Objectives. Outline 4/3/2014

Transcription

1 Jessica Litke PGY1 ISHP Spring Meeting April 12, 2014 Objectives Appreciate the significance of heart failure (HF) to a patient and to the health care system Understand 2013 ACCF/AHA guidelines for the management of heart failure including pharmacologic and non-pharmacologic therapies Know Joint Commission standards for certification in heart failure Outline Definition of heart failure Epidemiology Risk Factors Symptoms/Diagnosis Classification Guideline based treatment recommendations Joint Commission certification 1

2 What is Heart Failure (HF)? Structural or functional impairment of ventricular filling or ejection of blood Inefficient pump Systolic Dysfunction Diastolic Dysfunction Epidemiology About 5.1 million people in the US have HF Lifetime risk of developing HF is 20% for Americans 40 years old Approximately 50% people diagnosed with HF die within 5 years of diagnosis Heart failure costs are an estimated $39 billion per year (includes meds, services, and missed work days) Estimated lifetime cost of HF per patient is $110,000/yr Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics 2010 Update. Circulation 2010;121:e

3 From: Heart Failure JCHF. 2013;1(1):1-20. doi: /j.jchf *Approximately 20-25% readmission rate within 30 days after hospital discharge Figure Legend: Discharges From Hospitalization Due to Heart Failure, by Sex (United States, ) Date of download: 3/23/2014 Copyright The American College of Cardiology. All rights reserved. Risk Factors Age Increased body mass index (BMI) Abdominal fat accumulation Elevated fasting blood glucose/diabetes Hypertension Cigarette smoking Valvular heart disease Coronary artery disease (CAD) Symptoms Dyspnea Fatigue Edema Cough Limited exercise tolerance AKA congestive heart failure (CHF) 3

4 Diagnosis Symptoms Medical history Physical exam BNP ECG Echocardiogram Ejection fraction Classification NYHA I No symptoms with activity II Symptoms with usual activity III Symptoms with minimal activity IV Symptoms at rest ACC/AHA A High risk for development of structural disease B Asymptomatic C Symptomatic D Refractory, end-stage 4

5 Treatment Treatment Approach Non-Pharmacologic Pharmacologic Non-Pharmacologic Therapy Education Smoking cessation Decreased alcohol intake Control concomitant hypertension, hyperlipidemia, and diabetes Dietary sodium restriction CPAP Weight loss Exercise 5

6 Pharmacologic Therapy Diuretics ACE-I/ARBs (Angiotensin converting enzyme inhibitors/angiotensin receptor blockers) Beta Blockers Aldosterone inhibitors Hydralazine/Nitrates Digoxin Diuretics water pill Used to help relieve symptoms of congestion Loop diuretics preferred Dosing in acute setting Furosemide Bumetanide Torsemide mg/day mg/day mg/day Ideally last dose before 4 pm Taper dose to achieve euvolemia Can titrate dose based on weight gain Dipiro2008 ACEI/ARBs Help control BP and decrease cardiac remodeling Decrease mortality and improve symptoms Recommended in nearly all patients with heart failure Lots of different options, not 1 preferred ACEI: Ramipril, captopril, enalapril, lisinopril, quinapril, fonsinopril, trandolopril, etc. ARBs: losartan, valsartan, candesartan ACEI can cause a nagging cough, switch to ARB Should not be used in combination with an ACEI or if patient is pregnant 6

7 Beta-Blockers Rate control Improve quality of life, functional status, and decrease mortality Recommended in nearly all patients with heart failure Metoprololsuccinate, carvedilol(dose BID), or bisoprolol Increase dose slowly May worsen symptoms at first Aldosterone Inhibitors Increasingly recommended in heart failure Decrease mortality and improve symptoms 2 drugs: Spironolactone: dose 12.5mg-25mg daily Eplerenone: 25mg-50mg daily May have less side effects than spironolactone, but is much more expensive Hydralazine/Isosorbide Dinitrate Alternative to ACEI/ARBs or can be added May provide additional benefit, especially in African American patients Dosed TID to QID, compliance can be a problem 7

8 Digoxin Improves force of contraction of the heart Improve symptoms and exercise tolerance, not mortality Available IV and PO Can monitor with blood levels Goal in HF: ng/ml Signs of Toxicity: confusion, N/V/D, palpitations, vision changes, decreased consciousness Portrait of Dr. Gachet, 1890 Foxglove (Digitalis purpurea) HF Therapeutic Targets Digoxi n H/ID ACEI/ARB s H/ID Β-Blockers ACEI/ARB s AAs AAs Diuretics 8

9 Disease-Specific Care Certification Launched by The Joint Commission (TJC) in 2002 Designed to evaluate clinical programs across the continuum of care Available for a wide variety of conditions, including HF Benefits: Improved quality of care Demonstrates commitment to high standards Organizational framework Enhances staff development Recognized by third party payers Disease-Specific Care Certification Requirements Ongoing data collection and analysis Effective use of evidence-based medicine and guidelines Performance measurement and improvement activities On-site reviews and conference calls 9

10 Items to be Reviewed 1. Composition of team 2. Program mission and scope 3. Organization chart for the program 4. Emergency plans 5. Current list of patients treated in program 6. List of patients who came through program 7. Order sets/protocols 8. Educational materials 9. Written performance improvement plan and reports 10. Performance measure data 11. Evidence data being used to improve program Advanced Certification Available for 7 clinical areas, including HF Meet requirements for disease-specific care certification + additional requirements Standardized performance measures available for advanced certification in heart failure Heart Failure Measures (TJC) 10

11 Mandatory Core Measures for Heart Failure Certification HF-1: Discharge instructions HF-2: Evaluation for left ventricular systolic function (LVSF) HF-3: ACEI or ARB for left ventricular systolic dysfunction (LVSD) Mandatory Measures for Advanced Heart Failure Certification ACHF-01: Beta-blocker therapy for LVSD at discharge ACHF-02: Post-discharge appointment ACHF-03: Care transition record transmitted ACHF-04: Discussion of advanced directives/advanced care planning ACHF-05: Advance directive executed ACHF-06: Post-discharge evaluation References rt_failure.htm Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics 2010 Update. Circulation 2010;121:e Dipiro. Pharmacotherapy The Joint Commission. DSC_Organization_RPG.pdf YancyCW, Jessup M, et al ACCF/AHA guidelines for the management of heart failure: a report of the American college of cardiology foundation/american heart association task force on practice guidelines. Circulation. 2013;128e240- e

12 Questions 1. What is the approximate readmission rate for patient s discharged with a primary diagnosis of heart failure? A. 3-5% B % C % D % 2. Which of the following is not one of the primary recommended medications for all heart failure patients? A. Beta-blockers B. Warfarin C. ACE Inhibitors D. Diuretics Questions 3. What are the 3 mandatory core measures for heart failure patients defined by TJC? HF-1: Discharge instructions HF-2: Evaluation of LVSF HF-3: ACE-I or ARB for LVSD *Bonus What are the 6 mandatory advanced certification in heart failure measures for inpatients? ACHF-01: Beta-blocker therapy for LVSD at discharge ACHF-02: Post-discharge appointment ACHF-03: Care transition record transmitted ACHF-04: Discussion of advanced directives/advanced care planning ACHF-05: Advance directive executed ACHF-06: Post-discharge evaluation 12