CHF and Inotropes

CHF and Inotropes 101

1. Heart Failure and Inotropes in the Home Continuing Education

2. Course Objectives Define the clinical presentation of congestive heart failure Describe different management options for patients with CHF Determine suitable candidates for inotropic therapy in the home Provide patient and caregiver education for patient on home inotropic therapy

3. Heart Failure Definition: Heart failure is a condition in which the heart has lost the ability to pump enough blood to the body's tissues. With too little blood being delivered, the organs and other tissues do not receive enough oxygen and nutrients to function properly. HF or congestive heart failure (CHF) is a disease state that afflicts approximately 6.6 million people. It is more common in African American and Hispanic males. Half of HF diagnosed patient will die within 5 years, there are limited treatment options.

4. Clinical Presentation Symptoms of HF S hortness of breath Orthopnea P aroxysmal nocturnal dyspnea G eneralized exercise intolerance F luid retention/edema W eight gain J ugular distention Hepatomegaly Ventricular gallop / cardinal sign in older adults

5. Clinical Presentation, Con’t As the heart loses the ability to pump an adequate supply of blood throughout the body, blood is diverted to the heart and brain. Less vital organs (i.e. kidneys or the digestive system) receive sufficient amounts to function properly. Over time this can result in decreased urine production, nocturnal urination, and nausea and vomiting. The “worst symptoms” as defined by patients during hospitalization for HF are fatigue and abdominal swelling

6. Types/Staging Doctors usually classify patients' heart failure according to the severity of their symptoms. The following tables describes the most commonly used classification system, the New York Heart Association (NYHA) Functional Classification. It places patients in one of four categories based on how much they are limited during physical activity . For Example: A patient with minimal or no symptoms but a large pressure gradient across the aortic valve or severe obstruction to the left main coronary artery is classified: Function Capacity 1, Objective Assessment D A patient with severe anginal syndrome but angiographically normal coronary arteries is classified : Functional Capacity lV , Objective Assessment A

7. Types/Staging Class Functional Capacity: How a patient with cardiac disease feels during physical activity I Patients with cardiac disease but resulting in no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea or anginal pain. II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain. III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain. IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest.  If any physical activity is undertaken, discomfort increases. Class Objective Assessment A No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity B Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest. C Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest. D Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.

8. Device Therapy Treatment Device Therapy for Patients with Heart Failure Implantable cardiac defibrillator An implantable cardiac defibrillator (ICD) is an electronic device that constantly monitors the patient’s heart rhythm. When the device detects certain abnormal heart rhythms, it delivers a small shock to the heart muscle to restore a normal heart rhythm. The shock will be brief and may feel very uncomfortable. Studies show that an ICD can reduce the risk of sudden cardiac arrest (SCA ).

9. Device Therapy Treatment, LVAD LVAD What is a left ventricular assist device (LVAD)? The left ventricle is the large, muscular chamber of the heart that pumps blood out to the body. A left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that's surgically implanted. It helps maintain the pumping ability of a heart that can't effectively work on its own. These devices are available in most heart transplant centers . When is an LVAD used? This device is sometimes called a "bridge to transplant," but is now used in long-term therapy. People awaiting a heart transplant often must wait a long time before a suitable heart becomes available. During this wait, the patient's already-weakened heart may deteriorate and become unable to pump enough blood to sustain life. An LVAD can help a weak heart and "buy time" for the patient or eliminate the need for a heart transplant. Most recently, LVADs are being used longer-term as ‘destination therapy’ in end-stage heart failure patients when heart transplantation is not an option.

10. Device Therapy Treatment, LVAD How does an LVAD work? A common type of LVAD has a tube that pulls blood from the left ventricle into a pump. The pump then sends blood into the aorta (the large blood vessel leaving the left ventricle). This effectively helps the weakened ventricle. The pump is placed in the upper part of the abdomen. Another tube attached to the pump is brought out of the abdominal wall to the outside of the body and attached to the pump's battery and control system. LVADs are now portable and are often used for weeks to months. Patients with LVADs can be discharged from the hospital and have an acceptable quality of life while waiting for a donor heart to become available.

11. Device Therapy Treatment, LVAD Promising study results for LVADs In a study published in Circulation in 2005, LVADs restored failing hearts in some patients with heart failure, eliminating the need for a transplant. According to an abstract presented at the American Heart Association's 2005 Scientific Sessions, LVADs reduced the risk of death in end-stage heart failure patients by 50 percent at six and 12 months and extended the average life span from 3.1 months to more than 10 months

12. Device Therapy Treatment, Cardiomemes Device Cardiomems Device What is a cardiomems device? The CardioMEMS HF System measures and monitors the pulmonary artery (PA) pressure and heart rate in certain heart failure patients. The System consists of an implantable PA sensor, delivery system, and Patient Electronics System. The implantable sensor is permanently placed in the pulmonary artery, the blood vessel that moves blood from the heart to the lungs. The sensor is implanted during a right heart catheterization procedure . The PA sensor is about the size of small paper clip and has a thin, curved wire at each end.

13. How does a Cardiomem work? This sensor does not require any batteries or wires. The patient uses the CardioMEMS HF System at home or other non-clinical locations to wirelessly obtain and send PA pressure and heart rate measurements to a secure database for review and evaluation by the patient’s doctor. The Patient Electronics System includes the electronics unit, antenna and pillow. Together, the components of the Patient Electronics System read the PA pressure measurements from the sensor wirelessly and then transmit the information to the doctor. The antenna is paddle-shaped and is pre-assembled inside a pillow to make it easier and more comfortable for the patient to take readings. Device Therapy Treatment, Cardiomemes Device

14. When is a cardiomem used? The CardioMEMS HF System is used to wirelessly measure and monitor PA pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. The PA pressure and heart rate are used by doctors for heart failure management and with the goal of reducing heart failure hospitalizations . What will it accomplish? Access to PA pressure data provides doctors with another way to better manage a patient’s heart failure and potentially reduce heart failure-related hospitalizations. In a clinical study in which 550 participants had the device implanted, there was a clinically and statistically significant reduction in heart failure-related hospitalizations for the participants whose doctors had access to PA pressure data. Device Therapy Treatment, Cardiomemes Device

15. Inotropic Drug Treatments Inotropic drugs are given by injection or IV. Inotrope therapy for HF is usually offered when patient’s are decompensated and in the hospital. It should always be started in the hospital. Inotropic drugs come in 2 categories B-adrenergic antagonists Phosphodiesterase-III inhibitors

16. Inotropic Therapy Indications Short term therapy for decompensation management Used as a bridge to heart transplant Palliative end of life care Purpose Improve blood flow Reduce symptoms and improve quality of life Increase organ perfusion Goals Prevent exacerbation of Congestive Heart Failure Prevent readmissions to hospitals Decrease emergency room visits

17. Figure 2. Recommended approach to the use of inotropic support in patients hospitalized with acute HF exacerbation . Copyright © American Heart Association, Inc. All rights reserved Goldhaber J I , and Hamilton M A Circulation. 2010;121:1655-1660

18. Figure 2. Explained Figure 2. Recommended approach to the use of inotropic support in patients hospitalized with acute HF exacerbation. As long as patients appear clinically well perfused, usually with a systolic blood pressure (BP) >80 mm Hg, inotropes provide no outcome benefit and subject patients to significant risks of arrhythmia, remodeling, and death. Well-perfused patients with impaired functional capacity and frequent hospitalizations for HF exacerbation may benefit from digoxin. In hospitalized patients with worsening cardiorenal syndrome despite intravenous diuretic and vasodilator therapy, it is reasonable to add an inotrope in an attempt to acutely rescue renal function. If patients are hospitalized with clinical evidence of shock, inotropic support is clearly indicated as a temporary measure until stabilized on oral agents or bridged to transplant or mechanical assist device. Continuous home inotropes may also be considered for end-stage patients as a palliative measure. ACE-I indicates angiotensin-converting enzyme inhibitors.

19. B-adrenergic A gonists Inotropic Drugs Dopamine Improves heart output and may raise blood pressure. Administered as a continuous IV infusion. It increases the amount of norepinephrine active in the body. Patients can become tolerant to dopamine, so larger and larger doses are necessary to get the same effect over time. Dopamine is often used to eliminate edema because of the affects of the receptors in the kidney's blood vessels. Potential side effects include irregular heart rhythm, and increased demand for oxygen by the heart

20. Inotropic Drugs, Con’t Dobutamine Improves heart function and may lower blood pressure. It is used as a continuous IV infusion. It helps the body make more use of norepinepherine . Norepinephrine stimulates the heart to work harder. Patient’s can become tolerant to dobutamine faster than to dopamine, and larger doses are necessary to get the same effect over time. Eventually it may cease to be therapeutic. Potential side effects include irregular heart rhythm (although less than with dopamine), and increased demand for oxygen by the heart

21. Phosphodiesterase-III inhibitors Inotropic Drugs Milrinone ( Primacor ) This drugs make the heart beat more strongly and also relax the blood vessels. Most widely used drug of this type. Usually given by IV at 0.375 to 0.75 micrograms per kilogram of body weight per minute. Since milrinone does not increase the heart's oxygen demand, it is preferred over other inotropes in patients with ischemic cardiomyopathy. Preferred drug for treating severe CHF episodes in patients taking beta-blockers.

22. Home Inotrope Therapy Milrinone is the most common Inotropic drug used for home therapy Dopamine is rarely used in the home D5W is the preferred diluent due to sodium restrictions Standard Dosing: Drug Dosage Milrinone 0.25mcg/kg/min-0.75mcg/kg/min Dobutamine 2.0mcg/kg/min-20mcg/kg/min Dopamine 0.5mcg/kg/min-3mcg/kg/min

23. Risks/Benefits of Inotropic Therapy Risks Catheter related bloodstream infections Increase in mortality Arrythmias Hypotension Family Burden Benefits Enables patient to go home from the hospital Increases quality of life by decreasing s/s Fewer hospitalizations

24. Patient Selection Criteria for Home Inotropic Therapy During discharge planning the following issues should be addressed to determine whether patient is an appropriate candidate for home inotropic therapy. Patient must be clinically stable on current dose Home environment (water supply, electricity, phone service, and emergency services available) Central venous access- Picc / Tunnelled Central line/Port Insurance/reimbursement criteria met or costs to patient established Patient/Caregiver ability and willingness to participate Patient compliance

25. Home Inotrope Special Considerations Patient must have 2 pumps in the home, one as a back-up Routine pump battery changes Importance of monitoring of drug expiration dates Double lumen access preferred for labs and alternate lumen available A continuous inotrope infusion should not be flushed

26. Patient Monitoring Vital Signs (Heart rate, BP, Respiratory rate and temperature) Daily weight and evaluate record Assess degree and location of edema Record fluid intake and output Assess cardiac status (heart rate and rhythm and heart sounds. Use of nitroglycerin) Assess respiratory status ( rate, orthopnea, cough, activity tolerance, O2 use) Assess diet and compliance with sodium and fluid restrictions Measure and record patients abdominal girth Central line assessment and documentation, dressing change if needed Lab monitoring ( commonly CBC, Creatinine, electrolytes ,liver functions)

27. Patient/Caregiver Education Infection control-Line care Storage and handling of medications Pump operations, troubleshooting and alarms Inotropic infusion administration Medication therapeutic effects and side effects Emergency plan Low sodium diet Fluid restriction Activity Level Telecommunication system (if available) Oral medication use and side effects MD notification Daily weight Recording I&O

28. When should the Physician be notified? Weigh daily, call if weight increase > 2 lbs daily Unusual medication side effects Significant blood pressure or pulse changes Nocturnal dyspnea Increased cough, swelling, adventitious heart or lung sounds Decreased urination S/S confusion, dizziness, nausea or vomiting, increased fatigue, muscle cramps or weakness

29. Heart Failure Hospital Readmissions CHF is the #1 cause of hospital re-admissions within 30 days. Heart Failure readmissions are estimated to cost Medicare $12 Billion annually Studies show 50% of re-admissions can be prevented With Health Care reform, hospitals are now being penalized by Medicare and other payors for Heart failure readmissions within 30 days and have cut or refused reimbursement

30. Preventing Hospital Readmissions Discharge Teaching -intensive education about congestive heart failure and its treatment by an experienced cardiovascular nurse. Medication reconciliation – Within forty-eight hours of discharge, a physician or nurse reviews a list of the patient’s medications with explicit instructions on how to properly take them. Post-discharge appointments – Before being discharged, patients are scheduled for follow-up care. When possible, patients at high risk for readmission are scheduled to be seen within seven days of discharge; all others are scheduled to be seen within 14 days. Post-discharge phone calls – Within a specified time frame following discharge (again based on the patient’s level of risk for readmission), a member from the coordinated care team calls patients to assess their condition and see if they have any questions or are having any problems with their medications. Home Health Follow up -intensive follow-up after discharge with home care services and coordination of care with cardiology.

31. What does the Future Hold? Currently there are limited alternatives other than inotropic therapy and LVADS for End stage CHF patients. New pharmacologic agents are in research and develop phase Stem cell research being done with goal of replacing dead tissue from an acute MI with new tissue, improving cardiac function Gene therapy : process of altering defective genes to correct organ function Development of more sophisticated mechanical devices such as heart pumps. Improved availability of donor organs

32. Bibliography Sherrod, M., Graulty , R.,Crawford , M., Cheek, D. Intravenous Heart Failure Medication. Home Health care Nurse Vol 27,no. 10 Nov/Dec 2009; 613-619 Lyons, M.,Carey , L.Parenteral Inotropic Therapy in The Home: An Update for Homecare and Hospice. Home Healthcare Nurse; April 2013 Vol 31 Issue 4; 190-204 IV Heart Failure Drugs: www.CHFpatients.com/Inotropes; June 12 ,2006 Harjai , K., Mehra , M., Ventura,H., Lapeyre , Y., Murgo , J.,Stapleton , D. Smart, F.Home Inotropic Therapy in Advanced Heart Failure: Cost analysis and Clinical Outcomes: Chest Journal; Nov 1997;5.112; 1298-1303 Boger , J.,DeLuca , S.,Watkins , D., Vershave , K., Thomley , A. Infusion Therapy With Milrinone in the Home Care Setting for Patients Who Have Advanced Heart Failure: Journal of Intravenous Nursing: Vol 20,3 May/June 1997; 148-154 Samkowiak,J . Home Inotopic -therapy: www.slideshare.net McCloskey , W.Use of Intravenous Inotropic Therapy in the Home: American Society of Health-System Pharmacists Inc. Vol 55 May 1,1998; 930-935 Stevenson , L.Clinical use of Inotropic Therapy for Heart Failure Looking Backward or Forward part 11: Chronic Inotropic Therapy: AHA journal 2003,108: 492-497 Rich, M., Beckham, V., Wittenberg, C., Leven, C., Freedland, K. and Carney, R. A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure: AJM N ENGL J MED 1995; 333: November 2, 1995 1190-1195 http://www.sjm.com/cardiomems