Hi, my name is Michelle, and we'll be talking about patient volume management strategies. The use of generic and trade name medications will be listed. This is more for information related to guideline-directed medical therapy for heart failure. Commercial names will also be used, but these are notes where you can find heart failure technology in this location. Our objectives for this module is to review the pathophysiology briefly related to heart failure, discuss volume management, and look at different types of remote monitoring. In our last module, we briefly discussed that pathophysiology of heart failure. I wanted to discuss it a little bit more. Noting that heart failure starts with a risk factor and injury to the heart muscle. This can be related to an MI, such as coronary artery disease, hypertension, cardiomyopathies, viruses, or valvular disease to list a few. This causes the heart to not eject or fill with blood. The renin angiotensin system is activated, causing sodium and water retention. Unfortunately, the individuals have heart failure symptoms. These muscular changes cause remodeling and cause the LV not to function, or the left ventricle. Over time, the individual is at an increase for mortality with risk factors of arrhythmias as well as pump failure. Some of the symptoms for heart failure include that of shortness of breath, orthopnea that can be related to pulmonary, capillary pressure and volume, fatigue related to low cardiac output, chain stokes respirations that are present in 40% of individuals with heart failure, which are cyclic respirations noted in low output. GI symptoms are related to nausea and anorexia due to bowel wall edema and or liver congestion. In summary, there's increased pressures and volume overload. There's a decrease in ejection fraction, decrease in cardiac output, restrictive filling of the left ventricle, which can lead to a greater incidence of dysrhythmias and overtime death. How do we know if a patient's volume overloaded? Usually a physical exam is done first checking for dyspnea, extra heart sounds, edema, and a patted jugular reflex. The JVP, or jugular venous pressure, is also used as a tool to evaluate how a patient is doing from volume status. The JVP is measured in centimeters with an individual at 30 degrees as noted in the slide. A normal JVP is estimated at six to eight, centimeters of water. Labs are also used to monitor for volume status. Besides looking at chemistry, biomarkers or BMPs are used. Biomarkers such as the B-type naturopeptide is usually elevated in heart failure. The BMP is a hormone that is excreted by the myocytes of the heart in response to the stretch and increased blood volume. Diagnosis and management of heart failure is noted to have elevated BMPs. If a BMP is less than 100, then the differential for dyspnea is usually not related to heart failure. A BMP is also a significant indicator of mortality. It should be noted that individuals with renal failure, are women, older, and obesity, may have a greater BMP at baseline. Classification of patients presenting with acute decompensated heart failure depends on if a patient is perfused and what their volume status is. The best place for a heart failure patient is warm and dry, which is that of perfused and euvolemic. In this slide, we'll talk a little bit about diuretics. There are several diuretics for patients in IV and PO form. This chart compares the differences between the doses and also by availability. Loop diuretics are that of furosemide, torsemide, Bumex. Thiazides are that of hydrochlorothiazide or prothaladone. While this slide is busy, it shows where diuretics work within the kidney. Loop diuretics are number three, are the most potent diuretics that increase the elimination of sodium and chloride by primarily preventing that of absorption of sodium and chloride. The potency of the loop diuretics is due to the unique side of action, which is related in the loop of Henle, which is a portion of the renal tubule in the kidneys. Thiazide diuretics are number four, increase the elimination of sodium and chloride in equal amounts. They do this by inhibiting the reabsorption of sodium and chloride in the distal tubules of the kidneys. In the far distal part of the kidneys, potassium is excreted in the forming urine and there is reabsorption of sodium. Potassium sparing diuretics are number five, reduce the sodium reabsorption at the distal tubules, thus decreasing the potassium excretion. Potassium sparing diuretics are used alone or week. It is note that they're used more commonly with thiazide and loop diuretics. Monitoring parameters are related to overall volume status and volume depletion. Electrolytes and renal function need to be monitored. If extra volume is needed to be removed, then thiazides can be given a half an hour before a loop diuretic is given. Unfortunately, diuretics do not always help with volume retention due to diuretic risk resistance. So ultrafiltration is needed. Ultrafiltration is usually run by the heart failure department, is usually done more in the ICU, but can be done in step-down areas. Ultrafiltration is usually done through a CBC or two large 18-gauge IVs. Another way to monitor volume status is through a right heart cath. The right heart cath is placed in a vein and measures the pressures, including the hemodynamics, such as cardiac output, volume status, and lung pressures. The first heart cath, or right heart cath, was performed on a human in 1929 for that of a surgical resident by the name of Werner Fossmann in Germany, who incidentally did his cath on himself through his antecubital vein. A right heart cath is used also for monitoring during cardiogenic shock, pulmonary hypertension, restrictive pericardial disease, restrictive cardiomyopathy as well. The right heart cath is usually done through the IJ, or the internal jugular vein, the antecube, or the femoral vein. Normal mean right arterial pressures are between one and five. Normal right ventricular systolic and diastolic pressures are between that of 15 and 30, and then one and seven respectively. Normal pulmonary artery pressures and diastolic pressures are from 15 to 30. The mean pulmonary artery pressure is usually 15. Normal pulmonary capillary wedge pressure is usually four to 12. I like this slide overall. It's just very simple, and it gives you an example of what the pulmonary artery pressure should be. Noting that the right atria is usually that of a nickel or five. The right ventricle is gonna be that of like 25 over five for normal pressures. Looking at your pulmonary arteries, it's 25 over 10, with the pulmonary wedge being at 10. This is not the end-all be-all, but it gives you a quick and easy way to know what normal pulmonary pressures are. I want to talk a little bit about remote monitoring. Besides looking at typical measures of volume status through physical exam and weight and labs, the goal is to look at remote monitoring to also be a valuable tool for heart failure. Remote implantable device monitoring is available in many ICDs and CRTs. These devices, while monitoring an individual's rhythm, can also monitor level activities and overall volume status. How can we tell if a patient is volume overloaded through their device? The lung congestion can be assessed through thoracic impedance. Thoracic impedance relies on a principle of electricity traveling through the fluid, such as the bone, tissue, air, and there's less resistance or impedance if the individual has lung congestion. Cardiovascular implantable devices, including pacemakers and defibrillators, can show thoracic impedance across the generator of the chest wall to the leads of the heart. This is an example of a report of an implantable device. In the left picture on the first row, you will note the optival fluid level. The second row is that of thoracic impedance. As the optival fluid level increases, the thoracic impedance will decrease, noting that the patient has more volume. Implantable devices also show how a patient is doing related to atrial fibrillation, CRT pacing, activity, and as mentioned, optival can be used for heart failure management. Overall, the use of all this technology can let us know how a patient is doing related to their heart failure. Let's talk about other devices. There's also HeartLogic, which is available in ICDs. HeartLogic uses multiple sensors and an alert algorithm and implantable CRT and ICD devices to provide a complex index that detects worsening heart failure, heart sounds, impedance, respirations, activities, and heart rate. HeartLogic is highly sensitive to the early warning signs of heart failure and offers a clinical time to help risk stratify a patient for the right therapy. The clinical study to validate the HeartLogic was that of the MultiSense trial. There was a 70% sensitivity in detecting heart failure events. This slide shows what a report looks like for a HeartLogic. The HeartLogic index is computed daily and combines measurements of heart sounds, impedance, respirations, activity, and heart rate. The HeartLogic index crosses the threshold and then an alert is issued if the pressures are high. Another device for volume monitoring is the REDS, the remote dielectric sensing that measures the dielectric properties of the tissues. Low power electromagnetic impulses are emitted across the thorax through the lungs and given a volume status number. In contrast to assessments of thoracic impedance being implantable devices, the REDS monitoring requires a wearable device and is usually done in a hospital clinic setting. The machine provides an absolute measurement of volume level content located in the right mid lobe of the lung. The percent of fluid is compared to the lung volume with 20 to 35% representing a normal measure of fluid content. Another fluid monitoring device is the CardiOMS HF system. The CardiOMS device is a small sensor that is placed in the pulmonary artery during a right heart cath. The device is activated, for lack of a better word, when an individual lays on the pillow or the sensor. The pulmonary artery pressure is then sent to a database and the pressures can be trended to monitoring for fluid retention. The monitoring of the pulmonary artery pressure provides early detection and worsening heart failure symptoms before the symptoms even occur. I went ahead and included a couple trials related to CardiOMS. The first one is the CHAMPION trial. It was a parallel single-blinded multi-center trial related to that of individuals with class two heart failure symptoms and previous hospital admissions. There's 550 patients that were randomized between the control or the treatment group. It is noted that there was a 33% reduction in hospital admissions. The Lancet mirrored the results of the European studies with a 30% reduction in heart failure related hospitalizations. I like this slide and use it for patient education. It shows how the changes in the pulmonary artery pressures show long before the symptoms of heart failure occur. It can be used to encourage patients to send transmissions daily. This slide shows the example of what CardiOMS tracing look like from a single transmission on the left to on the right, transmissions over a period of time. Once again, the remote monitoring as discussed in this module is not inclusive. The goal is to show you different forms of devices and how they can be effective for volume status and heart failure management. And this also does not include clinical trials. These are my references for this slide. These modules. Thank you very much for your time. And I hope you learned a little bit more regarding patient volume management.

heart failure

symptoms

remote monitoring devices

diuretics

clinical trials