Professional Documents
Culture Documents
Anecita Fadol, PhD, RN,FNP-BC Nurse Practitioner Department of Cardiology UT MD Anderson Cancer Center
Objectives
Identify the different types of cardiomyopathy Describe the pathophysiologic mechanism of cardiomyopathy/heart failure Discuss diagnostic testing/procedures for heart failure diagnosis
Case Examples
A 16 year old male with a history of pneumonia. He was brought to the clinic by his mother because he did not seem to get better after 8 weeks since the initial flu like symptoms. Last night he had severe fatigue and shortness of breath while brushing his teeth.
A 63 year old female with a known history of breast cancer, treated with anthracycline-based chemotherapy 30 years ago. Recently, she noted progressively increasing shortness of breath with exertion, PND and lower extremity swelling.
Cardiomyopathy is a weakening or deformity of the heart muscle that causes decreased pumping force.
AHA, 2008a; DeMartinis et al, 2003; Hunt et al, 2005; Yahalom et al, 2005
A complex clinical syndrome in which the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.
Epidemiology of HF in the US
12 10 8 6 4 2 0 1991 2001 2037
10
HF Patients in US (millions)
5 million symptomatic patients in 2001; estimated 10 million in 20371,2 Incidence: about 550,000 new cases/year2 Prevalence is 1% between the ages of 50 and 59 years3; progressively increasing to 10% over age 804
5 3.5
1Adapted
from Gilbert E. Rev Cardiovasc Med. 2002;3:S42-S47. 2American Heart Association. 2004 Heart and Stroke Statistical Update. 2003. 3Ho KKL et al. J Am Coll Cardiol. 1993;22:6A-13A. 4Rich M. J Am Geriatric Soc. 1997;45:968-974.
Arrhythmia
Pathologic remodeling
Death
Pump failure
30%
(EF > 40 %) (EF < 40%)
70%
Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class
Asymptomatic
ACC/AHA HF Stage1
A At high risk for HF but without structural heart disease or symptoms of HF (eg, patients with HTN or CAD)
IV Symptomatic at rest
Symptomatic
1Hunt
SA et al. J Am Coll Cardiol. 2005;38:2101-2113. 2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890-897.
Cardiac Assessment
Measures heart size, wall thickness/mobility, flow gradients, valvular function, LVEF
Assesses cardiac rhythm, conduction; can detect myocardial infarction, arrhythmias Detects heart enlargement, fluid around heart or lungs Blood urea nitrogen (BUN), creatinine, albumin (liver function), glucose (diabetes) CBC detects anemia, infection Organ function as a contributing factor or resulting from HF Creatinine kinase (CK, CK-MB), cardiac troponins I and T Brain natriuretic peptide (BNP)
Follow-up: Assess signs and symptoms, functional capacity, body weight, understanding of treatment, compliance, exacerbating factors for HF
DeMartinis et al, 2003; Chang, 2007; Fadol, 2006; Hunt et al, 2005
Chronic HF
Diurese & Home SOB Weight
Hospitalization
IV Lasix or Admit
MDs Office
PO Lasix
Emergency Room
Physical activity (low-intensity) if stable Restrict fluid (~2 L/day) and sodium intake (<1.5-2 g/day)
Digoxin
Mechanism of action:
contractility
Inhibition of sodium/potassium ATPase pump which acts to increase intracellular sodium-calcium exchange to increase intracellular calcium leading to increased contractility
Neurohormonal
Blunt SNS activation Increase vagal tone Slow conduction, prolong AV refractoriness, slowing ventricular response in atrial fibrillation
Pharmacologic Management
Digoxin Enhances inotropy of cardiac muscle Reduces activation of SNS and RAAS
Digoxin
Warnings/Precautions
Acute myocardial infarction Acute myocarditis or amyloid cardiomyopathy
Digitalis Compounds
Like the carrot placed in front of the donkey
Pharmacologic Management
Diuretics Used to relieve fluid retention
Diuretics
Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention (Class I; LOE C)
Use until euvolemic stage is achieved
Continue to prevent recurrence of fluid retention
No long-term studies
Effects on morbidity and mortality are unknown
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.acc.org/clinical/guidelines/failure/hf_index.htm
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.acc.org/clinical/guidelines/failure/hf_index.htm
Dosing IV Diuretics
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.acc.org/clinical/guidelines/failure/hf_index.htm
ACE inhibitors
Mechanism of action:
preload and afterload Arterial and venous dilatation
Reduces formation of Angiotension II (vasoconstrictor) Reduces breakdown of bradykinin (vasodilator)
Clinical Effects:
Improve symptoms Reduce remodeling / progression Reduce hospitalization Improve survival
Ace Inhibitors
Recommendations
ACEIs are recommended for all patients with current or prior symptoms of HF and reduced LVEF , unless contraindicated (Class I; LOE A) ACEIs should be used in all patients with reduced LVEF and no symptoms of HF, even if they have not experienced MI (Class I; LOE A) ACEIs or ARBs can be beneficial in patients with HTN and LVH and no symptoms of HF (Class IIa; LOE B)
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult
http://www.acc.org/clinical/guidelines/failure/hf_index.htm
Cumulative Mortality
20 15 10 5 0
Placebo Enalapril
25
Mortality From All Causes (%)
P=0.30
0.75 0.5
Enalapril
P<0.0036
P<0.003
0.25
Hydralazine Isosorbide Dinitrate
Enalapril
12
24
36
48
0
0 6 12 18 24 30 36 42 48 54 60 Months
0 1 2 3 4 5 6 7 8 910 11 12
Months
Months
SOLVD Investigators. N Engl J Med. 1991;325:293-302. 2Cohn J et al. N Engl J Med. 1991;325:303-310. 3The CONSENSUS Trial Study Group. N Engl J Med. 1987;316;1429-1435.
ACE inhibitors
ACEI
Captopril
Initial Dose
6.25 mg tid
Maximum Dose
50 mg tid
Enalapril
Fosinopril Lisinopril Quinapril Ramipril Trandolapril
2.5 mg bid
5-10 mg daily 2.5-5 mg daily 5 mg bid 1.25-2.5 mg daily 1 mg daily
10-20 mg bid
40 mg daily 20-40 mg daily 20 mg bid 10 mg daily 4 mg daily
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult
http://www.acc.org/clinical/guidelines/failure/hf_index.htm
Ace Inhibitors
Contraindications:
Hypersensitivity Angioedema related to previous treatment with ACEI
Warnings/Precautions:
Anaphylactic reactions can occur Angioedema can occur at any time during treatment, especially after 1st dose
Hereditary angioedema
Bilateral renal artery stenosis Pregnancy (2nd and 3rd trimester)
ACEIs should be discontinued temporarily while precipitating factors for ARF are corrected
ARBs are not an appropriate substitute under these conditions!!! ACEI therapy can be reinstituted once these factors are corrected
ACE inhibitors
Start with a low dose Increase dose if well tolerated (hold parameters for BP and HR) Dose NOT determined by symptoms, titrate to target dose
ARBs
Recommendations
ARBs approved for the treatment of HF are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACEI intolerant (Class I; LOE A) ARBs are reasonable to use as alternatives to ACEIs as 1st line therapy for patients with mild to moderate H F and reduced LVEF, especially for patients already taking ARBs for other indications (Class IIa; LOE A) The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who have already been treated with conventional therapy (Class IIb; LOE B)
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult
http://www.acc.org/clinical/guidelines/failure/hf_index.htm
ARBs
Valsartan
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult
http://www.acc.org/clinical/guidelines/failure/hf_index.htm
Beta-blockers
Recommendations
Beta-blockers and ACEIs should be used in all patients with recent or remote history of MI regardless of EF or presence of HF (Class I: LOE A) Beta-blockers are indicated in all patients without a history of MI who have reduced LVEF with no HF symptoms(Class I: LOE C)
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adul
http://www.acc.org/clinical/guidelines/failure/hf_index.htm
Pharmacologic Management
Beta-Blockers Cardioprotective effects due to blockade of excessive SNS stimulation In the short-term, beta blocker decreases myocardial contractility; increase in EF after 1-3 months of use Long-term, placebo-controlled trials have shown symptomatic improvement in patients treated with certain beta-blockers1 When combined with conventional HF therapy, betablockers reduce the combined risk of morbidity and mortality, or disease progression1
1 Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001 p. 20.
Beta-blockers
Mechanism of action:
Density of 1 receptors Neurohormonal activation
Antiischemic Antihypertensive
Antiarrhythmic
Antioxidant, Antiproliferatiev
Beta-blockers
Increase EF Decrease ventricular mass
25 mg bid
Mortality
0.8
Placebo Risk 34 %
Placebo 0.8 Risk 34 % 0.6 P <0.0001 P=0.006 0 1 MERIT-HF II - IV (N=3391) LVEF 40% Metoprolol CR/XL 34% 2 0.6 0.8
Placebo
Risk 35 %
0.6
P<0.00013 0 1 2
Time (years)
1 CIBIS II
NYHA Class III-IV (N=2647) Entry criteria LVEF 35% Treatment Bisoprolol Results 34% (% reduction in death)
1. CIBIS II Investigators and Committees. Lancet. 1999;353:9-13. 2. MERIT-HF Study Group. Lancet. 1999;353:2001-2007. 3. Packer M et al. N Engl J Med. 2001;344:1651-1658.
Beta-blockers
Recommendations
Beta-blockers and ACEIs should be used in all patients with recent or remote history of MI regardless of EF or presence of HF (Class I: LOE A) Beta-blockers are indicated in all patients without a history of MI who have reduced LVEF with no HF symptoms(Class I: LOE C)
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.acc.org/clinical/guidelines/failure/hf_index.htm
Beta-blockers
Medication Mechanism of action b1-selective NYHA Class III-IV Initial dose Target Dose
Bisoprolol (Zebeta)
not FDA-approved
1.25 mg/day
10 mg/day
II-IV
3.125 mg bid
II-III
-Blockers
Limit the donkeys speed, thus saving energy
Beta-blockers
Contraindications:
Cardiogenic shock, symptomatic hypotension Hypersensitivity Bradycardia HR<45 2nd and 3rd degree heart block; (P-R interval greater than or equal to 0.24 sec) unless pacemaker places
Beta-blockers
Warnings/Precautions:
Anesthesia/surgery (myocardial depression) Bronchospastic disease (less with cardioselective agents)
Decompensated HF
May mask s/sx hypoglycemia May mask signs of hyperthyroidism/thyrotoxicosis PVD use with caution since may aggravate arterial insufficiency Avoid abrupt withdrawal (may result in hypertension, tachycardia, ischemia, angina, MI, and sudden death) discontinue over 1-2 weeks
Pharmacologic Management
Aldosterone Antagonists Generally well-tolerated Shown to reduce heart failure-related morbidity and mortality Generally reserved for patients with NYHA Class III-IV HF Side effects include hyperkalemia and gynecomastia. Potassium and creatinine levels should be closely monitored
Aldosterone Antagonists
Randomized Aldactone Evaluation Study (RALES)
30% relative risk reduction in all-cause mortality and 35% reduction in hospitalizations
The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival (EPHESUS) Trial
15% relative risk reduction in all-cause mortality and hospitalizations for HF
P<0.001
Probability of Survival 0.90 Spironolactone 0.80 0.70 0.60 Placebo 0.50 0.00 0 3 6 9 12 15 18 21 24 27 30 33 36 Months
Study Design NYHA Class III-IV (N= 1663) EF 35% Frequent monitoring of potassium Result: 30% reduction in death
Pitt,NEJM 2003,348,p.1309
Aldosterone Antagonists
Recommendations
Addition of an aldosterone antagonist is reasonable in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration.
Creatinine should be 2.5 mg/dL in men or 2.0 mg/dL in women and potassium should be 5.0 mEq/L (Class I; LOE B)
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult
http://www.acc.org/clinical/guidelines/failure/hf_index.htm
Aldosterone Antagonists
ARB
Spironolactone Eplerenone
Initial Dose
12.5-25 mg daily 25 mg daily
Maximum Dose
25 mg daily or bid 50 mg daily
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult
http://www.acc.org/clinical/guidelines/failure/hf_index.htm
Vasodilators
Hydralazine + Nitrates
Nitrates
Activate guanylate cyclase to cGMP in vascular smooth muscle venodilation preload Inhibit ventricular remodeling process
Hydralazine
Direct-acting vasodilator on predominantly arterial smooth muscle SVR (afterload) Prevent nitrate tolerance, antioxidant effects
V-HeFT-II
Hydralazine 75 mg po qid + ISDN 40 mg qid vs. enalapril and enalapril was superior
LVEF <35% or left ventricular internal diastolic dimension >2.9 cm/m2 plus LVEF <45%2
1% NYHA class II, 95% NYHA class III , 4% NYHA class IV Mean age upon entry: 571
Patients randomized to receive either their current standard therapies + BiDil (n=518) or their current standard therapies + placebo1 (n=532) BiDil tablet = Hydralazine 37.5 mg/ISDN 20 mg 2 tablets po tid
Additional 39% risk reduction in first hospitalization for heart failure beyond current standard therapies (P<0.001)
Significant additional improvement in symptoms of heart failure1
Vasodilators
Recommendations
The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACEI and beta-blocker for symptomatic HF and who have persistent symptoms (Class IIa; LOE A) A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who are who cannot be given a ACEI or ARB because of drug intolerance, hypotension, or renal insufficiency (Class IIb; LOE C)
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult
http://www.acc.org/clinical/guidelines/failure/hf_index.htm
Vasodilators: Precautions
Hydralazine
Systemic lupus erythematosus Hypotension
Nitrates
Hypotension Headaches
Tachycardia
Peripheral neuritis, evidenced by paresthesia, numbness, and tingling, which may be related to an antipyridoxine effect.
Pyridoxine should be added to therapy if such symptoms develop.
Therapy Treat Hypertension Treat lipid disorders Encourage regular exercise Discourage alcohol intake ACE inhibition
Therapy All measures under stage A ACE inhibitors in appropriate patients Beta-blockers in appropriate patients
Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2005
Reverse Remodeling in HF
10/10/03
8/13/07
* pluripotent cells
Knowing is not enough; we must apply. Willing is not enough; we must do.
- Goethe