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TREATMENT OF HEART FAILURE From Oral Medications to Intravenous Drips Mark Puhlman MSN ANP Slide 2 Slide 3 Heart Failure Slide 4 HF is a chronic condition that can usually be treated with medications Slide 5 Incidence 5.1 million heart failure patients in US 650,000 new cases per year 5-10% (255,000-650,000) with symptoms at rest (NYHA IV) (Yancy, 2013) Slide 6 Slide 7 Slide 8 Slide 9 What is HF? Slide 10 Heart = pump Slide 11 Slide 12 Heart failure = Inefficient pump Slide 13 weak (poor squeeze) Slide 14 stiff (poor filling) Slide 15 Systolic HF Diastolic HF Slide 16 NormalHeart failure Slide 17 What causes HF? Slide 18 Toxins CAD Valve disease Arrhythmia High BP Thyroid disease Idiopathic Myocarditis Familial Peripartum HIV Sarcoid Congenital Cardiomyopathy Anemia Obesity Diabetes Slide 19 Myocardial Infarction (MI) Slide 20 Slide 21 High blood pressure (hypertension) Slide 22 Slide 23 Valve disease Slide 24 Slide 25 What are the symptoms? Slide 26 Shortness of breath Fatigue Rapid or irregular pulse Swelling of legs Dizziness Cough Sudden death Difficulty lying flat Slide 27 No single test to diagnose HF in all cases Slide 28 Echocardiogram Slide 29 Slide 30 Slide 31 How is HF treated? Slide 32 Salt leads to fluid retention Slide 33 I dont add salt to my food Slide 34 Slide 35 Slide 36 2 L fluid Slide 37 Fluid pills (diuretic) Slide 38 Slide 39 ACE- inhibitors Angiotensin receptor blockers Beta- blockers Aldosterone antagonist Diuretics Slide 40 What Happens When Medications Fail ? Stage D/Class IV Heart Failure Heart Transplant Destination Heart Failure Palliative Care Slide 41 What Happens When Medications Fail ? Criteria For Heart Transplant CPET < 14 Class IV Heart Failure Failed Medical Therapy End organs intact No cancer within 5 years Social Structure Slide 42 What Happens When Medications Fail ? Criteria For Destination Therapy CPET < 14 Class IV Heart Failure Failed Medical Therapy End organs intact Life Expectancy > 2 years Except for Heart Failure Social Structure Not Candidate for Heart Transplant Slide 43 What Happens When Medications Fail ? Criteria For IV Inotrope Bridge to Advanced Therapies (TX or DT-VAD) Questionable Compliance Questionable Social Structure Palliative Care No increased risk for PICC Line Insertion Slide 44 Intravenous Inotropes Why do we give these drugs? Positive Inotropy Increases power of contraction Vasodilation Decreases the hearts work Slide 45 Intravenous Inotropes Milrinone: Vasodilates (pulmonary tree and peripheral) Increases strength of contraction of heart muscle Dose.376-.75 mcg/kg/min Side effects Arrhythmia 3% Hypotension 4% Head Ache 3% Slide 46 Intravenous Inotropes Dobutamine: Vasodilates (minor) Increases strength of contraction of heart muscle Dose 2-20 mcg/kg/min Side effects Arrhythmia 10 % Hypertension 7.5% Head Ache 3% Palpitations 5% Slide 47 Survival on Inotropes J Card Fail. 2003;9:180-187. Rematch Trial Randomized to LVAD or Medical Management Inotropes 1-Year Survival (N=46): 24% Circ. 2004;110:975-981. Slide 48 Survival On Inotropes MODERN ERA Single center retrospective review (University of Alabama) 197 Consecutive patients (2007-2013) Listed for transplant or awaiting LVAD (60) Undergoing evaluation for LVAD/transplant (20) Stabilization prior to CRT or PCI (4) Offered LVAD but chose inotropes (15) Palliation (98) Circ Heart Fail. 2015;8:880-886. Slide 49 Survival On Inotropes MODERN ERA Those not candidates for Transplant or LVAD Median Survival: 9 Months 1-Year Survival: 47.6% 2-Year Survival: 38.4% Circ Heart Fail. 2015;8:880-886. Slide 50 Survival On Inotropes Complications of Home Inotropes Complications of home inotropes and prolonged venous access Infection Thrombosis Arrhythmia Sudden Cardiac Death Worsening of end organ function Progression of heart failure Alteration in candidacy for advanced therapies Slide 51 Slide 52 Slide 53 Jacob Abraham, MD Gary Ott, MD * Alicia Ross, MD Josh Remick, MD Mark Puhlman ANP, VAD/TX coordinator Kate Evenson RN, VAD/Tx Coordinator Rebecca Lewis RN, VAD/Tx Coordinator KC Dailey, MSW-LCSW Renee Swanson, RN, Manager Center for Advanced Heart Disease