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Identifying Advanced Heart Failure and

Treatment OptionsLisa Smith MS, APRN, CCNS

Clinical Nurse SpecialistMinneapolis Heart Institute

Advanced Heart Failure Section

Disclosure Information

I have the following financial relationships to disclose:

None

Objectives

• Explain characteristics of Advanced/Stage D HF patients and how to recognize

• Discuss importance of referrals for patients with Stage D HF patients to advanced HF programs

• Identify possible treatment strategies for patients with Advanced/Stage D HF patients.

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Stages of HF — ACC/AHA Guidelines 2013

AHigh-risk patients

Hypertension, diabetes, coronary disease, family history, cardiotoxic drugs

BStructural heart disease

LVH, MI, low LVEF, dilatation, valvular disease

C

Prior, current symptoms

D

Refractory

Heart Failure

Jessup M et al, NEJM 2003.

What is Maximal Medical Therapy?

ACE inhibitor or ARB - titrated to goal or tolerance

Beta Blocker - titrated to goal or tolerance

Spironolactone - NYHA class II or III patients

Digoxin - NYHA class III patients

Diuretics - symptoms of congestion

Vasodilators: Hydralazine/Imdur - intolerant to ACE-I/ARB or persistently normotensive to hypertensive on maximal ACE-I & beta-blocker; African American population

ICD +/- CRT (QRS duration key, class IV too late)

European Heart Journal. 2008; 29 (19): 2388-2442

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Signs that a patient may be progressing to stage D HF

• Reduced functional capacity, intolerable symptoms

• HF symptoms at rest• “Cold and Wet”• Frequent hospitalizations• Decreasing EF: 15% increase in risk of CV death

or HF hospitalization with each 5% drop in LVEF below 45%

• Medication intolerance• End organ dysfunction• Inotropes or IABP

Kittleson et al. JACC 2003;41:2029-35.

Inpatient risk studiesAuthor n Risk Factors

Survival (%)

1 year

Chin 257 BP < 100, DM, non sinus rhythm

Alla 301 HR >100, Na < 134, Cr > 2.0, Age > 70, prior hosp 57.6

Cowie 220 Age, crackles, low BP, elevated Cr 62

Jong 38,702Male, age, malignancy, renal, dementia, cerebrovasc

dz, rheum, PVD, or pulmonary, ischemic etiology, DM66.9

Bouvy 152 DM, Cr, NYHA III/IV, low BMI, low BP, edema

Lee 4031 Age, low BP, high RR, high BUN, low Na 69.5

Kittleson 259 No ACE, low BP, low Na, Cr

Felker 949 Age, low BP, NYHA IV, high BUN, low Na

Fonarow 37,772 BUN > 43, SBP < 115, Cr > 2.75

Rector 769 Age, low BP, low Hgb, low Na, high BUN 50

Rohde 779 SBP < 124, Cr > 1.4, BUN > 37, Na < 136, age > 70

Outpatient Risk Studies

Study n Markers

Mahon 585CrCl, 6MW < 262, low EF, recent admit,

diuretic dose

Eshaghian 1354Low EF, low Na, low Hg, high BUN/Cr,

diuretic dose

Greenberg 4280 NYHA III/IV, HF admit, angina

Levy 1125

Diuretic dose, low BP, % lymph, Hgb < 16,

ischemic CM, EF, low cholesterol, high

uric acid/allopurinol, Na < 138, NYHA,

age, male sex

Teuteberg 160High BUN/Cr, low Na, low Hct,

recent admit, no ACE/BB

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Clinical Events/Findings

• >2 hospitalizations or ED visits for HF in past year

• Cardiac Cachexia

• Intolerance to ACEi/ARB or beta blockers

• Dyspnea with bathing or dressing requiring rest

• Unable to walk 1 block on level ground due to dyspnea or fatigue

• Frequent ventricular arrhythmias or ICD shocks

When “optimal medical therapy” fails, what are the options?

• Inotropes

• Mechanical circulatory support

• Transplant

• End of life/palliative measures

Continuous Outpatient Support with Inotropes

• High rates of hypotension, arrhythmia, syncope.

• PROMISE: 53% increase in mortality• Infection/sepsis common• Survival 3.4 months; most died at home• Milrinone as bridge to transplant

– 60 milrinone-dependent patients, listed for transplant

– 76% successfully bridged with milrinone (waited 59 days for txp)

– 24% required LVAD (waited 93 days for txp)– 5 died (waited 130 days for txp)

J Card Fail 2008;14(10): 839-843

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Intermittent Outpatient Inotrope Infusion

• No clinical benefit in randomized trials

– No significant improvement in NYHA class

– No change in 6-min walk distance

– No survival benefit

• High early mortality

– Hypotension

– Arrhythmia

– Ischemia

Circulation 2003; 108:492-497

Hershberger RE, Nauman D, Walker TL, et al. J Cardiac Failure 2003;9:180-7.Rose EA et al. NEJM 2001; 345:1435

Long-Term Inotropic Therapy is Associated with High Rates of Mortality

.

Advanced Cardiac Therapies

Miller LW, Guglin M; JACC 2012

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Ventricular Assist Devices

• Bridge to transplant

• Bridge to recovery

• Bridge to decision/candidacy

• Destination therapy

INTERMACS Profiles(Interagency Registry for Mechanically Assisted Circulatory Support)

1 Critical Cardiogenic Shock

2 Progressive decline on inotropes

3 Stable on inotropes

4 Resting symptoms on oral Rx

5 Exertion intolerant and housebound

6 Exertion limited; “walking wounded”

7 Advanced NYHA class III

Proposed LVAD Candidate “Triggers”

1. Acute cardiogenic shock (temporary device)

2. Refractory ventricular arrhythmia

3. Need for inotrope >24 hours

4. Intolerant or refractory to ACEi/ARB/BB

5. QRS > 140 ms without or refractory to CRT therapy

6. Inability to walk one block without SOB despite adequate medical therapy

7. Multiple HF-related hospital admissions

8. Diuretic dose > 1.5 mg/kg/day

9. Serum sodium < 135 mmol/L

10. BUN > 40 mg/dl or Serum Creatinine > 1.5 mg/dL

Russell SD, et al. Advanced Heart Failure: A Call to Action. Congestive Heart Failure 2008.

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Patient Selection

• Major advantage to elective implant; crisis management should be as a bridge to decision or temporary device

• No penalty for early referral• Nobody is sorry to hear “You don’t need this…yet”• Pre-operative pulmonary hypertension a good sign RV

can pump effectively: worry about the dilated RV with low PA pressures and high PCWP

• Significant pulmonary venous hypertension tends to respond very well

• Most patients need time to digest the concept

Do’s and Don’t’s• DO:

– Discuss and consider VAD when NYHA III– Consider with poor functional capacity and frequent

decompensations and hospital admission– Consider if frequent arrhythmias– Have a low threshold for RHC

• DON’T:– Wait for progressive renal dysfunction– Wait for multiple pressors– Wait for cardiac cachexia– Necessarily assume PA pressures contraindicate

Cardiac Transplant

• Gold standard for treatment of refractory end-stage HF

• First successful transplant done in 1967

• Advances in immunotherapy have significantly improved longterm survival

– 1 year 87.8%

– 3 year 78.5%

– 5 year 71.7%

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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Surv

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Years

2016JHLT. 2016 Oct; 35(10): 1149-1205

Adult and Pediatric Heart TransplantsKaplan-Meier Survival

Median survival = 10.7 years;Median survival conditional on surviving to 1 year = 13.3 years

N = 118,788

(Transplants: January 1982 – June 2015)

REGISTRY DATABASE:Number of Centers Reporting Heart Transplants

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250

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350

Nu

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North America

2016JHLT. 2016 Oct; 35(10): 1149-1205

Palliative Care and Hospice

Symptom management

• Diuretics for congestion

• Vasodilators

• Morphine for air hunger and dyspnea

• Inotropes

• ICD deactivation; leave CRT-P on

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Clinical vignette #1

31 yo femaleHodgkin’s lymphoma as a child rx with chemo and

XRTTransferred in acute HF; new dx; on dobutamineLikely chemo-induced CM, EF 20%, LV 6 cmRHC with elevated filling pressures and preserved

CIDobutamine weaned off, HF meds titrated,

discharged homeLimited social support, unable to work, lost

insurance

Clinical vignette #1

• Clinic follow-up: BP 84/60 HR 112

• Lisinopril 5 mg QD, metoprolol succinate 12.5 mg QD, spironolactone 12.5 mg QD, digoxin 0.125 mg QD, torsemide 20 mg QD

• NYHA III symptoms, Stage D

Clinical vignette #2

• 63 yo male with ischemic CM; CABG 10 years prior

• EF 25%, LV 6 cm

• 4 hospital admissions in the last 6 months for HF

• 6 month hx of fluid retention and progressive DOE and activity intolerance

• Transferred in acute decompensated HF

• Losartan 25 mg QD, Metoprolol succinate 25 mg QD, Digoxin 0.125 mg QD, furosemide 20 mg QD

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Clinical vignette #2

• BUN 47 Cr 1.9 BP 100/58 (72)

• NYHA IV symptoms

• RHC: RA=22 PA=75/35/50; PW=37; PA sat 41%; FCI 1.55

• Swan guided optimizationIABPVAD

Summary

• Heart Failure has high mortality

• Medical and device therapies have improved QOL and survival

• Inotropes, MCS, transplant and hospice are all options for advanced/end stage HF

• Refer early for discussion of options and for improved outcomes

And a reminder…