is high • Add thiazide; watch K+ • Add spironolactone
DIURETIC PROBLEMS • K + , Mg++ excretion • Volume depletion • Hypotension • Pre-renal azotemia ∀ ↑ renin, vasopressin, NE • Metabolic alkalosis
ACE INHIBITORS • All ACEi probably are equal • Lisinopril, enalapril, captopril studied in RCTs of chronic systolic heart failure • Therapy mandated at discharge • ACEi costs are similar
ANGIOTENSION RECEPTOR BLOCKERS • Probably similar efficacy to ACEi • Fewer side-effects than ACEi • ARB costs are higher • Losartan not FDA approved for HF • Valsartan reduces hospitalizations • Candesartan ↓ hosp / mortality
BETA-BLOCKERS • Don’t discontinue beta-blockers • Start beta-blocker when euvolemic • Therapy mandated at discharge • Plan outpatient uptitration • Don’t use metoprolol tartrate
IV VASOACTIVE MEDICATIONS • Nesiritide………...….12% • Nitroglycerin…..…….9% • Dobutamine………….6% • Dopamine…………….6% • Milrinone……………..3% • Nitroprusside………..1% ADHERE 2006
IV VASODILATORS • Nitroglycerin • Nitroprusside • Nesiritide
VASODILATOR PATHWAYS NATRIURETIC PEPTIDES: BNP, ANP NPR-A (pGC)
NITROGLYCERIN NITROPRUSSIDE NITRIC OXIDE (SGC)
cGM P
SMOOTH MUSCLE
VASODILATION CELL RELAXATION
NITROGLYCERIN Hemodynamic effects Low dose
High dose
Venodilation*
Arteriolar
dilation *Venodilation is the predominant effect
NITROGLYCERIN DOSE AND CHANGE IN PCWP DURING TREATMENT WITH NTG NTG dose (micrograms/min) 180
Change in PCWP (mmHg) 0
160
-1
NTG
140
-2
120
-3
100
*
80 60
*
*
PCWP
-5 -6
*
40 *
20 0
*
-4
0
-7 3
6
9
12 15 Time (hours)
Elkayam. Am J Cardiol 2004;93:237-240
18
21
24
-8
NITROPRUSSIDE • Potent IV vasodilating agent • Dilates arteries and veins • Decreases wedge pressure • Lowers intracardiac pressures • Rapidly lowers blood pressure • Increases cardiac output
NITROPRUSSIDE LIMITATIONS
• ICU: PA catheter, BPs • Difficult titration ( ↓ BP) • Light sensitivity • Coronary “steal” syndrome? • “Rebound” phenomenon? • Thiocyanate toxicity
NESIRITIDE • Balanced vasodilator • No inotropic effects • No chronotropic effects • Lusitropic properties • Not pro-arrhythmic
VASODILATOR PATHWAYS NATRIURETIC PEPTIDES: BNP, ANP NPR-A (pGC)
NITROGLYCERIN NITROPRUSSIDE NITRIC OXIDE (SGC)
cGM P
SMOOTH MUSCLE
VASODILATION CELL RELAXATION
NATRIURETIC PEPTIDE RECEPTOR Endothelin and Angiotensin Converting Enzyme K+
Natriuretic Degrading Surface Enzyme NEP 24.11
ANP + BNP CNP cGMP RA
RB
GC
GC
RC G
G
-
C +
G
G
GTP
cGMP - PK ATP cAMP
cGMP
PDE Biologic Effects Chem Proc Assoc Am Physicians 111:5, 1999
Relaxation
NESIRITIDE DOSING
Bolus
2 µg / kg (60
sec) Infusion min
0.01 µg / kg /
ASCEND STUDY • 7000 patients worldwide • Decompensated CHF • Fluid overloaded • Dyspnea (rest or min ADL) • Elevated filling
INOTROPIC THERAPY • Routine use not indicated • Hypotensive HF; shock: ok • Bridge to transplant: ok • Palliative therapy: ok • Outpatient infusions: no Felker. Am Heart J 2001; 142: 393
ULTRAFILTRATION “SCUF”
ULTRAFILTRATION • Removes sodium and water • Greater weight loss than diuretics • Avoids intravascular volume depletion, electrolyte imbalance • Expensive therapy • Useful for anasarca, cardiorenal Biogen Idec
HEARTMATE II LVAD
DISCHARGE
CHANGE IN WEIGHT FROM ADMISSION TO DISCHARGE 33
Enrolled Discharges (%)
35 30
24
25 20
13
15 10
7
11
6
3
5 0
(<-20)
(-20 to -15)
(-15 to -10)
(-10 to -5)
(-5 to 0)
(0 to 5)
(5 to 10)
2 (>10)
Change in Weight (lb) *Who were discharged home (including home with additional and/or outpatient care) chart, n = number of patients with both baseline and discharge weight; percentage calculated based on total patients in corresponding population. Patients without baseline or discharge weight omitted from histogram calculations ADHERE
PATIENT EDUCATION DOCUMENTATION
Diet
Daily weights
Fluids
BP Monitoring
ACE/BB
Smoking Cessation
Activities
Who to call for sx
Exercise
Follow-up visit
DISPOSITION Hospice 16%
Home + VN 9% Home 66%
ADHERE
Deceased 4% Hosp Trans 2% Other 3%
“I hope they fly”
OUTCOMES OF ACUTELY DECOMPENSATED HEART FAILURE • Hospital readmissions – 25% at 30 days 1 – 50% at 6 months 1
• Mortality – 11.6% at 30 days 2 – 33.1% at 12 months 2 – 50% at 5 years 1 1. Aghababian RV. Rev Cardiovasc Med. 2002;3(suppl 4):S3–S9. 2. Jong P et al. Arch Intern Med. 2002;162:1689–1694.
HIGH READMISSION RATE • Pathophysiology not understood • “One size fits all” therapy • Different clinical presentations • Ignore co-morbid conditions • LVEF does not predict prognosis • Core measures are inadequate
30-DAY READMISSIONS
CAUSES OF HOSPITAL READMISSION WITH HEART FAILURE Diet Noncompliance 24%
16% Inappropriate Rx
Vinson J Am Geriatr Soc 1990;38:1290-5
Rx Noncompliance 24%
19% Failure to Seek Care
17% Other
RISK FACTORS FOR READMISSIONS
Frailty family Dementia Uninsured home Illiteracy Complexity
No Poverty Nursing
READMISSIONS • Heart failure related • Renal failure related • Other co-morbidities • Planned readmissions • End-of-life care
PREVENTION OF ADMISSIONS • Adequate discharge planning • Educate: meds, diet, fluids, etc • Evidence based medications • Address co-morbidities • Telephone call 24-72 in hours • Followup visit in 1 week
WHAT WORKS?
Pill minder
Nurse
Scale Telephone BP cuff Pill chart Computer
Family
IT’S ALL ABOUT THE KIDNEY
FREQUENCY OF RENAL DYSFUNCTION IN 88,075 ADMISSIONS 70 60
Males Females
50
%
40 30 20 10 0
Nml GFR eGFR (mL/min) >90
Mild 60 - 89
Moderate 30 - 59
Severe 15 - 29
Renal Failure <15
Heywood JT, ADHERE data as of 8/2004: 88,075 admissions with complete information.
WORSENING RENAL FUNCTION • 30% patients with ADHF • Longer hospital stay • Higher hospital costs • Higher in-hospital mortality • More readmissions Biogen Idec
WHEN CREATININE RISES • Patient can’t go home • Diuretics held or decreased • ACE and ARB’s held • Tests and procedures delayed • To ICU for PA catheter • Inotroptes may be initiated Biogen Idec
CARDIORENAL SYNDROME HEART FAILURE
DIURETIC RESISTANCE
FLUID OVERLOAD
WORSENING RENAL FUNCTION
DIURETIC RESISTANCE • Increase diuretic dose • Different loop diuretic • Combination (loop + thiazide) • Continuous IV infusion • Ultrafiltration • Paracentesis Biogen Idec
TRADITIONAL THEORY FOR WORSENING RENAL FUNCTION ADHF Loop diuretics Low Cardiac Output
Volume Depletion
Renal Dysfunction
PREVALENCE OF WORSENING RENAL FUNCTION RELATED TO CVP, CI, SBP, AND PCWP
Mullens W, et al. JACC 2009;53:589-596
INCREASED INTRA-ABDOMINAL PRESSURE • Normal pressure 5-7 mm Hg • CHF pressure 15-20 mm Hg • Prevalence: 60% in ADHF • Visible ascites uncommon • Abdominal compartment syndrome Biogen Idec
INCREASED CONGESTION (RA PRESSURE) MAY IMPAIR TUBULAR FUNCTION RA Pressure 5 mmHg RA or venacaval/renal vein pressure (> 20-25 mmHg)
CHF
Biomarkers sensitive to subtle changes in GFR; may be superior to serum Cr
• Intracapsular pressure • Peritubular pressure • Medullary ischemia • Decreased GFR • Tubular dysfunction • Adenosine release • Activation of RAAS
↑ NGAL – Neutrophil gelatinase associated lipocalin Mishra et al. 2005 ↑ Cystatin_C, KIM-1
VENOUS CONGESTION • Only predictor of ARF • Occurs days-weeks before • Ascites not always present • Cytokines + neurohormones • Causes “renal tamponade”
CARDIORENAL SYNDROME NOT MECHANISMS • Low cardiac output • Low ejection fraction • Low blood pressure • Elevated PCWP • Use of diuretics Biogen Idec
CARDIORENAL SYNDROME MECHANISMS • ↑ venous pressure • ↑ renal vein pressure • ↑ renal interstitial pressure • ↓ glomerular filtration rate • ↓ sodium excretion Biogen Idec
“CONGESTIVE KIDNEY FAILURE” Elevated CVP
↑ Renal vein pressure
Renal Dysfunction
SUMMARY