I, Robin Harris, will not discuss any off- label or inves6ga6onal devices in my presenta6on.

Transcription

1 Healthy Kingsport Conference Heart Failure Management: Con6nuum of Care Robin Harris PhD, ANP- BC, ACNS- BC Clinical Assistant Professor University of Tennessee College of Nursing mportant nfo, Robin Harris, do not have any financial disclosures., Robin Harris, will not discuss any off- label or inves6ga6onal devices in my presenta6on. Objec6ves Discuss guidelines for care of the pa6ent with heart failure. Discuss strategies to prevent acute CHF illness exacerba6on. den6fy treatments for management of advanced heart failure. 1

2 Heart Failure - Defini/on A condi6on in which the heart fails to discharge its contents adequately (Thomas Lewis, 1933) A pathophysiological state in which an abnormality of cardiac func6on is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolising 6ssues (E Braunwald, 1980) A clinical syndrome caused by an abnormality of the heart and recognised by a characteris6c pa_ern of haemodynamic, renal, neural and hormonal responses (Philip Poole- Wilson, 1985) A syndrome in which cardiac dysfunc6on is associated with reduced exercise tolerance, a high incidence of ventricular arrhythmias and shortened life expectancy (Jay Cohn, 1988) A brief history of heart failure care William Harvey describes the circula6on William Withering publishes an account of medical use of digitalis René Laennec invents the stethoscope Wilhelm Röntgen discovers x rays Organomercurial diure6cs are first used nge Edler and Hellmuth Hertz use ultrasound to image cardiac structures Thiazide diure6cs are introduced Chris6aan Barnard performs first human heart transplant CONSENSUS- study shows unequivocal survival benefit of angiotensin conver6ng enzyme inhibitors in severe heart failure European Society of Cardiology publishes guidelines for diagnosing heart failure 1997 COMET Carvedilol first beta blocker with FDA approval for mild moderate heart failure 2015 PARADGM HF Entresto approved; 2015 Corlanor approved Famous People with Heart Failure Elizabeth Taylor Ginger Rogers Helen Hayes Barbara Stanwyck Donald O Connor Danny Thomas Randy Travis Karen Carpenter Dick Cheney James Monroe Harry Truman 2

3 Where we are today 5 million people diagnosed with heart failure Most common diagnosis for hospital admission for pa6ents > 65 Only cardiovascular diagnosis on the increase 555,000 new cases diagnosed each year ncidence 10 out of every 1000 people over age 65 Figure 6. Changing management of heart failure over the past 40 years. Katz A M Circ Heart Fail. 2008;1:63-71 Copyright American Heart Association, nc. All rights reserved. 3

4 Prognos/c Significance of Heart Failure Stages Circulation. 2007;115: ACC Stages of Heart Failure At risk for development of heart failure Stage A High risk for developing heart failure Stage B Asymptoma6c LV dysfunc6on Heart Failure Stage C History of heart failure/current sx. Stage D End stage heart failure Stage A Heart Failure Management Treat known risk factors Evalua6on for S/S heart failure Rhythm control Echocardiogram to assess LV control Treat Lipid disorders Control diabetes Lifestyle modifica6ons Medica6ons: ACE nhibitors, ARBs 4

5 Mortality Findings in Large Placebo-Controlled ACE Trials J Am Coll Cardiol 2001;37: Patients With Reduced Left Ventricular Ejection Fraction Angiotensin ll Receptor Blockers Angiotensin receptor blockers are recommended inpatient with current or prior symptoms of HF and reduced LVEF who are ACE- inhibitor intolerant (see full text guidelines). Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., nonsteroidal antiinflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs). NO CHANGE J Am Coll Cardiol 2009, 53: Val- HeFT: Valsartan in Heart Failure N Engl J Med 2001;345:

6 CHARM- Alterna/ve: Candesartan in Place of ACE Lancet 2003; 362: Patients With Reduced Left Ventricular Ejection Fraction ARB and Conventional Therapy The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy. Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF. Calcium Channel Blocking Drugs Calcium channel blocking drugs are not indicated as routine treatment for HF in patients with current or prior symptoms of HF and reduced LVEF. J Am Coll Cardiol 2009, 53: Stage B Heart Failure Management Same general measures as Stage A Medica6ons: ACE nhibitors, ARBs, Beta blockers mplantable Cardioverter Defibrillator EF < 35% on op6mal medical therapy Treat structural disorder: CABG, PTCA/PC, valve repair/replacement Avoid use of calcium channel blockers with nega6ve inotropic effects 6

7 Lancet 1999;353:9-13. JAMA 2000;283: N Engl J Med 2001;344: N Engl J Med 2001;344: Stage C Heart Failure Management Same general measures as Stage A and B Medica6ons: ACE nhibitors, ARBS, Beta blockers, Diure6cs Other Medica6on that may be indicated: Aldosterone Antagonists, Digitalis, Hydralazine/nitrates mplantatable Cardioverter Defibrillator Cardiac Resynchroniza6on (biventricular PM) Patients With Reduced Left Ventricular Ejection Fraction The Risks of Aldosterone Antagonists Addition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine 2.5 mg/dl or less in men or 2.0 mg/dl or less in women and potassium should be less than 5.0 meq/l. Under circumstances where monitoring for hyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists. J Am Coll Cardiol 2009, 53:

8 RALES: Spironolactone Plus Usual Therapy N Engl J Med 1999; 341: Patients With Reduced Left Ventricular Ejection Fraction Recommendations for Hydralazine and Nitrates The combination of hydralazine and nitrates is recommended to improve outcomes for patients selfdescribed as African-Americans, with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics. The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACE inhibitor and beta blocker for symptomatic HF and who have persistent symptoms. J Am Coll Cardiol 2009, 53: Patients With Reduced Left Ventricular Ejection Fraction Hydralazine and Nitrate Combination A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency. J Am Coll Cardiol 2009, 53:

9 A- HeFT: sosorbide Dinitrate Plus Hydralazine in Black Pa/ents N Engl J Med 2004;351: Patients With Reduced Left Ventricular Ejection Fraction Recommendations for Atrial Fibrillation and Heart Failure a b t is reasonable to treat patients with atrial fibrillation and HF with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone. J Am Coll Cardiol 2009, 53: Patients With Reduced Left Ventricular Ejection Fraction The Benefits of Digitalis Digitalis can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF. J Am Coll Cardiol 2009, 53:

10 DG Trial: Digoxin in Heart Failure N Engl J Med 1997; 336: Stage D Heart Failure Management Control/Prevent fluid reten6on Heart Failure Clinic Program/Specialist Discuss end- of- life care Discuss deac6va6on of defibrillator Cardiac transplant/lvad Evalua6on Drug Therapy con6nuous inotrope infusion Heart Failure Management: Goals ncrease access to heart failure care mprove outcomes Reduce mortality Reduce rehospitaliza6on rates mprove quality of life Provide quality, evidence- based pa6ent care ndividualized pa6ent care mprove pa6ent adherence to treatment regimen Minimize acute heart failure exacerba6ons and reduce hospitaliza6ons 10

11 Heart Failure Management: Con/nuum of Care npa/ent Care Management of Acute llness Fluid Volume Reduc6on Diure6cs Symptom Management Hemodynamic Support Evalua6on and Treatment of HF E6ology Outpa/ent Care Pharmacologic Management Evidence- Based Guidelines Nonpharmacologic Management Heart Failure Management: Con/nuum of Care - Barriers Decentralized health care delivery Cost, complexity, and standards for HF care Management of complex drug regimens den6fica6on of treatment side effects Mostly elderly popula6on Pa6ents with mul6ple comorbidi6es Disease Management Models Telephone Nurse Follow- up Nurse calls pa6ent at designated intervals Review of treatment plan, goals Telemonitoring System Daily weights, vital signs transmi_ed to remote site nforma6on shared with providers Home Health Nurse follow- up CHF programs V Lasix protocols, home infusion therapy Outpa6ent Follow- up Team approach to heart failure care Op6mize medical therapy Regular/frequent follow- up Pa6ent/caregiver educa6on Rapid response to clinical change Coordina6on of care 33 11

12 HF Treatment Protocols Evidence- based Protocols Heart Failure Management Pharmacologic Medica6on up6tra6on Beta blockers ACE /ARB Aldosterone agonists Diure6cs Nonpharmacologic Diet Fluid restric6on Daily weights Lifestyle changes E6ology of Heart Failure Laboratory and diagnos6c tes6ng as indicated Advanced Heart Failure Care EP referral CRT, CD Fluid volume monitoring Referral for LVAD, cardiac transplant evalua6on Advanced Direc6ves, Pallia6ve Care 34 Advanced Heart Failure Management Fluid Management Decompensated heart failure Fluid management strategies New Therapies valsartan- sacubitril (LCZ696, Entresto; Novar6s) an angiotensin- receptor/neprilysin inhibitor (ARN), showed as sharp an edge against the ACE- inhibitor comparator for the CV death/heart- failure hospitaliza6on primary end point regardless of baseline LV ejec6on frac6on or whether the target dosage was achieved. Corlanor (ivabradine) indicated to reduce the risk of hospitaliza6on for worsening heart failure in pa6ents with stable, symptoma6c chronic heart failure with lev ventricular ejec6on frac6on 35%, who are in sinus rhythm with res6ng heart rate 70 beats per minute and either are on maximally tolerated doses of beta- blockers or have a contraindica6on to beta- blocker use. Referral for LVAD evalua6on/cardiac transplant evalua6on Referral for Advanced Heart Failure Care LVAD Cardiac Transplant 12

13 Lev Ventricular Assist Device Lev Ventricular Assist Device HeartMate Devices HeartWare Lev Ventricular Assist Device 13

14 LVAD Shared Care Center The LVAD Shared Care program includes: Pa6ent management protocols with partnering LVAD implan6ng center Extensive in- person and online training/cer6fica6on on HeartMate pa6ent management Equipment to interrogate the HeartMate LVAD for local follow- up in coordina6on with LVAD center 40 LVAD Shared Care Center Work in collabora6on with implant centers Coordinate pa6ent visits for follow- up and device interroga6on with implant centers Heart Failure: Quality of Life 14

15 When to refer to Pallia6ve Care Discussion of pa6ent wishes should occur early in treatment Discussion between pa6ent and primary physicians Heart Failure: Cost of care Heart Failure: Readmissions 15

16 High- risk for heart failure readmission Pa6ents recently hospitalized for heart failure High- risk for readmission Renal insufficiency Diabetes COPD Chronic NYHA FC or V symptoms Frequent hospitaliza/ons of any cause Elderly pa/ents or other pa6ents with mul/ple comorbidi/es History of nonadherence to medical therapy nadequate social support system Why all the focus on heart failure? The Pa6ent Protec6on and Affordable Care Act (PPACA) established the Hospital Readmissions and Reduc/on Program. October 1, 2012: hospitals penal6es in effect ni6al penal6es for AM, CHF, and Pneumonia Focus is on all- cause readmissions within 30 days n 2015, at least four more condi6ons will be added (likely COPD, coronary artery bypass grav, percutaneous coronary interven6ons, vascular procedures, and orthopedic procedures.) Timeline for Readmissions Reduc/on Program We are HERE FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 Data Available on Hospital Compare Year 1: 1% Penalty Maximum Data Available on Hospital Compare Penalties: AM, CHF, Pneumonia Year 2: 2% Penalty Maximum Data presently being updated on Hospital Compare Penalties: AM, CHF, Pneumonia Year 3: 3% Penalty Maximum Data available September 2014 Penalties: AM, CHF, Pneumonia, possibly COPD, THA/TKA Year 4: At least 3% Penalty Maximum Data available September 2015 Penalties: TBD Year 5: At least 3% Penalty Maximum Data available September 2016 Penalties: TBD 48 16

17 Heart Failure Readmissions Evidence- based therapies improve pa6ent outcomes 25% of pa6ents admi_ed for heart failure are readmi_ed within 30 days; 50% of pa6ents are readmi_ed within 6 months CMS changes in reimbursement/penal6es for hospitals effec6ve October 1, 2012 An es6mated 40% of readmissions are avoidable Discharge teaching/pa6ent educa6on has been shown to reduce readmission rates Heart Failure Management: Reducing Readmissions Early post- discharge follow- up within 7 days Pa6ent and Caregiver Educa6on: Disease Process and Progression Pharmacologic Management: ndica6ons, Dosage, side effects Nonpharmacologic management Monitor weight daily Dietary Sodium Restric6on Fluid Restric6on Exercise Symptom recogni6on 10/5/15 Heart Failure 50 Ques6on 1 Which of the following condi6ons increase risk of readmission for heart failure? 1. recent admission for heart failure 2. history of COPD 3. lives alone/poor social support 4. all of the above 17

18 Ques6on 2 Which beta blockers have FDA indica6on for heart failure? 1. Carvedilol, Atenolol, Metoprolol tartrate 2. Carvedilol, Metoprolol tartrate, Bisoprolol 3. Carvedilol, Metoprolol tartrate, Metoprolol succinate 4. Carvedilol, Metoprolol succinate, Bisoprolol Ques6ons? 18