OWL_HobbsHandout

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