HeartFailureeducationforMDandnurse060209.docx

HeartFailureeducationforMDandnurse060209.docx

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HeartFailureeducationforMDandnurse060209

DanSorescu,MD,updatedJune2,2009

HeartFailureEducationforMDsandNurses

Apracticalguideforinpatientmanagementofpatientsadmittedfor

Acutelydecompensatedheartfailure（ADHF）

EmoryUniversityMidtownHospital

PartA:

CarefortheHospitalizedPatientwithHeartFailure

Whatnursesandphysicianneedtoknowforagoodpatientcareoutcome…

1.

HeartFailureSymptoms:

AskthepatientabouttheirsymptomsandINFORMthephysicianofanyneworworseningHFsymptoms（donotassumethephysicianisawarethatthepatientisexperiencingneworworseningsymptoms）.

2.Symptomsofleftsidedheartfailure（congestionontheleftside）:

∙Orthopnea/PND:

Isthepatientwakingatnightwithdifficultybreathingordoesthepatienthavedifficultyfallingasleepdueto“anxiety”?

Doesthepatientdescribenighttimesymptomsof“drowning”,“smothering”,insomnia,orhavingadrycoughatnight?

Thesec/o’sareoftentimesequivalentsymptomsforparoxysmalnocturnaldyspnea（PND）duetoshiftofwaterfromperipherytolungsatnight.

∙DOE:

Isthepatientexperiencingworseningdyspneaonexertion（DOE）andifso,whendiditstart?

Isthepatientexperiencingworseningexercisetolerance（feelingmoretiredorfatiguedwithanyactivity）—whenwasthisworseningexercisetolerancefirstnoticed?

Worseningexercisetolerance（DOE）mayindicateworseningcardiacoutputandheartfunction.

∙OrthostaticDizziness:

Doespatientreportdizzinesswheninverticalposition?

Orthostaticdizzinesssuggestsintravasculardepletionfromoverdiuresis,sepsisorverylowcardiacoutput.

3.Symptomsofrightsidedheartfailure（congestionontherightside）:

∙Poorappetite,earlysatiety:

Ispatientexperiencingaworseningofappetite?

Assessifthepatientcaneatacompletemealwithoutfeelingfullornauseated.

∙Payattentionifthepatientishavingepigastricpainorfullnessbeforefinishingamealandwhichisclearlyaggravatedbymealsassociatedwithanincreaseintheirabdominalgirth（ascites）.Theabovesymptomsareoftenduetoliverandstomachcongestionfromheartfailure.Thesesymptomsareespeciallypresentinpatientswithadvancedheartfailurewhorequirechronicdiureticuse.Donotbefooledifthereisminimalevidenceofperipheraledemainpresenceofrightsidedheartfailurewithvolumeoverload.

∙Decreasedurineoutput:

Payattentiontotheeffectivenessofthediureticregimen.Aretheyhavingthesameeffectaswheninitiallydosed（causingsimilaramountofurineoutputasbefore）?

Whenthereisstomachandlivercongestion,medicationabsorbtiondecreases,especiallyforfurosemideandhydralazineandreducestheireffectivenessandpatientswillcomplaintheydon’tworkanymore.

∙LowerextremityEdema（LEE）:

Anylowerextremityswelling?

Inordertoquantifyedemaseebelow.

4.Importantinformationaboutthepatient’soutpatientHFcarepriortoadmission:

∙Whoisthephysicianwhomanagestheirheartfailure;whenwaslasttimetheysawhim/her?

∙Whoistheir“helper”orcoachathome?

Studieshaveshownthatpatientswhohaveacoachathometohelpimplementthetherapyanddietaryinstructionsdomuchbetterthantheoneswhodon’t.Ifthepatientdoesnothavea“helper”or“coach”,whoistheirmainsupportandisthispersonabletoprovidesupportatthistime?

∙HomeMedicationspriortoadmission?

Aretheytakingthemroutinely?

∙WhenwaspatientfirstdiagnosedwithHFandhowfrequentlydotheyrequirehospitalizations/ERvisits?

AretherebarrierstoHFtreatments（financial,social,perceptionofillness,cognitiveimpairment）?

∙Saltrestriction（dotheyeatout,etc）,dotheyknowhowtoreadlabels?

∙PriorTests/Therapies:

Didtheyhavearecentstresstest,cardiaccatheterization,pacemaker/defibrillatorandifsowhenwaslasttimetheyreceivedashock.Whoisfollowingtheirpacemaker/ICDandwhattypeofdevicedotheyhave（Medtronic,etc）.

5.Otherillnesses（co-morbiddisorders）thatcandecompensateheartfailureandaffect/complicateitstreatmentinhospital:

∙Anysignsofinfection（URI,UTI,etc）.

∙Anyjointaches,swelling?

（GOUTattackswhichalwaysoccur1-2weeksafterarecentincreaseindiureticsuse）.

oEitherinflammation（gout）orinfectionswillcauseinappropriatevasodilatationofperipherywithvasoconstrictioninthekidneys,whichwilldecompensatetheirheartfailureandoftenuspreventfromtreatingit（needtoholddiureticsandvasodilatorsuntilUTI/goutresolves）.

∙Anydiarrhea（causeslostofKandMgandtriggersarrhythmiasandshocksfromICD）orconstipation（alterstheabsorbtionofvitaminKandthereforeresponsetowarfarin）.

∙Headache（mostcommonsideeffectfromnitrates）anddizziness（mostcommonsideeffectfromhydralazine）.

6.Physicalexamofthepatientadmittedwithacutelydecompensatedheartfailure（ADHF）:

VitalSigns

oIdeally,everypatientadmittedwithADHFshouldhaveorthostaticBPandpulseperformed/documentedonadmission.Iforthostatichypotensionispresent,thepatientlikelyhasintravasculardepletionorissepticandoftenrequireswithholdingofdiuretics.

oDocumentsystolic,diastolicandmeanarterialpressure（MAP）.Note:

AnidealMAPis65-70mmHg（thiscorrespondstoanSVRof900-1000）inthosepatientsadmittedwithacuteCHF.Thepulsepressure（PP）isdifferencebetweensystolicanddiastolicBPdividedbysystolicBP.

oSBPreflectsmorethestrokevolumeandthereforecardiacoutputandwilldecreaseascardiacoutputdiminishes.Typically,eveninpriorhypertensivepatients,thesystolicBPwillgodowninadvancedheartfailurebecauseoflowEF.ForexampleaBPof110/90isactuallyseverehypertensionforthesepatientsbecausehighMAPreflectssevereperipheralvasoconstriction（iftheyhadnormalEF,SBPwould’vebeen200mmHg!

）andthisisofteninterpretedwronglybyMDsashypotensionandleadtoinappropriatewithholdingofvasodilators!

Oftenthesepatientswillbecomehypertensiveagainoutpatient,2-3monthsaftertheyareplacedonappropriatedrugstoimprovetheirEF.

oDBPreflectsmoretheperipheralvasculartoneandwillincreasewithvasoconstriction（highsystemicvascularresistance（SVR））andwilldecreasewithvasodilatation（highSVR）.Therefore,asmallPPequalslowcardiacoutputwhileahighPPequalsnormalorhighcardiacoutputwhichstronglysuggestssystemicinflammation（gout）orsepsis（UTI,etc）.Anydiastolic>70mmHgisabnormalhighinpatientswithADHF（patientisvasoconstrictedandneedsvasodilators）,thesameanydiastolic<50mmHgisinappropriatelow（patientistoovasodilatedandmayhaveSIRSorsepsisandmayneedpressors）.

∙IftheMAPis>70mmHg;thisisinappropriatelyhighforapatientwithacutelydecompensateheartfailureandvolumeoverload.

∙Ifthepatientiscold（vasoconstricted）andwet（edema,volumeoverload）

oA）Ifthepulsepressureisnormal（SBP-DBP>25%ofSBPbutlessthen50%）,thenpatientneedsvasodilatorsfirst（tovasodilateandincreasecardiacoutput）andthendiuretics.

oB）Ifthepulsepressureislow（PP<25%ofSBP,example90/70mmHg）,thenpatienthaslowstrokevolume,treatmentisthesamebutthepatientmayalsobenefitfrominotropes（milrinoneordobutamine）.IngeneralthereisnoneedforinotropesaslongasMAP>70mmHgandpatienthasgoodrenalfunction.Howeverifrenalfunctionworsens（renalhypoperfusionduetolowcardiacoutputandrenalvasoconstriction）andpatientisstillsymptomaticwithcongestion（stillneedsdiuretics）thenmaybenefitfromadding/switchingtoaninotropbeforeadministeringdiuretics.

∙IftheMAPis<65mmHg.

∙A）Andthepatientiswarmandwet,withpulsepressure>50%（exampleBP90/40mmHg）thereismostlikelyconcomitantsepsis（UTI,etc）orotherinflammatoryexplanation（suchasgoutorSIRS=systemicinflammatoryresponsesyndrome）whichinappropriatelyvasodilatestheperiphery（lowSVR）andvasoconstrictsthekidneyoftenwithworseningrenalfunction.Thevasodilatorsanddiureticsneedtobewithholdbecausewillaggravaterenalfunction.Oncontrary,oneneedstoincreaseMAPto65-70mmHgtoshiftthebloodbackfromperipherytomainorganstoimprovetheirperfusion.Occasionally,patientneedtobetransferredtoICU/CCUtoreceivelowdosepressors（norepinephrine2-5mcg/min）toraisetheMAPandimproverenalperfusionwhilewearetreatingtheunderlyinginflammatory/septiccondition）.

∙B）Andthepatientiswarmanddry,thencheckorthostaticstoconfirmthatpatientisintravasculardepleted.Thisconfirmstrueoverdiuresisandweneedtostopdiureticsandvasodilatorsandgive2litersofwater-ideallyorally.Ifpatientispersistenthypotensiveonemayrepletefluidwithiv500-1000mlof½NSover2-4hours（avoidNSwhichgivestomuchsaltandwillalwayscausenextdayinappropriatevolumeexpansionduetoexcessivesodiumloadandpatientrecurringCHF）.

∙C）Andthepatientiscoldandwet-thenlikelypatienthasseverelyreducedcardiacoutputduetobothinappropriatevasoconstrictionandlowEF.Thetreatmentwillbetofirststartaninotrope（dobutamine5mcg/kg/min）andcheckagainBPin30min.Ifindeedthatisthecase,usuallytheMAPwillincrease>65mmHgandthenwecanalsoaddthevasodilators（again,weneedtodothisbeforegivingdiuretics）.

∙D）Andthepatientiscoldanddry（liesflatwithoutbeingSOBandnoevidenceofperipheralandcentraledema）,-patientmaybeintravasculardepletedfromoverdiuresisandmayneedinotropes（severelyreducedcardiacoutput）.Ifthatisthecase,administrationof500mlof1/2NSover1hourshouldincreasetheMAP>65mmHg.IftheMAPisstilllessthen65mmHgthepatientneedsinotropestooandmayben