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Inpatient Heart Failure Inpatient Heart Failure

Management:

Management:

Risks & Benefits Risks & Benefits

Dr. Kenneth L. Baughman Dr. Kenneth L. Baughman

Professor of Medicine Professor of Medicine Harvard Medical School Harvard Medical School

Director, Advanced Heart Disease Section Director, Advanced Heart Disease Section

Brigham & Women's Hospital Brigham & Women's Hospital

Harvard

Medical School

(2)

Inpatient Heart Failure Management Inpatient Heart Failure Management

„„

Most common DRG > 65 years old Most common DRG > 65 years old

„„

Today Today ’ ’ s focus s focus

„„ Exacerbation of established CHFExacerbation of established CHF

„„

Not Not

„„ New onsetNew onset

„„ Acute ischemiaAcute ischemia

„„ MechanicalMechanical

(3)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Outline Outline

„„ Indications for hospitalizationIndications for hospitalization

„„ Etiology of exacerbationEtiology of exacerbation

„„ Risk stratificationRisk stratification

„„ Modifications of standard therapyModifications of standard therapy

„„ Management of refractory CHFManagement of refractory CHF

„„ IV diureticsIV diuretics

„„ Indications for hemodynamic monitoringIndications for hemodynamic monitoring

„„ Vasodilatos/InotropesVasodilatos/Inotropes

„„ Mechanical Mechanical UF, VAD, IABPUF, VAD, IABP

„„ Discharge planningDischarge planning

(4)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Indications for hospitalization Indications for hospitalization

„„

Congestion Congestion – – symptoms, weight gain symptoms, weight gain

„„

Low output Low output – – mentation mentation , renal perfusion , renal perfusion

„„

Arrhythmia Arrhythmia

„„

Co Co - - morbid conditions morbid conditions

„„

Electrolyte abnormalities Electrolyte abnormalities

(5)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Etiology of exacerbation Etiology of exacerbation

„„

Noncompliance Noncompliance

„„

Cardiac deterioration Cardiac deterioration

„„

Toxins Toxins – – alcohol, medications alcohol, medications

„„

Non cardiac Non cardiac

„„ ThyroidThyroid

„„ InfectionInfection

„„ PulmonaryPulmonary

(6)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Risk stratification Risk stratification

Fonarow

Fonarow GC, JAMA 2005; 293: 572GC, JAMA 2005; 293: 572

(7)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Decomposition categories Decomposition categories

Congestion & output Congestion & output

Nohria A, Stevenson L, Nohria A, Stevenson L,

Wet & warm Wet & warm Dry & warm

Dry & warm

Wet & cold Wet & cold Dry & cold

Dry & cold

(8)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Standard management Standard management

„„

NaCl NaCl limitation (2 grams) limitation (2 grams)

„„

Fluid restrict (2 liters) Fluid restrict (2 liters)

„„

Oxygen Oxygen

„„

Diuretics Diuretics

„„

Vasodilators Vasodilators

„„

Beta blockers Beta blockers

(9)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Diuretics Diuretics

„„

Intravenous Intravenous

„„ Dose IV = 2x oral (except torsemideDose IV = 2x oral (except torsemide))

„„ LasixLasix 40 IV = 80 orally40 IV = 80 orally

„„ Frequency Frequency –– 22--3x/day bolus 3x/day bolus

„„ Continuous infusionContinuous infusion

„„

“ “ Stacking Stacking ” ”

(10)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Continuous infusion vs. bolus Continuous infusion vs. bolus

Cochrane Database 2004: (1): CD003178 Cochrane Database 2004: (1): CD003178

RR 0.52 RR 0.52 Decreased mortality

Decreased mortality

p < 0.001 p < 0.001 Decreased LOS

Decreased LOS

p 0.005 p 0.005 Decreased

Decreased ototoxicityototoxicity

p 0.50 p 0.50 Decreased electrolyte toxicity

Decreased electrolyte toxicity

p < 0.01 p < 0.01 Stable effect

Stable effect –– volume & volume & diuresisdiuresis

Cochrane analysis Cochrane analysis Advantages

Advantages

(11)

Inpatient Heart Failure Management Inpatient Heart Failure Management

1.1. LoopLoop

2.2. Late distalLate distal

3.3. Early distalEarly distal

4.4. Proximal (toxicity)Proximal (toxicity)

amiloride amiloride torsemide

torsemide

triamterene triamterene ethacrynic

ethacrynic acidacid

eplerenon eplerenon metolazone

metolazone bumetinide

bumetinide

spironolactone spironolactone thiazide

thiazide furosemide

furosemide acetazolamide

acetazolamide

Late distal Late distal Early distal

Early distal LoopLoop

Proximal Proximal

(12)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Standard therapy modifications Standard therapy modifications

„„ DiureticsDiuretics

„„ Efficacy Efficacy symptoms, congestionsymptoms, congestion

„„ Toxicity Toxicity systemic under perfusion (renal), electrolytessystemic under perfusion (renal), electrolytes

„„ BNP vs. clinically guidedBNP vs. clinically guided

„„ VasodilatorsVasodilators

„„ Maximize when “Maximize when drydry

„„ Beta blockersBeta blockers

„„ Continue if possibleContinue if possible

„„ Reduce doseReduce dose

„„ Stop if sympathomimeticStop if sympathomimetic usedused

(13)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Predischarge initiations of beta blockers in patients Predischarge initiations of beta blockers in patients

hospitalized for decompensated heart failure hospitalized for decompensated heart failure

Gattis WA JACC 2004; 43: 1534 Gattis WA JACC 2004; 43: 1534

(14)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Refractory CHF

Refractory CHF – – Phase I Phase I

„„ IV TNGIV TNG

„„ Nesiritide (BNP)Nesiritide (BNP)

„„ MilrinoneMilrinone

„„ Dopamine/Dopamine/dobutaminedobutamine

(15)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Nesiritide in ADHF Nesiritide in ADHF

Colucci

Colucci WS NEJM 2000; 343: 246WS NEJM 2000; 343: 246

„„ 127 patients127 patients

„„ Hemodynamic Hemodynamic monitoring

monitoring

„„ RandomizedRandomized

„„ PlaceboPlacebo

0.015 mcg/kg 0.015 mcg/kg

„„ NesiritideNesiritide

0.030 mcg/kg 0.030 mcg/kg

„„ Six hour infusionSix hour infusion

5%5%

38%38%

Fatigue Fatigue

12%12%

53%53%

Dyspnea Dyspnea

+ 14%

+ 14%

+ 67%

+ 67%

Global clinical Global clinical

+ 2%+ 2%

10%10%

PCWP (mmHg) PCWP (mmHg)

Placebo Placebo BNPBNP

(16)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Short term risk of death after treatment with Short term risk of death after treatment with

Nesiritide for DHF Nesiritide for DHF

Sackner

Sackner--Bernstein JD JAMA 2005; 293: 1600Bernstein JD JAMA 2005; 293: 1600

(17)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Risk of worsening renal function with Nesiritide in Risk of worsening renal function with Nesiritide in

patients with ADHF patients with ADHF

Sackner

Sackner--Bernstein JD Circulation 2005; 111: 1487Bernstein JD Circulation 2005; 111: 1487

(18)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Safety and feasibility of using serial infusions of Safety and feasibility of using serial infusions of

Nesiritide for CHF in outpatients Nesiritide for CHF in outpatients

Yancy

Yancy CA AJC 2004; 94: 595CA AJC 2004; 94: 595

„„ 210 patients210 patients

„„ CreatineCreatine 1.81.8

„„ EF 28%EF 28%

„„ Randomized to weeklyRandomized to weekly

„„ PlaceboPlacebo

0.005 mcg/kg 0.005 mcg/kg

„„ NesiritideNesiritide

0.010 mcg/kg 0.010 mcg/kg

„„ Outcomes Outcomes –– NSNS

„„ Significant adverse Significant adverse events

events –– NSNS

„„ Higher risk Higher risk -- eventsevents

(19)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Effect of Nesiritide vs. Dobutamine on short term Effect of Nesiritide vs. Dobutamine on short term

outcomes in treatment of patients with ADHF outcomes in treatment of patients with ADHF

Silver MA JACC 2002; 39: 798 Silver MA JACC 2002; 39: 798

(20)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Milrinone Milrinone

„„ PhosphodisterasePhosphodisterase inhibitorinhibitor

„„ VasodilatorVasodilator

„„ InotropeInotrope

„„ DoseDose

„„ Load 50mcg/kgLoad 50mcg/kg

„„ Drip 0.375 Drip 0.375 0.750 mcg/kg/min0.750 mcg/kg/min

(21)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Short term intravenous milrinone for acute Short term intravenous milrinone for acute

exacerbation of chronic heart failure exacerbation of chronic heart failure

Cuffe

Cuffe MS JAMA 2002; 287: 1541MS JAMA 2002; 287: 1541

(22)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Dopamine Dobutamine Dopamine Dobutamine

„„

General General

„„ SympathomimeticsSympathomimetics –– betabeta11 > beta> beta22 > alpha> alpha

„„ InotropesInotropes

„„ Increase cardiac output, mild resistanceIncrease cardiac output, mild resistance

„„ Toxicity dose dependentToxicity dose dependent

„„

Specific Specific

„„ Dopamine Dopamine –– renal vascular effectsrenal vascular effects

„„ Dobutamine Dobutamine -- eosinophiliaeosinophilia

(23)

Inpatient Heart Failure Management Inpatient Heart Failure Management

„„ MechanicalMechanical

„„ UltrafiltrationUltrafiltration

„„ Biventricular pacingBiventricular pacing

„„ IABPIABP

„„ Left ventricular assistLeft ventricular assist

„„ ReplacementReplacement

„„ Heart transplantHeart transplant

End stage 10%

End stage 10%

Advanced 20%

Advanced 20%

Standard 70%

Standard 70%

(24)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Indications for hemodynamic monitoring Indications for hemodynamic monitoring

„„

Refractory CHF Refractory CHF

„„

Volume status unknown Volume status unknown

„„

Use of any Use of any vasoactive vasoactive agent agent

„„

Hypotension (with or without renal Hypotension (with or without renal insufficiency)

insufficiency)

(25)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Patients with heart failure Patients with heart failure 60 60 - - 90 day mortality 8.6% 90 day mortality 8.6%

60 60 - - 90 day rehospitalization 29.6% 90 day rehospitalization 29.6%

Mortality Mortality

„„ AgeAge

„„ CreatinineCreatinine

„„ Lung diseaseLung disease

„„ Liver diseaseLiver disease

„„ Low BPLow BP

„„ Low NaLow Na

„„ Lower wtLower wt

„„ DepressionDepression

Readmission & death Readmission & death

„„ CreatinineCreatinine

„„ BP (systolic)BP (systolic)

„„ HemoglobinHemoglobin

„„ Lung diseaseLung disease

(26)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Refractory Heart Failure Refractory Heart Failure

All therapies beyond standard treatment All therapies beyond standard treatment

increase mortality

increase mortality

(27)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Discharge planning Discharge planning

„„ Stable weight & electrolytes 24Stable weight & electrolytes 24--48 hours48 hours

„„ Off inotropes Off inotropes –– 2424--48 hours48 hours

„„ Off IV diuretics Off IV diuretics –– 2424--48 hours48 hours

„„ Stable oral regimen 24 hoursStable oral regimen 24 hours

„„ Exacerbating etiology correctedExacerbating etiology corrected

„„ Patient and family educationPatient and family education

„„ Early followEarly follow--upup

„„ Disease managementDisease management

(28)

Inpatient Heart Failure Management Inpatient Heart Failure Management

Outline Outline

„„ Indications for hospitalizationIndications for hospitalization

„„ Etiology of exacerbationEtiology of exacerbation

„„ Risk stratificationRisk stratification

„„ Modifications of standard therapyModifications of standard therapy

„„ Management of refractory CHFManagement of refractory CHF

„„ IV diureticsIV diuretics

„„ Indications for hemodynamic monitoringIndications for hemodynamic monitoring

„„ Vasodilatos/InotropesVasodilatos/Inotropes

„„ Mechanical Mechanical UF, VAD, IABPUF, VAD, IABP

„„ Discharge planningDischarge planning

References

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