Chapters Transcript Video Medical Management of HF Patient in Outpatient Setting Click here to view presentation deck Back to Symposium Good afternoon everyone. My name is Lauren Feeney. Um I am a nurse practitioner. I started in about 2018. I joined our um advanced heart failure practice at that time. And ever since then I loved heart failure before, but I really love it now. And I think most of this talk is really coming from a lot of the work that I've done at our free clinics at the AC C. I know there was um a very lovely woman in the back who was talking about, you know, my patients that are uninsured and how do I get the medicine? And um the goal of this particular talk really is to talk to primary care and how I can partner with you. Um because even though the heart failure guidelines have changed and it would be lovely if advanced heart failure could see every heart failure patient, we, you know, we have access problems ourselves. And so my goal in this is to empower you to feel comfortable as much as you can. Um and to kind of help me along with working, you know, alongside of you and make sure our patients are on the best possible medicine to keep them out of the hospital and to keep them uh going strong. So here we go. Um Here's my disclosure statement. Um I do uh work with Astrazeneca as a paid consultant for their FARA my objectives here. Um Heart failure review, we're going to go over the basics of systolic versus um diastolic heart failure, kind of some of the new terminology that you'll see that's out there. Um As well as what we do typically with diagnosing heart failure. First time we see that patient and I am going to talk um about the four pillars, but really focusing on, on two of them particularly. And uh the fourth objective, I just forgot to uh remove. So we're not doing that one. That'll be Kristen's job. OK. All right. So, um if you look at the new universal uh classification system of heart failure, if you look at the far right side, um they've kind of changed some of the verbiage. So now we do have ref or heart failure with reduced ejection fraction. That's the patient with an ejection fraction, less than 40% right. Um They're usually a dilated, they could be ischemic or non ischemic. It's also the most common type of heart failure. It's the patients that, you know, have kind of a bigger boggier heart, they end up with a lot of fluid overload. Um We have those that are mildly reduced or midrange ejection fractions, those are, um, about 40 to 55 ish percent. We have the preserved EF group, which is a greater than 50 to 55 depending on the literature. And then we have the really all important group of the improved ef and this is um, one of these subsets of patients where they think they no longer have heart failure. But that's not really true. Is it, it's like a diabetic who is diet controlled, right? If you stop doing what you're doing, you're gonna end up being a bad diabetic again. So, the same thing with heart failure there, um, in the center or just kind of the stages, typically we see the stage D but we actually have a lot of stage C and that's where we like to see early referrals. Those are the patients that are symptomatic with heart failure. Um, the stage DS are the ones you can't keep out of the hospital, the ones that no matter what you're trying to do, no matter what the patient's doing, they're failing that therapy and they need, you know, some bigger guns like doctor Ya. All right. So hef ref this is the ejection fraction. That's less than 40%. So, if you think of your heart like a toilet, right? Every toilet has a tank and every toilet has a bowl. All right, the right side of your heart, it's just like the tank. Its job is to fill up with blood and send it on over to the left side. In this case, the bowl every time it flushes. Right. What separates the tank in the bowl? Well, it's the lungs, right. So what happens when your toilet begins to back up because it can't flush everything down? That water starts to back up. The number one place that it's gonna go is the easiest because it's these two open holes that sit in your chest. It's called your lungs. Number one symptom of heart failure is usually shortness of breath or apnea, dyspnea on exertion, right? And then if they get really backed up, then we start to see the leg swelling, the belly swelling. Um and sometimes uh they end up getting hospitalized and needing a lot of fluid removal. This is the patient that just simply has too much fluid. It's too big of a heart and we're unable to get that blood flow to squeeze. Ok. This is one of this is the most common and this is the one that's usually the most treatable with what we call the four pillars of medication. The other type of heart failure, the hef puff heart failure with preserved ejection fraction. This is a little bit harder to understand and explain to a patient. This is the stiff ventricle, right. Your ejection fraction is normal. It has no problem squeezing. The problem with the heart is it can't fill, it doesn't know how to rest, it doesn't know how to relax. So it can't get all the fill and squeeze out that it needs to, that also causes backup of fluid. It also causes really bad shortness of breath. And there's very limited options for these patients because they don't meet that classic, you know, standard of, oh, you just need a heart transplant. We can give you a new one because they have a normal ejection fraction and they have normal, you know, cardiac index for the most part. Um So there's actually been a couple of medications um, recently that have been approved for them that I'm excited to share with you. We're going to kind of walk through this 61 year old gentleman here. He has a past medical history of hypertension type two diabetes, obesity and tobacco use. Um by a show of hands. How many here in primary care, take care of this patient? All right. So it's a very familiar patient, right? He presented to the emergency room with shortness of breath, cough orthopnea and now he's got some edema. He reported about six weeks ago, you know, I started feeling more tired. It was harder to go from here to there. Maybe a little chest heaviness, maybe not. And you know, oh, it's the middle of cold and flu season and his daughter had the flu and maybe he's not feeling too well. Right. They treated him for an upper respiratory infection, failed two rounds of antibiotics. And now we're finally getting to that chest X ray prior to admission that it was important to note that he was being treated with Lisinopril for his hypertension, which it's a ok, by me and he was on Metformin for his diabetes. His ace was recently stopped though because by golly, that cough would not go away. And maybe it's that Brady Ken reaction, right. Ok. So what are the common signs of heart failure? I think you all know them. They're right there on the right hand side. Uh, shortness of breath at rest. The one that I really get the most concerned about though is really the orthopnea and the PND. Um, those are pretty progressive. They're pretty late and they're also the ones that patients come in complaining about the most, you know. Oh, I can't sleep through the night I wake up. I feel panicked or I don't know if I'm just having a panic attack that for me, um, if I was in primary care routinely, if I had somebody that kept saying I keep waking up and I, I gotta sit on the edge of the bed to catch my breath for me. I'd be starting to think. All right, I need an NT pro B and P level on this guy. Maybe even a basic chest X ray something to kind of because it, it doesn't fit, you know, the usual, um, Frothy Sputum. Sometimes blood tinge, sometimes you can see some JVD, but that's going to be a pretty volume overloaded patient. That one's usually a no kind of no brainer, you know what you need to do. Um Let's see. So, on our case study, here's his vitals. You have room air 95%. Not too bad. He's a little hypertensive, notably tachycardic, he's got a little bit of tachypnea. He's got normal uh S one S two and S3. No new murmurs, no thrills, significant JB D and he's got some lower extremity edema, some crackles, but everything's warm and dry. Now in primary care, we hear S one we hear. S two are any of you really trained on S three's S fours, have you heard? I mean, I, I would think that the longer your career you're probably a little bit easier for you to hear. But I know starting out even just in cardiology, it was, I couldn't distinguish the difference between the two of them. I just knew the difference between normal and abnormal, right? So that would be, you know, if you say Kentucky and it sounds like Tennessee, that's fine. It really doesn't matter to me. My, my biggest goal is like, you know, you're hearing that Lub Dub. If you hear something else in addition to that, that would be a great cause to start. Maybe I need an echocardiogram on this person, especially if that heart rate's going fast for no particular reason. And we're hearing some extra heart sounds. That's where I would want the brain to start to think about. Maybe I need a baseline echocardiogram for this patient. These are my go to, oh, the heart didn't show up. It's kind of there. Um These are my go to. So anytime I get a brand new consult, the first thing I go through the chart and I look for, do they have a chest X ray? Do they have an echocardiogram? And do they have an EKG that's inpatient or outpatient? Those are my first three. Looking at the size of the heart, I'm looking at the rhythm of the heart. And I'm so looking at the function and the valves and the hearts. So, you know, when we get referrals from cardiology, standpoint, it's always helpful, especially if we've had an echo. You know, you don't have, I'm not asking anybody here to interpret it because I don't interpret them. But it's nice for us to be able to go back and look through that information. Um The labs that I always check uh interestingly enough thyroid panel should be number one. Um You'd be surprised how much cardiac dysfunction happens in hypo and hyperthyroidism. Also checking that C MP, troponin and anti pro B MP levels. And then the invasive stuff that I go and look, have they ever had a left or a right heart catheterization when we talk about diagnostics for heart failure, we get tied up a lot with brain natural peptide. There's BNP and then there's NT pro BNP, we have the substrate versus the actual thing bnps job is to actually tell the kidneys and the rest of the body to offload the fluid, right. But then we have this little nagging guy. His name is Nephro Lysin and he likes to break that down. All right, he does not want you to get rid of salt and water because the kidneys will then be dehydrated. So, NT pro B and P is that substrate. So you can always look and see what are the levels. If a patient's in heart failure, you'll have an elevated BNP or an elevated NT Pro BNP. Some things that can make it falsely elevated, very high would be renal failure. Some things that can make it falsely low would be obesity, right, the higher the BM I actually the lower the level of circulating BNP. So even though your patient might have normal BNP level, but say their BM I is 45 and they have heart failure symptoms. I would actually still be looking for heart failure on that patient because that number, that circulating BNP number might actually falsely be low just based on obesity. So this is our patients labs. They don't look horrible. We do have an elevated NT Pro B and P at 5300. His chest X ray and his echocardiogram both supportive of um heart failure with reduced ejection fraction. He's got a mildly uh dilated left ventricle, his right heart cath shows a normal cardiac index but he's got too much fluid on him. So some pictures, this is pulmonary edema. We have some led stenosis, some cerc stenosis and just overall hypertension diabetes looking type vessels. They tend to be a little bit more narrow and you know, really hypertensive patients, they can be more tortuous too. So we have to think about these, you know, even if you go in and stent that he was diagnosed with heart failure with reduced ejection fraction, secondary to cardiomyopathy. Now, what here it is. Are you guys ready? Can I get a wave start? There we go. All right. Some lively. All right. So this is the newest one to the game I would say and but not for you, for me. Yes, but I believe primary care has been prescribing this drug for well over a decade. This is not a new drug, it's just a new indication, right? You had patients that would come in, you had them on Metformin. Now you're gonna add SGLT two where I want you to start to kind of think about this is ok. I have a patient with chronic kidney disease and diabetes. They actually need to be on this with or without heart failure, right? Or I have a patient with heart failure without diabetes as part of their chronic care management. They should actually be on this. So I need to partner with everybody in this room because if I haven't done it and I don't, and there's no real good reason why we didn't start it yet. Absolutely. I would want you to go ahead and initiate it. It's actually one of the most well tolerated medications as well. The SGLT two class, um, does not do much to the blood pressure at all. Um, we know about the side effects of possible ut I, possible, um, mycotic infections, but we teach good hygiene with that, right. We it's not new symptoms, but it will actually reduce your patient's rehospitalization and cardiovascular death risk by about 20 to 25% which is huge patients feel better on this particular medication. And this is one of the medications that's actually indicated for both heart failure with reduced ejection fraction, heart failure, with preserved ef heart failure, with midrange ef heart failure with recovered ef it's all of it and there's no titration on either one of these. The two that are currently indicated are the jardines, uh and PLIF Loin and Fara Diplo Lozon. Both 10 mg doses. That's it. 10 mg a day and that's what you want to keep your patient on. There's no titration necessary. Sorry, we have five more minutes. No problem. I will be done. I promise. All right. The next one, everybody in this room is probably really comfortable prescribing Aces and Arbs. I would like you to get as comfortable prescribing Arnie for patients that have an ejection fraction. That's less than 54% with or without, you know, that that dysfunction piece, this particular medication can be life saving and it reverses remodeling. It prevents further cardiac damage. And this medication was actually should be taking the place of patients. You know, if you have a heart failure patient and they're on Losartan at 50 it's actually a super easy conversion straight over to midrange um interest of 4951 twice a day. Sometimes patients can have slightly lower blood pressures with it. There is a lower dose. The 2426 I will say during the clinical trials though 2426 did not exist. It was only 4951 and 97 103, they made 2426 as kind of that entry level dose. So if you're worried about somebody's blood pressure, you can start them at 2426. But the goal would be to get them at least to 4951. This particular medication actually helps stop nepro lysin from breaking down the BNPAK. It lets your body do what your body is programmed to do. It lets that BNP get rid of the extra volume. So this is something that, you know, you can initiate in one day, two weeks later. I know I don't sometimes have an appointment in two weeks, but I can usually get a nurse visit, nurse visit to check the vital signs if his vitals are ok. Plan to uptitrate. So that's what we do with them beta blockers. I think everybody in this room is pretty comfortable with these ones. Um And then the last one here, the Mr A, we've got Spironalactone and a plain, they give you great skin and they hold on to your potassium. So for the people that don't want to take a lot of heart failure meds or want to know what this does for them. In addition to keeping them out of the hospital into addition to helping that tank not be over full, they will have glowing beautiful pores. Um It is recommended to check labs on this one though about a week after initiating, make sure their potassium is not too high. Um Don't typically start it in somebody who's creatinine or GFR is less than 30 without at least discussing with nephrology. Um And once your patient goes on dialysis, then you're free to use as much of it as you'd like because you still get the cardiovascular benefit. You just got to let nephrology know so they can adjust their KF. All right. And this is what we do daily standing weights, low sodium diet. Avoid taking too much, take your medications, see them early and often utilize the nurse visits as best you can. Ok, to help you get to where you need to go. Um, just a very, very one last 30 seconds. Um, every patient I always ask, do you have a, uh, issue affording your medication are your meds affordable? Even though it's a 1530 $40 copay. Is that still undoable? Are you choosing between gas in your car or are you choosing your medications? And that oftentimes I think is the biggest culprit of decompensation. It's not that patients don't want to be compliant. They're spacing out their medications, they're not taking them as directed because of affordability and I'm really hopeful that Kristen here is going to be able to help us all out with that. Ok. Any questions or comments or do you want to wait till the end? Yeah, let's wait till the end. And, um, big round of applause for Lauren, please. Ok. Published November 5, 2024 Created by Related Presenters Lauren M. Feeney, NP-C Nurse Practitioner, CardiologySentara Advanced Heart Failure Center View full profile
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