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Palliative Care of Congestive Heart Failure PowerPoint Presentation

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Description : Check out this medical presentation on Congestive Heart Failure, which is titled "Palliative Care of Congestive Heart Failure", to know about the Palliative Care of Congestive Heart Failure. Also know about the difference between systolic and diastolic heart failure, and, why is the combination of heart and kidney failure so challenging.

Tags : Congestive Heart Failure, Palliative Care, systolic, diastolic heart failure, kidney failure

Published on : Jul 01, 2021 | Views : 1843 | Downloads : 0

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Slide 1-

Palliative Care of Congestive Heart Failure David Kregenow, MD Evergreen Health Hospice and Palliative Care
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Disclosures I have no relevant financial conflicts of interest My background is in Pulmonary and Critical Care Medicine, hence I think like a physiologist The 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.
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Common Questions How do we tell the difference between systolic and diastolic heart failure, and why does it matter? Why do my CHF patients have so many medications? Why do my CHF patients have so many non-cardiac symptoms? Why is the combination of heart and kidney failure so challenging, and when is it best to use secondary diuretics? What are the non-pharmacologic things I can do to help my patients with heart failure? What are the most effective pharmacologic tools I have for my patients with heart failure?
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Case 1 Presentation Phyllis 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, 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 an AFH.
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Case 2 Presentation Paul is a 54 year old man with ischemic cardiomyopathy living at home on hospice hoping for a heart transplant He has a family history of early death from MI, and suffered his first heart attack at age 45, presenting initially with a large anterior MI He’s had an ICD placed for syncope for paroxysmal ventricular fibrillation His CHF progressed over the last 9 years
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Case 2 Presentation Continues He had been felt to be a good candidate for heart transplant, but deteriorated before a suitable organ became available He had been placed on mechanical circulatory support (LVAD) and a milrinone infusion However, he developed a chronic strep infection associated with his device and is no longer able to have a transplante has been counselled to prepare for EOL and use hospice, but still hopes he will get a transplant
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Cardiovascular Physiology
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Neurohumoral Activation Adrenergic Activation Vasoconstriction Na+ and H2O Retention Normal
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Normal Echocardiogram
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Classification of Heart Failure NYHA (Clinical) Classification
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Two Main Paths to CHF HFnEF Normal HFrEF Case #1 Case #2 Diastolic Systolic
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HFnEF and HFrEF HFnEF Older F > M Hypertension Few Treatment Options Maintain Euvolemia HFrEF Younger M > F Ischemia Medical Therapies Inotrope Infusions Implantable Devices Mechanical Circulatory Support Cardiac Transplantation
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Classification of Heart Failure Objective Assessment
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Reduced Ejection Fraction
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Neurohumoral Activation Adrenergic Activation Vasoconstriction Na+ and H2O Retention HFrEF
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HFnEF ECHO
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Neurohumoral Activation Adrenergic Activation Vasoconstriction Na+ and H2O Retention HFnEF
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Prognosis and Hospice Eligibility Guidelines NYHA Class IV Symptoms Symptoms despite maximal therapy Persistent resting tachycardia Physiology Combination of heart failure and renal impairment is medically very challenging Statistical Models (See Case #2) www.seattleheartfailuremodel.org/ HF Survival on Hospice is 81 days longer on average than without Hospice. J Pain Symp Mgmt 2007; 33(3): 238-46.
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Prognostic Tool Seattle Heart Failure Model www.seattleheartfailuremodel.org/
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ACE Inhibitors Beta Blockers Diuretics Potassium Sparing Diuretics Diuretics
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The Picture of CHF
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Fatigue and Weakness in CHF Multifactorial Cardiac insufficiency Muscle loss Deconditioning Other: anemia, sleep disorders, depression, hypothyroidism Optimize what you can Stimulants?
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Sleep Disorders in CHF Approximately 50% of HF patients have sleep disordered breathing Orthopnea Nocturia Obstructive Sleep Apnea Central Sleep Apnea Cheynes-Stokes Respirations Sleep Maintenance vs. Insomnia Treatments: Sleep Hygiene CPAP Nocturnal Oxygen Nocturnal urination aids
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Depression and Anxiety in CHF 1/3 of patients with advanced HF have clinical depression Higher symptom burden Increased adverse outcomes Spiritual Care Cognitive Behavioral Therapy Medications SSRIs at low dose, watch for fluid retention and hyponatremia (mental status changes with edema) TCAs can prolong the QTc Psychostimulants
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GI Disorders in CHF Cardiac cachexia Anorexia Increased catabolism Nausea Medications (e.g.. ASA) Reduced Intestinal Perfusion Constipation Decreased intake and activity Medications (e.g. Opioids)
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Cough Often worse at night Pulmonary Congestion Pneumonitis Bronchitis ACE Inhibitors Transition to ARBs Secretions
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Causes of Confusion and Delirium in CHF Impaired cerebral blood flow and micro emboli Medications (e.g. Sleep aids) Sleep-wake cycle disturbance Low BP associated with high doses of ACE Inhibitors and Beta Blockers
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Pain in CHF Common in advanced CHF Angina Nitrates Other types of pain Opiates Avoid NSAIDs
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Kidney Physiology
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Diuretics Loop of Henle: Furosemide, Torsemide Distal Tubule: Metalazone, Thiazides Potassium Sparing/Neurohumoral: Spironolactone
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Kidney Physiology Loop Diuretics Thiazide Diuretics
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Sensation of Dyspnea
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Sensation of Dyspnea
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Treatments for Dyspnea Maintenance of euvolemia Sodium and fluid restrictions Diuretics Leg elevation above the atrium Digoxin (Narrow therapeutic window) When near EOL: Opioids (Careful of impaired renal excretion) Oxygen if hypoxemia is present Benzodiazepines Elevation of the Head of the Bed, Fan
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Leg Elevation
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Dilated Cardiomyopathy ECHO https://www.youtube.com/watch?v=37KDMNiV3AU&feature=player_detailpage
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Discontinuing Medications for CHF on Hospice Medical management of CHF (that has helped raise life expectancy in the last 40 years) truly pushes the limits of low BPs and low HRs On Hospice, the Goals of Care are more nuanced than survival so expectations and therapies need adjusting ACE Inhibitors Beta Blockers
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Conclusion Heart Failure is common and often chronic Salt and water retention produce much of the morbidity so understanding diuretics helps management Normal EF vs. Reduced EF are significantly different entities that can look alike clinically There is a high symptom burden, but many tools Often less is more for the patient “The LVADs are coming!”