Management of CHF on Hospice

Management of CHF on HospiceDavid Kregenow, MDEvergreen HealthHospice and Palliative CareDisclosuresI have no relevant financial conflicts of interestMy background is in Pulmonary and Critical Care MedicineThe material that follows comes from:Consensus Statement: End-of-Life Care in Patients with Heart Failure. J Cardiac Failure 2014;20:121-134 on behalf of the Quality of Care Committee for the Heart Failure Society of America.OutlineClassification and Prognosis in HFCase #1Diastolic vs. Systolic FailureConnections to Renal and Respiratory PhysiologySymptom Inventory #1Case #2Systolic Failure and TherapiesSymptoms Inventory #2Mechanical Circulatory Support (LVAD)

Prognosis of Heart Failure, NYHA ClassificationClassSymptomsICardiac disease, but no symptoms and no limitation in ordinary physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).IIMild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).IIIMarked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20100 m).Comfortable only at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.IVSevere limitations. Experiences symptoms even while at rest. Mostly bedbound patients. Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.Prognosis of Heart Failure, Objective AssessmentClassDescriptionANo objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity. Risk factors but no structural heart disease. BObjective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest. Structural heart disease but minimal symptoms.CObjective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest. Symptomatic heart failure.DObjective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest. Refractory symptoms despite guideline-directed medical therapy.Prognostic ToolSeattle Heart Failure Model

www.seattleheartfailuremodel.org/

Hospice EligibilityModels may helpGuidelines helpNYHA Class IV SymptomsSymptoms despite maximal therapyPersistent resting tachycardiaPhysiology helpsCombination of heart failure and renal impairment is medically very challenging

HF Survival on Hospice is 81 days longer on average than without Hospice. J Pain Symp Mgmt 2007; 33(3): 238-46.Case 1 PresentationPhyllis is an 87 year old woman hospitalized four times this year with shortness of breath and fluid overload.She has a long history of hypertension, with moderate chronic kidney disease, macular degeneration, and paroxysmal atrial fibrillation, and a history of TIAs.She has recurrent difficulty with falls complicated by persistent lower extremity edema, and chronic bilateral pleural effusions.Her ECHO shows LVH, EF 65%, Biatrial Enlargement, and Mod-Severe Pulmonary Hypertension.She is widowed and lives in a AFH.

The Picture of CHFTwo Main Paths to CHF

HFnEFNormalHFrEFHFpEF and HFrEFHFpEFOlderF > MHypertensionFew Treatment OptionsMaintain EuvolemiaHFrEFYoungerM > FIschemiaMedical TherapiesInotrope InfusionsImplantable DevicesMechanical Circulatory SupportCardiac Transplantationhttps://www.youtube.com/watch?feature=player_detailpage&v=7TWu0_GklzoNormal EchocardiogramNormal Echocardiogram

HFpEF ECHO

Sensation of Dyspnea

Sensation of Dyspnea

Treatments for DyspneaMaintenance of euvolemiaSodium and fluid restrictionsDiureticsLeg elevation above the atriumDigoxin (Narrow therapeutic window)When near EOL:Opioids (Careful of impaired renal excretion)Oxygen if hypoxemia is presentBenzodiazepinesElevation of the Head of the Bed, Fan

Leg Elevation

Sleep Disorders in CHFApproximately 50% of HF patients have sleep disordered breathingOrthopneaNocturiaObstructive Sleep ApneaCentral Sleep ApneaCheynes-Stokes RespirationsSleep Maintenance vs. InsomniaTreatments:Sleep HygieneCPAPNocturnal OxygenNocturnal urination aidsKidney Physiology

DiureticsLoop of Henle: Furosemide, TorsemideDistal Tubule: Metalazone, ThiazidesPotassium Sparing/Neurohumoral: SpironolactoneKidney Physiology

Loop DiureticsThiazide DiureticsFatigue and Weakness in CHFMultifactorialCardiac insufficiencyMuscle lossDeconditioningOther: anemia, sleep disorders, depression, hypothyroidismOptimize what you canStimulants?Causes of Confusion and Delirium in CHFImpaired cerebral blood flow and micro emboliMedications (e.g.. Sleep aids)Sleep-wake cycle disturbanceLow BP associated with high doses of ACE Inhibitors and Beta BlockersCase 2 PresentationPaul is a 54 year old man with ischemic cardiomyopathy living at home on hospice hoping for a heart transplantHe has a family history of early death from MI, and suffered his first heart attack at age 45, presenting initially with a large anterior MIHes had an ICD placed for syncope for paroxysmal ventricular fibrillation

Case 2 Presentation ContinuesHis CHF progressed over the last 9 yearsHe has been felt to be a good candidate for heart transplant, but deteriorated before a suitable organ became availableHe has been placed on mechanical circulatory support (LVAD) and a milrinone infusionHowever, he has developed a chronic strep infection associated with his device and is no longer able to have a transplantDilated Cardiomyopathy ECHOhttps://www.youtube.com/watch?v=37KDMNiV3AU&feature=player_detailpageDilated Cardiomyopathy ECHO

ACE InhibitorsBeta BlockersDiureticsPotassium Sparing DiureticsDiureticsPain in CHFCommon in advanced CHFAnginaNitratesOther types of painOpiatesAvoid NSAIDsGI Disorders in CHFCardiac cachexiaAnorexiaIncreased catabolismNauseaMedications (e.g.. ASA)Reduced Intestinal PerfusionConstipationDecreased intake and activityMedications (e.g.. Opioids)Depression and Anxiety in CHF1/3 of patients with advanced HF have clinical depressionHigher symptom burdenIncreased adverse outcomesSpiritual CareCognitive Behavioral TherapyMedicationsSSRIs at low dose, watch for fluid retention and hyponatremia (mental status changes with edema)TCAs can prolong the QTcPsychostimulantsCoughOften worse at nightPulmonary CongestionPneumonitisBronchitisACE InhibitorsTransition to ARBsSecretionsDiscontinuing Medications for CHF on HospiceMedical management of CHF (that has helped raise life expectancy in the last 40 years) truly pushes the limits of low BPs and low HRsOn Hospice, the Goals of Care are more nuanced than survival so expectations and therapies need adjustingACE InhibitorsBeta Blockers

ConclusionHeart Failure is common and often chronicSalt and water retention produce much of the morbidity so understanding diuretics helps managementPreserved EF vs. Reduced EF are significantly different entities that can look alike clinicallyThere is a high symptom burden, but many toolsOften less is more for the patientThe LVADs are coming!