CHRONIC HEART FAILURE

Sandra McCreanor CNS Darron Webber CNC Fiona Love CNS

BACKGROUND
It is estimated that 300,000 Australians are affected by heart failure (based on US data)* In over 50% of new cases IHD is the underlying cause of heart failure*

* National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. Guidelines for the prevention, detection and management of chronic heart failure in Australia. Updated July 2011.

Five-year survival post hospitalisation

1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0

Women

1.0 0.9 0.8 0.7 Breast 0.6 0.5 MI 0.4 Bowel 0.3 Ovarian Heart Failure 0.2 0.1 Lung 0.0 Survival (%) 0 12 24

Men Men

(%) Survival

MI Bladder Prostate Bowel Heart Failure Lung

12 24 36 48 60 Month of follow-up

36

48

60

Month of follow-up

3 Stewart et al Eur J Heart Fail

Estimated numbers of people living with chronic heart failure in Australian census collection districts and locations of CHF management programs

Robyn A Clark, Andrea Driscoll, Justin Nottage, Skye McLennan, David M Coombe, Errol J Bamford, David Wilkinson and Simon Stewart Med J Aust 2007; 186 (4): 169-173.

Causes of systolic heart failure (impaired ventricular contraction)

Coronary Artery Disease Essential hypertension

Less common causes of heart failure

Non ischaemic idiopathic dilated cardiomyopathy

Uncommon causes

Valve Disease Non ischaemic idiopathic dilated cardiomyopathy secondary to alcohol Chronic arrhythmia Thyroid dysfunction HIV related cardiomyopathy Drug induced cardiomyopathy Peripartum cardiomyopathy
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Causes of heart failure with preserved systolic function (impaired relaxation)

Coronary Artery Disease Hypertension Diabetes

Less common causes of heart failure

Valve Disease

Uncommon causes

Hypertrophic cardiomyopathy Restrictive cardiomyopathy

Patient Assessment Symptoms

Symptoms physical examination

Raised JVP Apex beat displaced laterally Third heart sound Soft fine creps in bases of lungs Liver enlargement Oedema
Peripheral and abdominal

 SY

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New York Heart Association Grading (NYHA)

Class I No limitations. Ordinary activity does not cause S&S Asymptomatic LV dysfunction Slight limitation of physical activity Mild CHF Marked limitation of physical activity Do you get short of breath showering? Moderate CHF Unable to carry on any physical activity without symptoms Do you get short of breath dressing or at rest? Severe CHF

Class II

Class III

Class IV

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Pharmacological management
ACE Inhibitors or Angiotensin II receptor blockers
Blockers Diuretics Aldosterone Antagonists Digoxin

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Drugs to avoid in chronic heart failure

There are many drugs that can impact on CHF common ones that are important from a nursing perspective include: Non steroidal anti-inflammatories Over the counter medications that effervesce Ural, Berroca, soluble Panadol

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Factors that increase the risk of emergency admission

Hx of non adherence in the past Poor social support Increased age Depression Hx of failure to seek help early Co morbidities Poor health literacy
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Most Common Symptoms Before Hospitalisation

Dyspnoea (76%) Acute dyspnoea (37%) Oedema (35%-66%) Fatigue (37%) Cough (33%) Chest pain (25%)
Friedman,1997 Evangelista et al 2001
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THE MAIN FACTORS THAT CONTRIBUTE TO EMERGENCY RE-ADMISSION

1) Failure to seek medical help (32%)

2) Non adherence to diet (Na+ / fluid) & medication (40%)

Source: Moser, D 2002

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Home-based Intervention in CHF

Stewart et al, Lancet 199919

Nurse led heart failure management

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Non pharmacological management general dietary recommendations

Maintain healthy weight range Saturated fat limit especially in those with CAD unless end stage CHF Fibre due to fluid accumulation in gut and poor blood supply & constipation is common Malnutrition (cardiac cachexia) small frequent meals high in energy with referral to dietitian For alcohol related cardiomyopathy the person should abstain. For others 10 20 g / day maximum (min 2 ETOH free days / week)
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Non pharmacological management specific dietary recommendations

SODIUM is directly related to fluid overload and impacts quickly on symptoms Assess current diet and assist with low Na options Pay attention to packaged food: processed meat, vegemite, crackers & biscuits Low Na product = 120 mg / 100g
In winter some elderly people eat packaged soup leading to what heart failure nurses call a Cup of Soup epidemic
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- Oats 8mg / 100g

vs

Cornflakes 720mg / 100g

Non pharmacological management FLUID MANAGEMENT 1kg = 1 litre Daily weighing and recording of weight Should be digital scales sensitive to 0.2 kg Fluid intake in general 1.2 1.5 L / day

Dry mouth mouth spray, sips of H20, suck ice

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Considerations need to be made in hot weather and for those people who are stable or spending time outdoors

ACTION PLAN
CHECKLIST FOR STAYING WELL Take your medications Weigh yourself every day to watch for fluid build up Limit salt intake Drink sensible amounts of fluid; around 1500mls Report warning signs early Exercise most days at a comfortable pace Keep your vaccinations up to date - (Fluvax once a year & Pneumovax every 5 years)
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ACTION PLAN WARNING SIGNS AND SYMPTOMS THAT FLUID IS BUILDING UP A sudden increase in weight (2kgs in 48 hours) Feeling more short of breath than usual New swelling in feet, legs or abdomen Develop a cough that does not go away Waking up at night short of breath WHAT TO DO Contact your Heart Failure Nurse and / or take an extra fluid tablet, Frusemide (Lasix, Urex, Uremide,) for one day only or as prescribed. Do not take extra Frusemide unless your doctor has given you permission.

OTHER IMPORTANT SIGNS

Develop a temperature or infection Palpitations or racing heart with feeling light headed  Contact GP
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Psychosocial assessment & considerations welcome to my world

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Psychosocial assessment and considerations

Symptoms Co-morbidities Family, living arrangements, social support Current or previous work, hobbies Cognition, coping, hygiene ADLs, mobility problems Psychological Hx depression, anxiety, stress etc Financial and / or social stressors
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Traditional approach to

education-> persuasion
Advise Explain Warn Make suggestions Disagree, quote statistics Reassure
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Persuasion encourages the person to reaffirm the reasons why they cannot change and increases their resistance to change. Telling the person what to do will lead them to say:

yes but

yes but

yes but
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Approaches that are effective Utilising good communication skills in particular active listening Personalised & realistic goal setting Motivational Interviewing Health Coaching Group programs / mentoring
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PROFESSIONAL CONSIDERATIONS
Remember one day you or some one you love will be faced with a crisis and/or death
Treat people how you would like to be treated

Contemplate the issue of power Remain professional People in crisis often behave in ways not usual for them Try not to be judgmental

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CASE STUDY 76yr old male (Robert)

Issues prior to admission to rehabilitation - MI while overseas - Presented to ED with leg cellulitis / lethargy - Found to be in AF with Congestive Cardiac Failure. - Cardiac arrest in ED - Coronary Angiogram for CABGs - Echo impaired LVEF
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Post op recovery following CABGs

- Intra-aortic balloon pump inserted - AF, hypotension requiring inotrope support - VF arrest day 2 - Extubated day 7 - AICD day 13 (Automated Implantable Cardioverter - Oedema legs, PEG bandages - Mild SOB on exertion
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Defibrillator)

Transfer to Rehabilitation Hospital

Underwent a multi-disciplinary team assessment involving nursing staff, physiotherapist, occupational therapist and social worker Echo showed LVEF 20-25% with severe global systolic dysfunction. Remained in AF Hypotensive asymptomatic Oedema of legs improved with PEG bandaging Walking with rollator. Falls prevention program. Denied pain throughout admission
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Discharged home
Married. Wife in good health Function at discharge - Mobility independent with stick - Self care independent - Cognition intact - Continent - Wounds small areas ooze in both legs - Wears compression stockings
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Medications on discharge
Carvedilol 3.125mg Bd Frusemide 60mg mane Atorvastatin 40mg nocte Omeprazole 20mg Bd Spironolactone 12.5mg mane Amiodarone 100mg mane Warfarin variable dose daily
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 Participated in Heart Failure program learning about heart failure signs and symptoms and self management of heart failure Completed Heart Failure program but returned to participate in heart failure maintenance exercise class

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 Completed Cardiac Rehabilitation program (learnt about secondary prevention for his ischaemic heart disease) and also returned to complete exercise program Admission to hospital 6 months later gained 6kgs! Despite having Flexible Diuretic Regime approved (? Non compliance of self management plan) On discharge lasix increased to 40mg Bd

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 ECHO 18 months showed severely dilated left ventricle with severe global systolic dysfunction and EF of 14% Also diagnosed with sleep apnoea Admission to hospital around this time required inotropic support for BP At one time lasix dose was up to 120mg Bd Amiodarone was ceased and Digoxin 62.5mcg daily commenced

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 Approximately 18 months later referred to Palliative care due to deterioration of his condition Arrangements were made to have Roberts AICD turned off Admitted to Palliative care ward for a short stay for respite and then returned home At this time medications were warfarin 3mg daily, Digoxin 62.5mcg daily, slow K+ 1 Bd, Isosorbide Mononitrate 30mg nocte, Frusemide 120mg Bd, Caltrate 2 Tds, somac 40mg mane, Ostelin 2 Bd and Aranesp weekly however client non compliant
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 Over the next 11 months despite continual review of medications Roberts condition continued to deteriorate and was under palliative care team at home until he passed away 4
years after initial MI

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Unpredictable illness trajectory

Functional Disability or Severity of Illness

LungCancer

Clear Phase of Decline-Allows PC Referral

Chronic Heart Failure

Death Unpredictable--No Clear Decline Path

Time
Source: Lynn et al. American Center to Improve Care of the Dying (with permission) in Davidson et al JCVN 2004.

Death
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Thankyou!
Illawarra Heart Failure Service & Cardiac Rehabilitation Service Level 3 Port Kembla Hospital Heart Failure Service 4223 8413 Cardiac Rehabilitation 4223 8149 Fax number 4223 8008
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