Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Cardiologists and generalists: Our top 10 mistakes in heart-failure managementFeb 19, 2012 15:35 EST
When it comes to managing drowning patients, it's not just the generalists or primary-care providers who need a tutorial. Even the most seasoned heart-failure specialists will fail their patients if they focus on pharmacology more than pathophysiology. Patients frequently wander into my office still drowning on "maximum medical therapy," having never participated in a conversation about water pitchers, saltshakers, or the importance of compliance. Their medication lists are yards long; their wallets empty from frequent changes in therapy or additions of costly medications. Although the basic tenets in pharmacotherapy are a must, much of the medication manipulation in heart-failure management is unnecessary. Here are the top 10 mistakes in the management of waterlogged patients currently spanning all specialties:
Mistake 1: Allowing our patients to take on water like the Titanic. When ankles are nothing more than weeping pegs of "peau d'orange" and patients pant for air like a marathon runner crossing the finish line, direct them to restrict their volume intake. A goal of 1700 cc in a 24-hour period should help. (That's milk, water, colas, tea, anything liquid!) Ask them to remember the saying, "The more I drink, the more I drown" in order to avoid ramming themselves headlong into that iceberg just ahead.
Mistake 2: Allowing patients to congregate daily at the "salt lick"—ie, their kitchen table. As a child, I often saw my father pack a large, glistening-white, 15-pound salt block to the cow lot for dietary supplementation. He placed it under a large shady oak tree with gnarly roots. The cattle would come running to it and would lick it like a kid with a giant ice cream cone. I confess I sneaked out there once and licked it, too (don't tell mom). Many CHF patients love salt that much. If they confess to having a shaker on the table, instruct them to never—and I mean never—touch it. Teach them to read labels and restrict sodium to less than 2400 mg in 24 hours. Teach the salt mantra: "Treat a salt shaker like a cobra."
Mistake 3: Assuming that anyone will ever fill a prescription, much less take it. ACE inhibitors, ARBs, carvedilol, metoprolol, spironolactone, and bisoprolol all work well in outpatients, but only if they are swallowed. Patients at best have a 50% compliance rate, so trust no one. Teach your patients the compliance mantra: "Bring all bottles of medication to each visit," and check the fill dates. Encourage compliance by prescribing a comfortable regimen. Only give Lasix at night to those patients you don't like (kidding), because ruining sleep patterns in the elderly is double punishment. Also, don't just grab Lasix as a therapy; actually prescribe therapy that gets at the basic pathophysiology of the specific driver of their heart failure.
Mistake 4: Failing to understand the implication of findings on cardiac ultrasound. If the EF is "normal" and if there is no significant valvular pathology and none of the other masqueraders of heart failure listed in this piece are present, assume possible diastolic dysfunction. Weight loss, beta blockers, sleep apnea, volume restriction, sodium restriction, blood-pressure control, and other medical therapies for systolic dysfunction can provide benefit. Do the mitral and/or aortic valves leak moderately? Is the LV size large? Is the EF impaired? Is there evidence of ischemia, stunned or hibernating myocardium (ie, an opportunity for pump-function improvement)? A referral to a cardiologist for fine-tuning of medications and serial echos to discuss whether surgery for valve leak (MV or AV) or revascularization is appropriate. They will also decide if the tricuspid valve gets a "me-too" approach. Timing of valve repair or replacement is an ongoing debate in the literature and in conference rooms across the world, but an optimal plan can usually be formulated.
Mistake 5: Being LVAD/BiV phobic. If heart failure is resistant after meds are maximized, please refer for a discussion of device therapy. These devices improve quality of life dramatically and decrease mortality. A BiV can shrink an MR jet and an LVAD can transform a life into something worth living, so don't resist throwing out the lifeline to your drowning patient.
Mistake 6: Failing to look in the mirror and repeat these words over and over until you hear this statement in your sleep: "I hate Actos. I hate Actos. I HATE ACTOS!" Banish it and loathe it in heart-failure patients. Make like Curly of Three Stooges fame; put your head down, twist your butt, slap the top of your head twice, then do a little dance and butt heads with Actos every single time. Giving pioglitazone to someone with big legs or shortness of breath is no different than tying a concrete block to your patient and pitching them in the river . . . except you won't go to jail for prescribing Actos in heart failure . . . at least not yet. "Nyuk, nyuk, nyuk"—geesh!
Mistake 7: Ignoring calcium-channel blockers on the medication list in those with peripheral edema. I often wonder just how many millions of gallons of fluid are sloshing around in our heart-failure patients' legs the world over. Turning them into camels isn't fair, and not recognizing we are responsible is worse. Just like bikinis, not everyone can rock them (calcium-channel blockers), so tailor your medical therapy to fit your patients' physiology and stop those calcium-channel blockers if there is any way possible.
Mistake 8: Always blaming the LV for peripheral edema. Survey for nephrotic syndrome. I find a bunch of sneaky massive protein spillers every year with a 24-hour urine. Sleep apnea, caval obstruction, or offending medications could also be the culprit, and consider lymph edema or venous drainage issues. Cirrhosis is another sneaky one. Finally, constrictive physiology can be at play, so a right heart cath performed by an experienced interpreter of right heart pressures may be necessary.
Mistake 9: Calling it CHF when it's asthma or COPD. A CHF patient once told me, "Dr Melissa, I'm not trying to play doctor, and I know I have heart trouble, but this doesn't feel like fluid, it feels like the asthma I had when I was a child." Even if the BNP is a little elevated, make certain pulmonary issues aren't at play. That patient's PFT and the addition of good asthma meds changed his life.
Mistake 10: Hanging our hats on data derived from "heart-failure trials" when the left ventricular end diastolic pressure or PCWP have not been measured as a prerequisite to enrollment. Shortness of air does not necessarily equal heart failure, so results are often skewed.
Other than Lasix and maybe some captopril, there was really nothing I could do for CHF patients in the late 1980s. I approached each consult back then with fear and loathing. Now, I literally skip to the patient's room with life-changing and lifesaving help in hand! If we as providers slow down, take time, ask questions, and give some very basic direction, whether we are generalists or cardiologists, all of us can still help save a broken heart. Who knows? With stem-cell therapy coming down the pike, we might even be able to mend one!