3/2/2017. Identifying the Patient for Advanced Therapies. Why is Identifying the Adv HF patient important? CHF Stages and Steps of Treatment

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1 Identifying the Patient for Advanced Therapies Cindy Bither Chief NP- Adv HF Program Medstar Heart and Vascular Institute Stage A High risk with no symptoms Stage B Structural heart disease, no symptoms Stage C Structural disease, prior or current symptoms Stage D Refractory symptoms requiring special intervention CHF Stages and Steps of Treatment ACE-I / ARBs and B-blockers in all patients, epleronone Treat HTN, DM, CAD, dyslipidemia. ACE-I/ARBs when appropriate Risk factor reduction, patient and family education Spironolactone, ARBs, Hydralazine/Nitrates Sodium restriction, diuretics, and digoxin ACE-I, B-blockers when appropriate Inotropes VAD,Tx,hospice MVR, Paracor or other surgery Nesiritide Cardiac resynchronization if Bundle Branch Block Jessup M NEJM 2009 Why is Identifying the Adv HF patient important? There are 5.7 million people living with heart failure and 10% of those have Adv HF. The majority of cost for these patients is in the last six months of life and much of that is inpatient 1

2 The Costs Mount Congestive Heart Failure Volume 17, Issue 4, pages , 21 JUL 2011 DOI: /j x Why is it so difficult to identify? Outcomes in Patients Hospitalized with Heart Failure Hospital Readmissions Mortality N = 38, N = 38,702 50% 50 33% 20% 25 12% 60% 0 30 Days 6 Months 0 30 Days 12 Months 5 Years Median length of hospital stay: 6 days References: Aghababian RV. Rev Cardiovasc Med. 2002;3(suppl 4):S3-S9. Jong P et al. Arch Intern Med. 2002;162:

3 Median Survival Decreases Progressively after Each Hospitalization 3.0 Setoguchi et al. AHJ 07 Medial Survival (years) Average age of HF hosp In community = years 0.0 1st (n=14,374) 2nd (n=3,358) 3rd (n=1,123) 4th (n=417) Impact of Renal Function on Survival in HF Ibopamine Trial n=1906 Hillege et al. Circ. 2000; 102: Median Survival Decreases Progressively after Each Hospitalization Impact of Chronic Kidney Disease (CKD) 3.0 Setoguchi et al. AHJ 2007 Medial Survival (years) CKD CKD Average age of HF hosp In community = years CKD CKD 0.0 1st (n=14,374) 2nd (n=3,358) 3rd (n=1,123) 4th (n=417) 3

4 Serum Sodium to Select Heart Failure Populations Class IV LVEF< 25% Class III-IV 100 % MORTALITY > 136 <136 <134 <132 <130 1 year 2 year Stevenson, Couper et al Circulation Suppl 96 Reduced Survival with Inability to take ACEI Due to Cardio-Renal Limitations Kittleson et al JACC 2003, RV Enlargement Increases Mortality In Idiopathic Dilated Cardiomyopathy 1.0 No RV enlargement Sun (Cleve Clinic) Am J Cardiol 80:158 3(1997 ) Survival Probability p = RV enlargement Months RV area/lv area >0.5 4

5 The Prognostic Value of Maximal Oxygen Consumption Circul ation 1991;8 3: Cumulative Survival (%) VO 2 14 ml/kg/min (listed)* VO 2 > 14 ml/kg/min VO 2 14 ml/kg/min (not listed)* * p<0.005 for VO2 14 vs > 14 Duration of Follow-up (Mo) components MAP HR Long QRS Pk VO2 CAD LVEF PCW Na Death, Urgent Tx, LVAD Risk Stratification in Advanced HF Heart Failure Survival Score Aaronson, Mancini Circulation 1997; 95: Low Risk Hi Risk Medium Teuteberg, Stevenson et al, J Cardiac Failure 06; 12: Who Is Dying With Heart Failure N=160 Deaths Peak creatinine past 6 mo 3.1 Peak BUN / past 6 mos 62 Lowest serum Na 128 RV dysfunction 53% 0 / 1 / > 2 hosps / 6 mos 26 / 32/ % were in Class IV HF 5

6 Prognostic Predictors in HF Clinical Age Gender Etiology HR SBP Cachexia S3 Hemodynamic/Echo CVP/PCWP CI SVR LVEF and RVEF LVEDD Functional NYHA Class 6 Minute Walk Peak VO 2 VE/VO 2 Laboratory Norepinephrine Renin BNP and ANP Endothelin - 1 IL6,TNFα, TNF R1 and TNF R2 SODIUM BUN/Cr/Cr Clearance Hemoglobin Uric acid Cholesterol % lymphocytes Medications/Device ACEI/ARB* Beta Blocker* Aldosterone Blocker Statins ICDs + BiV Pacers Current Management of Advanced/End Stage HF Optimized Oral HF Drug Rx High Risk CV Surgery Investigational Drugs Pulm HTN RV Failure BiV Pacer LATE REFERRAL Malnutrition End Organ Dysfx DT VADs Tx Indications for CRT in Advanced HF Only 10% of the data on CRT is in Class IV Pts Can be very helpful but 1/3 do not respond Data from MADIT CRT reconfirmed that only pts with QRS> 150 msec, NSR, LBBB likely to respond;may be equally beneficial Class I, II Data from FREEDOM trial demonstrated 22% actually have a deterioration with CRT even with optimization of PR interval. Suggested the device be turned off in some patients 6

7 Candidate Selection for Heart Tx No biochemical criteria like renal, liver disease Class IV HF on maximal HF meds Peak VO2 < 14 ml/kg/min or 50% predicted Formal Eval is look for Contraindications AGE alone can not be a contraindication Hemodynamics: CI< 2.0l/min Pulm HTN: PAS<60, PVR<3.0; TPG<15 Renal Fx: Creat < 3.0, no dialysis(ht-kidney) Candidate Selection for Heart Tx Pulm: FEV1> 1 liter; no O2 need; Coronary Angiogram: once and if > 3 yrs Cancer: no solid organ for 5 years Age appropriate cancer screening Organ dysfunction evaluation Signifcant reduction Hgb, WBC, Plts Liver functions: RV Failure vs Primary Dis Mech Circ Support as BTT Eligbility Criteria Class IV HF on maximal HF meds Peak VO2 < 14 ml/kg/min or 50% predicted No contraindications to Tx (cancer, renal,etc) Severe Pulm HTN not a contraindication Listed for Heart Tx-active list* Tightening of criteria last 2 months to reduce the practice of listing likely DT as BTT 7

8 Current CMS Indications For Mech Circ Support as DT Class IV heart failure on optimized HF meds Prognosis of < 2 yrs EF< 25% VO 2 < 12 ml/kg/min or 55% predicted Not eligible for Heart Tx at the time of need The Right Time for LVAD Implantation Key to Survival after Destination Therapy Operative Risk Death Futile Implants Too Late 1-Year Survival 19% Lietz, Miller Circulation. 2007;116(5):497 Successful Implants Worsening of nutritional state, end-organ and RH function 1-Year Survival 69% AHA GWTG Markers for Adv HF Referral More than 2 s (or ED visits) in the past year 8

9 AHA GWTG Markers for Adv HF Referral More than 2 s (or ED visits) in the past year End organ dysfunction (ie progressive CKD) AHA GWTG Markers for Adv HF Referral More than 2 s (or ED visits) in the past year End organ dysfunction (ie progressive CKD) Symptomatic hypotension AHA GWTG Markers for Adv HF Referral More than 2 s (or ED visits) in the past year End organ dysfunction (ie progressive CKD) Symptomatic hypotension Dose reduction of ACE or BB 9

10 AHA GWTG Markers for Adv HF Referral More than 2 s (or ED visits) in the past year End organ dysfunction (ie progressive CKD) Symptomatic hypotension Dose reduction of ACE or BB Weight loss without trying cachexia AHA GWTG Markers for Adv HF Referral More than 2 s (or ED visits) in the past year End organ dysfunction (ie progressive CKD) Symptomatic hypotension Dose reduction of ACE or BB Weight loss without trying cachexia Unable to walk one block progressive dyspnea Continued Repeated ICD shocks VT 10

11 Continued Repeated ICD shocks VT Daily lasix dosing of 160 mg or more with the occasional metolazone Continued Repeated ICD shocks VT Daily lasix dosing of 160 mg or more with the occasional metolazone Hyponatremia <133 meq/l Continued Repeated ICD shocks VT Daily lasix dosing of 160 mg or more with the occasional metolazone Hyponatremia <133 meq/l High BNP that does not decrease by 50% with GDMT 11

12 Continued Repeated ICD shocks VT Daily lasix dosing of 160 mg or more with the occasional metolazone Hyponatremia <133 meq/l High BNP that does not decrease by 50% with GDMT No reversible causes or precipitants Risk Factors for Mortality in HF Hospitalization for HF on oral HF therapy Inability to take ACEI/ARB/BB BUN> 45, Creat>2.5, CrCl< 45 cc/min BNP >4 x s upper limit of normal Na+ < 136 Malnutrition/Cachexia VO2 <55% predicted LVEDD >7.0 cm >2 Prompt Referral for Advanced Rx Patient Selection for Advanced HF Careful Patient Selection is the most important aspect of determining outcomes in Adv HF Good progress in use of scores and models that can help evaluate patients Important to be aware of Risk Factors. EARLIER IDENTIFICATION IS KEY Some patients have HF that is too advanced for successful use of most aggressive options 12