6/16/2016. Heart Failure Review Course Part 2. Objectives. Case Study 1 CKD, PVD, Atrial Fibrillation

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1 Heart Failure Review Course Part 2 Connie M. Lewis MSN, ACNP-C, NP-C, CCRN, CHFN, FHFSA Vanderbilt University Medical Center June Objectives Recognize heart failure symptoms Discuss HF guidelines related to medications, ICD, CRT, exercise, sodium restriction Discuss palliative care indications CKD, PVD, Atrial Fibrillation 64 YO female transferred from OSH July 2009 with biventricular failure. Her overall long-term prognosis is poor. I have discussed the critical nature of the patient's illness with her family and they acknowledge understanding. They would like everything done for her for now. The patient is too drowsy and obtunded at present to communicate her wishes. History of present illness: Ischemic cardiomyopathy (LVEF 20-30%) Atrial fibrillation Acute kidney injury Altered mental status ACCF/AHA stage --- NYHA class --- ACCF/AHA stage D NYHA class IV Symptomatic with: Weight gain, fatigue, shortness of breath at rest, PND, orthopnea, increased abdominal girth, early satiety 3 1

2 7/2009 Past medical history: CAD (age 45), CABG 1989, PCI LAD graft 2001, anterior MI in medically managed. Not a repeat surgical candidate CKD with left renal atrophy COPD, 2ppd for 20 years HTN PVD Hyperlipidemia Atrial fibrillation DVT Gout Family history: Multiple family members on paternal side with early CAD 4 Ten Most Common Hypertension % Co-Morbidities Among Medicare Beneficiaries with HF >65 and <65 Ischemic heart disease % Hyperlipidemia % Anemia % Diabetes % Arthritis % Chronic kidney disease % COPD % 2013 ACC/AHA Clinical Guidelines Atrial fibrillation % in >65 years Alzheimer's disease/dementia 27.6% in >65 years Asthma 15.5% in <65 years Peripheral Artery Disease (PAD) Associated with a 2-fold increase in the prevalence of HF Concomitant PAD associated with an increased risk for hospitalization and mortality PAD is not a contraindication to beta-blocker treatment in HF : PAD increased risk of transplant complications, as does CKD Anand.Congest Heart Fail

3 Chronic Kidney Disease Risk factor for development of HF Independent risk factor for morbidity and mortality Cardiorenal syndrome describes concomitant cardiac and renal dysfunction Nephrology consult if: * GFG<60ml/min to identify the cause of the kidney disease and management of the disease * All potential dialysis patients with GFR<30ml/min HF Nursing Certification: Core Curriculum Review 2 nd Edition 2014 Stages of Chronic Kidney Disease (CKD) Stage Description GFR Level Normal kidney function Healthy kidneys 90 ml/min or more Stage 1 Kidney damage with normal 90 ml/min or more or high GFR Stage 2 Kidney damage and mild 60 to 89 ml/min decrease in GFR Stage 3 Moderate decrease in GFR 30 to 59 ml/min Stage 4 Severe decrease in GFR 15 to 29 ml/min Stage 5 Kidney failure Less than 15 ml/min or on dialysis In Stage 1 and Stage 2 CKD, there are often few symptoms Early CKD is usually diagnosed when there is: High blood pressure Higher than normal levels of creatinine or urea in the blood Blood or protein in the urine Evidence of kidney damage in an MRI, CT scan, ultrasound, or contrast X-ray A family history of polycystic kidney disease Levey AS. Am J Kidney Disease. 2012;60: Atrial Fibrillation ACCF/AHA Guidelines for the Management of Heart Failure. Circulation

4 Atrial Fibrillation Optimal ventricular rate control *60-80 beats per minute at rest * with moderate exertion Beta blockers first choice for rate control Digoxin may be helpful with beta blocker Verapamil and diltiazem are effective for rate control, not used in HFrEF due to negative inotropic effect If rate control strategy not effective, consider AV nodal ablation and CRT Anand.Congest Heart Fail Atrial Fibrillation Disabling symptoms in AF Anticoagulation and rate control as needed Rhythm control has not been shown to be superior to rate control Antiarrhythmic therapy AF ablation if antiarrhythmic therapy treatment fails For patients with continued disabling symptoms in spite of rate control therapies consider rhythm control, antiarrhythmic agents ACCF/AHA Guidelines for the Management of Heart Failure. Circulation.2013 Antiarrhythmic Agents Amiodarone and dofetilide are the only antiarrhythmic agents to have neutral effects on mortality in clinical trials of patients with HF Sototolol, dronedarone, propafenone, flecainide, quinidine should be avoided in HF due to their pro-arrhythmic and negative inotropic effects in the setting of decreased LV function. ACCF/AHA Guidelines for the Management of Heart Failure. Circulation

5 Antiarrhythmic Agents Amiodarone is not felt to cause worsening LV dysfunction or HF symptoms Not recommended for primary prevention of sudden death in patients with HF May be considered to reduce occurrence of recurrent symptomatic arrhythmias and subsequent ICD shocks When amiodarone is initiated, potential for drug interactions with concomitant therapies must be reviewed The maintenance doses of digoxin, warfarin and some statins should be reduced and then monitored closely Monitor liver and thyroid function at baseline and every 6 months Pulmonary function test at baseline and as needed based on symptoms PA and lateral chest x-ray recommended at baseline and annually 7/2009 Admitted to CCU PA catheter, milrinone, furosemide drip, creatinine 3.9 on admission, atrial fibrillation Diuresed 30 lbs over 2 weeks Discharged after 2 weeks 14 Recommendations for Noninvasive Cardiac Testing Yancy C et al. Circulation 2013;128:e240-e

6 6/16/2016 Chest X-Ray Establish baseline Assess the following: - Cardiac shape/size - Pulmonary vasculature - Pulmonary infiltrates/congestion - Pleural effusion - Device and lead position Cardiothoracic ratio greater than 1:2 (50%) is abnormal Echocardiogram ECHO: Atrial size, ventricular size and function Ejection fraction Wall and septal thickness Wall motion Valve function and severity of valve insufficiency Doppler of valve flow to measure pressures Congenital heart defect Non-compaction syndrome Effusion Thrombus Catheterization: LHC and RHC Left heart catheterization Direct measurement of left heart pressures Valvular function and surface area Coronary angiography to assess for coronary artery obstruction and determine if surgical revascularization is possible Right heart catheterization Hemodynamics Right heart pressures Pulmonary arterial pressures Pulmonary capillary wedge pressure Cardiac output and index Thermodilution Fick Method 6

7 Electrocardiogram (12 Lead ECG) To assess: Ischemic changes, arrhythmias, left ventricular hypertrophy Monitoring for drug side effects or electrolyte imbalances Conduction abnormalities Bundle branch block QT interval related to drug levels Identify appropriate candidates for biventricular pacemaker insertion 7/2009 ECHO 7/2009 LVEF 20-30% LVIDd 5.6 cm (nl ) Four chamber enlargement with evidence for anteroapical MI with severely depressed LV systolic function and moderately depressed RV systolic function Moderate to severe mitral regurgitation Moderate tricuspid regurgitation EKG Atrial fibrillation HR 65, LBBB, QRS 160 ms. 20 7/2009 cmri to determine: Cardiac structure Blood flow velocity Tumors Non-conpaction syndrome May be helpful in diagnosing infiltrative disorders: Amyloidosis Sarcoidosis Cardiac MRI 7/22/2009 LVEF 20% Ischemic heart disease Severely depressed global left ventricular systolic function; dilated left ventricle Dilated and moderately hypokinetic right ventricle Transmural myocardial infarction in the proximal-mid left anterior descending coronary artery territory No MRI evidence for LV apical thrombus Small right-sided pleural effusion Mild mitral regurgitation Moderate biatrial enlargement Dilated IVC and hepatic venous congestion consistent with right atrial hypertension 21 7

8 7/2009 Discharge medications: Lisinopril 2.5 mg daily Metoprolol succinate (extended release) 100 mg daily Furosemide 80 mg bid Warfarin 4mg tablet, by mouth daily Allopurinol 100 mg daily Aspirin 81mg by daily Diazepam 5 mg three times daily as needed ProAir HFA 3 puffs every 4 hours as needed for wheezing Fluoxetine 20 mg daily at bedtime Simvastatin 20 mg daily at bedtime Spironolactone 25 mg daily Is she on GDMT? ACE-I Beta blocker Diuretic Aldosterone Antagonist 22 She has chronic AF, on metoprolol succinate. Should she be on antiarrhythmic? A. Loading does of ammiodarone should be initiated. B. Beta blockers are first choice for rate control. C. Schedule for AF ablation D. Schedule for DCCV. B. Beta blockers are the first choice for rate control. Rhythm control has not been shown to be superior to rate control. 23 Drugs Commonly Used for HFrEF (Stage C HF) Mean Doses Achieved in Drug Initial Daily Dose(s) Maximum Doses(s) Clinical Trials ACE Inhibitors Captopril 6.25 mg 3 times 50 mg 3 times mg/d (421) Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg/d (412) Fosinopril 5 to 10 mg once 40 mg once Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg/d (444) Perindopril 2 mg once 8 to 16 mg once Quinapril 5 mg twice 20 mg twice Ramipril 1.25 to 2.5 mg once 10 mg once Trandolapril 1 mg once 4 mg once ARBs Candesartan 4 to 8 mg once 32 mg once 24 mg/d (419) Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/d (420) Valsartan 20 to 40 mg twice 160 mg twice 254 mg/d (109) Aldosterone Antagonists Spironolactone 12.5 to 25 mg once 25 mg once or twice 26 mg/d (424) Eplerenone 25 mg once 50 mg once 42.6 mg/d (445) Yancy C et al. Circulation 2013;128:e240-e327 8

9 Practice Guideline: ACE- inhibitors (ACE-I) Considerations for use of ACEI: Inhibit the renin-angiotensin-aldosterone system (RAAS) by inhibiting the conversion of angiotensin I to angiotensin II Promote afterload reduction and vasodilation Promote reverse remodeling of left ventricle Recommended if LVEF < 40% Do not automatically withhold for renal insufficiency Monitor electrolytes and renal function May cause cough and angioedema Drugs Commonly Used for HFrEF (Stage C HF) (cont.) Mean Doses Achieved in Drug Initial Daily Dose(s) Maximum Doses(s) Clinical Trials Beta Blockers Bisoprolol 1.25 mg once 10 mg once 8.6 mg/d (118) Carvedilol mg twice 50 mg twice 37 mg/d (446) Carvedilol CR 10 mg once 80 mg once Metoprolol succinate extended release 12.5 to 25 mg once 200 mg once 159 mg/d (447) (metoprolol CR/XL) Hydralazine & Isosorbide Dinitrate 37.5 mg hydralazine/ 75 mg hydralazine/ Fixed dose combination ~175 mg hydralazine/90 mg 20 mg isosorbide 40 mg isosorbide (423) isosorbide dinitrate daily dinitrate 3 times daily dinitrate 3 times daily Hydralazine and Hydralazine: 25 to 50 Hydralazine: 300 mg isosorbide dinitrate (448) mg, 3 or 4 times daily daily in divided doses and isorsorbide and isosorbide dinitrate dinitrate: 120 mg daily in 20 to 30 mg divided doses 3 or 4 times daily Yancy C et al. Circulation 2013;128:e240-e327 Guideline-Directed Medical Therapy (GDMT) Strategies for Achieving Optimal GDMT 1. Uptitrate in small increments 2. Certain patients (e.g., the elderly, patients with chronic kidney disease) may require more frequent visits and laboratory monitoring during dose titration and more gradual dose changes. 3. Monitor vital signs closely 4. Alternate adjustments of different medication classes 5. Monitor renal function and electrolytes for rising creatinine and hyperkalemia, recognizing that an initial rise in creatinine may be expected and does not necessarily require discontinuation of therapy 6. Patients may complain of symptoms of fatigue and weakness with dosage increases 7. Discourage sudden spontaneous discontinuation of GDMT medications by the patient and/or other clinicians without discussion with managing clinicians. 8. Carefully review doses of other medications for HF symptom control (e.g., diuretics, nitrates) during uptitration 9. Consider temporary adjustments in dosages of GDMT during acute episodes of noncardiac illnesses (e.g., respiratory infections, risk of dehydration, etc.). 10. Educate patients, family members, and other clinicians about the expected benefits of achieving GDMT, VanderbiltHeart.com Yancy C et al. Circulation 2013;128:e240-e327 9

10 Implantable Cardioverter Defibrillators (ICD) Primary prevention of sudden cardiac death (SCD) is indicated for those at greatest risk for SCD but have not had arrhythmias. Inducible, sustained VT can result in a risk of SCD of approximately 5-6% per year Secondary prevention dictates the implantation of ICDs in HF patients who have had life threatening arrhythmias. Poor Cardiac Output leads to increase catecholamine release thereby potentiating arrhythmia Epstein. Circulation 2013;127:e283-e352 Primary Prevention in HFrEF Ischemic (at least 40 days post MI) or selected with nonischemic Do not have a prior history of arrhythmias or syncope HFrEF LVEF < 35% NYHA Class II or III after 3-6 months of GDMT Expected to live >I year - OR LVEF < 30% after MI NYHA Class I At least 40 days post-mi Expected to live > I year Yancy C et al. Circulation 2013;128:e240-e327 ICD Today Extended Multiprogrammable tiered therapy Longevity (> 5-7 yrs) Endocardial lead systems Smaller, thinner Pectoral implant Advanced rhythm discrimination State-of-the-art pacing therapies Powerful diagnostics Atrial therapies 10

11 ICD Therapy Delivery and Effects Ventricular Tachycardia Sinus Rhythm A V Tachycardia ICD activated Normal rhythm restored A V Secondary Prevention ICD VF arrest survivor - OR - Sustained VT - OR - Syncope with inducible VT/VF Cardiac Resynchronization Therapy (CRT) Biventricular Pacing (Bi-V) CRT Coordinates activation of the ventricles and septum Indicated for patients with: Symptomatic NYHA class II, III, or ambulatory IV symptoms on GDMT LVEF < 35% NSR LBBB with QRS > 150 ms > 3 months after diagnosis cardiomyopathy > 40 days after MI Improves hemodynamic performance by forcing the left ventricle to complete contraction and begin relaxation earlier, allowing an increase in ventricular filling time Associated with improvement in: Functional class Quality of life Survival Yancy C et al. Circulation 2013;128:e240-e327 11

12 Biventricular Pacing: Cardiac Resynchronization Therapy (CRT) Transvenous Approach Standard pacing lead in right atrium Standard pacing or defibrillation lead in right ventricle Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus Back-up epicardial approach Device Therapy for Stage C HFrEF Recommendations COR LOE ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post-mi with LVEF 35%, and NYHA class II or III symptoms on chronic GDMT, who are expected to live 1 year* CRT is indicated for patients who have LVEF 35%, sinus rhythm, LBBB with a QRS 150 ms ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post-mi with LVEF 30%, and NYHA class I symptoms while receiving GDMT, who are expected to live 1 year* CRT can be useful for patients who have LVEF 35%, sinus rhythm, a non- LBBB pattern with a QRS 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT. CRT can be useful for patients who have LVEF 35%, sinus rhythm, LBBB with a QRS 120 to 149 ms, and NYHA class II, III or ambulatory IV symptoms on GDMT CRT can be useful in patients with AF and LVEF 35% on GDMT if a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) AV nodal ablation or rate control allows near 100% ventricular pacing with CRT I I I IIa IIa IIa A A (NYHA class III/IV) B (NYHA class II) B A B B Yancy C et al. Circulation 2013;128:e240-e327 10/2009 October 2009 Laparoscopic cholecystectomy ECHO: LVEF 15-25%. Severe Dilated CM with 4-chamber dilatation with severe LV systolic/diastolic dysfunction; moderate reduction in RV systolic function with moderate MR and mild pulmonary HTN On optimal GDMT 36 12

13 What would you expect next? A. Consider ICD, CRT-D B. Consult Hospice C. Continue to monitor disease progression D. Refer for heart transplant A. Consider ICD, CRT-D. *ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post-mi with LVEF 35%, and NYHA class II or III symptoms on chronic GDMT, who are expected to live 1 year *CRT is indicated for patients who have LVEF 35%, sinus rhythm, LBBB with a QRS 150 ms January 2010 CRT-D, cardiac resynchronization therapy with implantable cardioverter-defibrillator June 2010 ECHO LVEF 25-35%, LVIDd 5.7 cm ( CM) LA and RA moderately dilated Mildly depressed RV, RVIDd 3.8 cm ( cm) Mild-moderate MR, trace TR 38 Case Study1 8/2011 Increase in HF symptoms: Fatigue, shortness of breath with minimal exertion, requiring increasing dosages of diuretics 08/19/11 15: * 08/02/11 06: * *More aggressive diuresis 07/05/11 06: *Evaluate for advanced HF therapies 06/06/11 14: * 05/06/11 14: * 03/14/11 06: * ECHO LVEF 15-25%, LVIDd 5.7 cm ( CM) LA and RA severely dilated Mildly depressed RV, RVIDd 3.1 cm ( cm) Moderate to severe MR, moderate TR 39 13

14 Recommendation for Biomarkers 2013 ACCF/AHA Heart Failure Guidelines B-type natriuretic peptide (BNP)/ NT-proBNP Increased level correlates with excess intravascular volume and increased filling pressures, causing ventricular stretch and releasing BNP Levels tend to be lower in obese patients and HFpEF; levels elevated with MI and acute pulmonary embolism; also affected by age, gender, and renal function. Helpful in determining if dyspnea is related to cardiac or non-cardiac cause. Should be used in conjunction with other assessment tools to identify HF. BNP level <100 pg/ml = normal BNP pg/ml suggest possible HF, but is not definitive BNP >300 pg/ml = mild heart failure BNP >600 pg/ml = moderate heart failure BNP levels >900 pg/ml = severe heart failure. NT-proBNP levels are substantially greater than BNP levels in patients with HF due to increased stability (half-life) of NT-proBNP in circulation; results from the two tests are not interchangeable; NT-proBNP concentrations are approximately four-fold higher than BNP concentrations HF Nursing Certification: Core Curriculum Review 2 nd Edition Causes for Elevated Natriuretic Peptide Levels Cardiac Heart failure, including RV syndromes Acute coronary syndrome Heart muscle disease, including LVH Valvular heart disease Pericardial disease Atrial fibrillation Myocarditis Cardiac surgery Cardioversion Noncardiac Advancing age Anemia Renal failure Pulmonary causes: obstructive sleep apnea, severe pneumonia, pulmonary hypertension Critical illness Bacterial sepsis Severe burns Toxic-metabolic insults, including cancer chemotherapy and envenomation 2013 ACCF/AHA Heart Failure Guidelines 14

15 Cardiopulmonary Exercise Testing The ability to perform physical exercise is critically related to: Pulmonary system s ability to permit oxygen uptake and carbon dioxide elimination and Cardiovascular system s capacity to supply oxygen to exercising muscles. *Determine whether symptom limitation is related to cardiac or pulmonary cause, or deconditioning* Cardiopulmonary Exercise Testing *Criteria for advanced heart failure: Peak VO2 <12 to 14 ml/kg/min *Directly measures VO2, VCO2, and air flow (minute ventilation, tidal volume, and respiratory rate) CO2 Cardiopulmonary Testing VO2 6.3 ml/kg/min RQ 1.13 Right Heart Catheterization RA 8 PA 42/21 PCWP 15 PA sat 58% CO 4.46 CI 2.3 Outpatient Testing Normal Results Right atrial pressure (RA) is -1 to 6 mmhg Pulmonary artery systolic pressure (PAS) 15 to 30 millimeters of mercury (mmhg) Pulmonary diastolic pressure (PAD) is 4 to 12 mmhg Pulmonary capillary wedge pressure(pcwp) is 6 to15 mmhg Cardiac output (CO) 4-8 L/min Cardiac index (CI) liters per minute per square meter (of body surface area) SVO2 >60% BNP 1340 Na 139 BUN 37 Creatinine 1.65 K 5.0 BP 90/

16 Structural heart disease remodeling appropriate appropriate valvular surgery as appropriate Development of symptoms of HF Refractory symptoms of HF at rest, despite GDMT 6/16/2016 Stages, Phenotypes and Treatment of HF At Risk for Heart Failure Heart Failure STAGE A At high risk for HF but without structural heart disease or symptoms of HF STAGE B Structural heart disease but without signs or symptoms of HF STAGE C Structural heart disease with prior or current symptoms of HF STAGE D Refractory HF e.g., Patients with: HTN Atherosclerotic disease DM Obesity Metabolic syndrome or Patients Using cardiotoxins With family history of cardiomyopathy e.g., Patients with: Previous MI LV remodeling including LVH and low EF Asymptomatic valvular disease e.g., Patients with: Known structural heart disease and HF signs and symptoms e.g., Patients with: Marked HF symptoms at rest Recurrent hospitalizations despite GDMT HFpEF HFrEF THERAPY Goals Heart healthy lifestyle Prevent vascular, coronary disease Prevent LV structural abnormalities Drugs ACEI or ARB in appropriate patients for vascular disease or DM Statins as appropriate THERAPY Goals Prevent HF symptoms Prevent further cardiac Drugs ACEI or ARB as Beta blockers as In selected patients ICD Revascularization or THERAPY Goals Control symptoms Improve HRQOL Prevent hospitalization Prevent mortality Strategies Identification of comorbidities Treatment Diuresis to relieve symptoms of congestion Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Revascularization or valvular surgery as appropriate THERAPY Goals Control symptoms Patient education Prevent hospitalization Prevent mortality Drugs for routine use Diuretics for fluid retention ACEI or ARB Beta blockers Aldosterone antagonists Drugs for use in selected patients Hydralazine/isosorbide dinitrate ACEI and ARB Digoxin In selected patients CRT ICD Revascularization or valvular surgery as appropriate THERAPY Goals Control symptoms Improve HRQOL Reduce hospital readmissions Establish patient s endof-life goals Options Advanced care measures Heart transplant Chronic inotropes Temporary or permanent MCS Experimental surgery or drugs Palliative care and hospice ICD deactivation ACCF/AHA Guidelines for the Management of Heart Failure. Circulation Advanced HF Clinical Events and Findings 1. Severe symptoms of HF with dyspnea and/or fatigue at rest or with minimal exertion NYHA class III or IV 2. Episodes of fluid retention (pulmonary and/or systemic congestion, peripheral edema) and/or reduced cardiac output at rest (peripheral hypoperfusion) 3. Objective evidence of severe cardiac dysfunction shown by at least 1 of the following: a. LVEF <30% b. Pseudonormal or restrictive mitral inflow pattern c. Mean PCWP >16 mm Hg and/or RAP >12 mm Hg by PA catheterization d. High BNP or NT-proBNP plasma levels in the absence of noncardiac causes 4. Severe impairment of functional capacity shown by one of the following: a. Inability to exercise b. 6-Minute walk distance 300 m (984 feet) c. Peak VO2 <12 to 14 ml/kg/min 5. History of 1 HF hospitalization in past 6 mo 6. Presence of all the previous features despite attempts to optimize therapy, including diuretics and GDMT,* unless these are poorly tolerated or contraindicated, and CRT when indicated *GDMT: Guideline Directed Medical Therapy ACCF/AHA Guidelines for the Management of Heart Failure. Circulation Transplantation? The benefit of transplantation is clear if a person requires continuous intravenous medications in the hospital. In unhospitalized patients, the following requirements have been recommended for consideration for cardiac transplantation: A history of repeated hospitalizations for heart failure Need for ventricular assist device or artificial heart to support circulation Increasing types, dosages, and complexity of medications A reproducible VO2 of less than 14 ml/kg per minute Patients are stratified into low, medium, and high risk of death without transplant. The final decision about listing a patient for transplant is determined by an established cardiac transplant center. 16

17 The Organ Procurement and Transplantation Network/United Network for Organ Sharing Thoracic Committee (OPTN/SRTR) 2013 Annual Data Report: Heart American Journal of Transplantation Volume 15, Issue S2, pages 1-28, 27 JAN 2015 DOI: /ajt Advanced Therapies Evaluated for heart transplant and denied listing due to age and comorbidities Referred for consideration for DestinationTherapy LVAD She declined Palliative Care: When Palliative care begins at the time of diagnosis and continues through the trajectory of the disease Assessing emotional readiness of patient and family is vital for effective communication Annually the provider should review and discuss options of current and potential therapies Clinical Practice Guidelines for Quality Palliative Care 2009 Allen LA. Decision making in advanced heart failure. Circulation 2012 Yancey CW ACCF/AHA Guideline for the Management of Heart Failure. Circulation

18 Palliative Care Palliative care is an interdisciplinary medical specialty that focuses on the care of patients with serious illness. Can be delivered concurrently with lifeprolonging care or as the main focus of care Clinical Practice Guidelines for Quality Palliative Care 2009 Palliative Care in Heart Failure 600,000 newly diagnosed HF patients every year $33.2 billion annual cost (direct and indirect costs) One in five patients die within one year of diagnosis Higher mortality rates found in a. Advanced age b. Multiple comorbidities c. Frailty d. Advanced HF (stage D) Five year survival rate worse than most types of cancer Clinical Practice Guidelines for Quality Palliative Care 2009 Heart Failure Disease Trajectory Loss of functional abilities during progression from Class I to Class IV Repeated exacerbations and hospitalizations during progression from Class III to Class IV Sudden death more common during Class II to Class III Class IV deaths mostly occur from prolonged deterioration caused by chronic pump failure Goodlin SJ. Journal of Cardiac Failure 2004;10(3):

19 Triggers for Specialist Palliative Care Referral Is the patient having more distressing physical or psychological symptoms? Are there social or spiritual concerns that are distressing and impacting the patient s/family s daily life? Is there poor understanding of current health concerns, prognosis, and options for treatment? Is there inadequate identification of patient and family goals of care? Is there concern about the safety and sustainability of post-discharge plan of care? Comprehensive Palliative Care Establishing goals of care that are in keeping with the patient s values and preferences Consistent and sustained communication between the patient and all those involved in his or her care Psychosocial, spiritual, and practical support both to patients and their family caregivers Coordination across all sites of care Prevent and relieve suffering Support the best possible quality of life for patient and their families regardless of the stage of the disease or the need for other therapies. Shared Decision Making Institute of Medicine identified patient-centered care as 1 of the 6 pillars of quality Shared decision making is the process through which clinicians and patients share information with each other and work toward decisions about treatment options that are aligned with the patients values, goals, and preferences Prognosis is not just about survival, but about outcomes relevant to the individual including: Quality of life Costs and burdens of treatments a. Caregiver burden b. Self-care burden c. Uncertainty 57 19

20 Shared Decision Making Review all conditions when having honest discussion of prognosis: 1. Other serious illnesses eg. CKD, COPD 2. Coexisting conditions 3. Dementia 4. Frailty a. Weight loss: Unintentional loss >10 pounds of dry weight in past year b. Weakness, poor grip strength c. Poor endurance, exhaustion d. Slowing of movements, ambulation e. Low activity and energy expenditure 58 The Rest of the Story 6 years later, continue end of life discussions and goals of care 1-2 times a year O Case Study 2 Outpatient Sodium, Fluid, Exercise Recommendations 47 year old single father with history of ischemic cardiomyopathy, HFrEF, and hypertension referred to HFDM clinic for medication titration. Symptoms: can not walk up one flight of steps without stopping due to shortness of breath and fatigue. No shortness of breath or fatigue walking on level ground, no chest pain, palpitations, edema, PND, orthopnea. ACCF/AHA Guidelines for the Management of Heart Failure. Circulation

21 O Case Study 2 Outpatient Sodium, Fluid, Exercise Recommendations What is his ACCF/AHA stage? What is his NYHA Class? ACCF/ AHA stage C NYHA class II NYHA Functional Classification II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF ACCF/AHA Stages of HF C: Structural heart disease with prior or current symptoms of HF ACCF/AHA Guidelines for the Management of Heart Failure. Circulation.2013 O Case Study 2 Outpatient Sodium, Fluid, Exercise Recommendations Case study 2: ACCF/AHA stage C, NYHA class II Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms Clinicians should consider some degree (e.g., <3g) of sodium restriction in patients with stage C and D HF for symptom improvement ACCF/AHA Guidelines for the Management of Heart Failure. Circulation.2013 O Case Study 2 Outpatient Sodium, Fluid, Exercise Recommendations Exercise training or regular physical activity is recommended as safe and effective for patients with HF who are able to participate to improve functional status Fluid restriction (1.5-2L/day) is reasonable in stage D, especially in patients with hyponatremia, to reduce congestive symptoms ACCF/AHA Guidelines for the Management of Heart Failure. Circulation

22 Conclusion Look to the guidelines they will guide you in the knowledge of heart failure and patient management 22