The Purpose of the Chronic Heart Failure Model Practice

Transcription

1 The Purpose of the Chronic Heart Failure Model Practice The 2018 PACE Chronic Heart Failure Model Practice provides relevant diagnostic and treatment recommendations to PACE primary care providers (PCPs). The Model Practice was adapted specifically for PACE participants from evidence-based published guidelines for older adults and offered with the belief that shared decision-making between individual PCPs and participants/caregivers is optimal. This Model Practice is not intended to replace the clinical judgment of the individual provider or establish a standard of care. PACE participants are a heterogeneous group, with differing health profiles, prognoses, preferences, and goals of care. Life expectancy and quality of life issues require an individualized context within which to apply practice guidelines that may have been developed from and for a population of non-frail adults. We recommend that whether a PCP follows any of the summary recommendations for an individual participant will depend upon factors specific to that participant, including the participant s preferences, prognosis and life expectancy, co-morbid conditions, functional status, and goals of care. This Model Practice assumes that the goals of care for PACE participants can be divided into three broad categories: promoting longevity, optimizing function, and comfort care. Accordingly, the Model Practice suggests different approaches to interpreting the 2013 American College of Cardiology Foundation / American Heart Association HF recommendations, and the update on pharmacology in (SEE REFERENCES 1 and 2 below), in the context of the participant s goals--whether life-extension, optimizing current function, or comfort care. The PCP will need to determine which recommendations are appropriate for each individual participant, considering the participant s preferences, life-expectancy, and the expected benefit versus burdens of specific interventions. Definitions: ACC-AHA Stages of Heart Failure: (SEE APPENDIX 1) Stage A: High risk for heart failure with no structural damage or heart failure symptoms Stage B: Structural damage without heart failure symptoms Stage C: Structural damage with previous or current heart failure symptoms Stage D: Refractory heart failure, specialized intervention Goals of Care: Longevity: Participant expresses a preference for life-prolonging treatment. A participant with a goal of longevity typically desires unrestricted use of medically-indicated treatments, including CPR, invasive procedures and life-sustaining treatments (ACLS, surgery, ventilator support, dialysis, IV fluids and tube feedings). Function: Participant s main goal is to maintain function. Participant makes individualized choices to limit some invasive procedures that are not consistent with that goal. Limited procedures may include CPR, mechanical ventilation, and other life-sustaining treatments. Comfort Care: Relieving pain and other symptoms and limiting invasive, life-sustaining treatments such as CPR, mechanical ventilation, dialysis and surgery.

2 Item Assessment and Intervention Categories Goal: Goal: Goal: Goal: Longevity Functional Comfort Care End of Life? Who? When? A. Diagnosis and Staging 1 Echocardiogram to determine EF Consider 2 Identify etiology (CAD, HTN, PVD, DM, Valvular, PCP Initially 3 Identify AHA Stage (see Appendix 1), to guide Rx B. Recommended Treatment for Stage A Control of HTN 5 Control of DM, address tobacco use, avoidance of PCP During all visits cardiotoxic agents C. Recommended Medication for HFpEF Stage B-D (EF>0%) SEE APPENDIX 2 FOR HF DEFINITIONS 6 NOTE: Unlike HFrEF, no regimen has been shown to be definitively effective at improving outcomes in HFpEF including Beta Blockers, ACE/ARB, and CRT; Control of HTN, arrhythmias, and symptoms including edema are goals. Cardiac rehab could be considered. For Edema/sx control For Edema/sx control For Edema/sx control PCP, Pharm D During all visits

3 Item Assessment and Intervention Categories Goal: Goal: Goal: Goal: Comfort Longevity Functional End of Life? Who? When? Care D. Recommended Medication for HFrEF-Stage B-D (EF< =0%) SEE APPENDIX 2 FOR HF DEFINITIONS, APPENDIX 3 for Algorithm 7 ACEI (preferred) or ARB (if ACEI intolerant). If Cr<3.0 8 Hydralazine and Isosorbide 9 Hydralazine and Isosorbide in African-Americans, if unable to take ACE/ARB. Additive therapy to ACE/ARB and Beta Blockers. If Cr<3.0, if unable to take ACE/ARB Consider. Additive therapy to ACE/ARB and Beta Blockers Consider Consider 10 Diuretics if evidence of fluid retention 11 Beta-Blockers (Bisoprolol, Carvediol, Sustain Release Metoprolol are the three proven to reduce mortality) (unless 2nd or 3rd degree heart block, Consider 12 Spironolactone: NYHA Functional Stage II-IV**. If. If GFR>30 GFR>30 Consider Digoxin (for symptom relief, reduced hospitalization advanced 13 CHF, if indicated Consider Amlodipine (if need Ca. Channel blocker for angina, BP 1 control Consider Consider Continue (n-dihydropyridine) Calcium Channel Blockers 15 and NSAID s Antiarrhythmic Rx (if Indicated): Ventricular Arrhythmias, 16 A.Fib. (Amiodarone, Dronardarone, Dofetilide only). Consider Consider 17 Warfarin (INR 2-3) or DOACS (if atrial fibrillation), if indicated Consider 18 Statins (IF recent or remote history of MI or ACS) Consider Angiotensin receptor blocker /neprilysin inhibitor combination (ARNI) (e.g., valsartan/sacubitril; (from 2016 ACCF/AHA HF Guideline Update) If stable symptomatic NYHA Class II or III symptoms, and tolerance of maximal ACEI or ARB and NO history of angioedema) Ivabradine (from 2016 ACCF/AHA HF Guideline Update) (If sinus rhythm at HR 70, EF of <=35% and stable symptomatic NYHA Class II or III symptoms, and on maximally tolerated beta blocker dose Consider replacement of ACEI or ARB to reduce hospitalizations and mortality Consider for reduction of hospitalization Consider Consider PCP, Pharm D Minimal reassessment at 6-12-month intervals. For EOL: At least maybe daily visits during the active dying process, during Unscheduled Assessment and Care Plan Meetings

4 Item Assessment and Intervention Categories E. n-pharmacologic Interventions: Goal: Goal: Goal: Goal: Longevity Functional Medical Interventions Comfort Care 21 Tobacco cessation counseling Consider 22 Oxygen (if indicated) 23 BP Goal 130/80, see notation Consider Device Interventions (SEE FOOTNOTE 1) 2 Implantable Cardioversion- Defibrillator (ICD) A 25 Cardiac Resynchronization Therapy (CRT) Biventricular Pacing B 26 Mechanical circulatory support C Consider 27 Cardiac Transplantation D Consider F. Participant/Caregiver Education: 28 Cause/prognosis of CHF/end of life considerations 29 Warning signs when to call nurse (swelling, SOB, fatigue weakness, anorexia, chest pain, nausea, lightheadedness 30 Effects of medication, diet, activity 31 Weigh Daily, notify RN Consider G. Monitoring 32 Record Weekly Weights ( Weight gain/loss of 3 lb. in a week reported to PCP immediately, (PCP evaluates adjusts medications if needed) Consider 33 Symptom review (orthopnea, presence of edema,) from 1 Consider 3 Serum electrolytes/renal function (from 1) 35 Natriuretic peptide (BNP or NT probnp) can be useful in achieving optimal dosing) te: value limited when using neprilysin inhibitors 36 Interval echocardiography a) for significant change in clinical status, b) those where treatment may have effect on cardiac function, c) for consideration of device therapy H. Diet: 37 Diet Counseling with participant and/or caregiver Consider Low Salt Diet (Mild: 3- grams/day. Severe: 2 grams/day) 38 (Mild: 1.5g/day, Severe: 3 grams/day) Consider End of Life? Who? When? Deactivate -- see Footnote 2 PCP PCP PCP/RNSW RN RD, PCP Biannually and as indicated clinically As indicated At Diagnosis and as status changes, EOL: Unscheduled Assessment and Care Plan Meeting Weekly-Monthly Upon diagnosis, then review annually

5 39 Fluid Restriction: 2 Liter/day Consider Consider Item Assessment and Intervention Categories I. Exercise / Cardiac Rehab Goal: Goal: Goal: Goal: Longevity Functional Comfort Care End of Life? Who? When? 0 (appropriate if pt. is cognitively and functionally able to perform a METS of at least 2.9) NOTE: METS, Metabolic Equivalent of Task: A 2.3 METS is equivalent to walking at ground level, strolling, very slow, whereby 2.9 METS is walking 2.5 mph, km/hour. Cited Website: see notation Consider Rehab As indicated J. Potential Quality Indicators: Assessment of LV Function? Consider ACE /ARB use for HFrEF unless contraindicated Use of Beta blockers for HFrEF (unless contraindicated Cessation Assistance offered to smokers? Consider PRT/Caregiver education on CHF Advance Planning Conducted? Admission rate for CHF 30-day readmission rate for CHF Quality Manager, Medical Director EOL: Unscheduled Assessment and Care Plan Meeting, Death Review/Monthly QM tracking Selected Measures Quarterly - Annually

6 FOOTNOTE 1--DEVICE MANAGEMENT (FROM SECTION E--Device Interventions) A: Class I, level of evidence A: ICD is indicated in nonischemic cardiomyopathy and ischemic heart disease > 0 days post M.I. with EF 35%, has NYHA symptom class II or III on treatment, and good expected survival and good functional status. Improvement in survival not seen until 1 year out from implantation. There can be significant impact on the quality of life from electrical discharge from the defibrillator which can be quite painful. B Class I, Level of Evidence A. CRT is indicated in patients with LVEF 35%, NSR, LBBB with QRS 0.15, NYHA class II, III, or ambulatory IV on GDMT. This results in significant improved quality of life, exercise ability, and EF. It lowers risk of hospitalization and all-cause mortality by 20%. C: Class IIa, level of evidence B: MCS beneficial in pts with stage D HFrEF in whom definitive management (cardiac transplantation) or cardiac recovery is anticipated or planned. Indications for referral: patients with LVEF <25% and NYHA class III-IV functional status despite GDMT, including, when indicated, CRT, with either high predicted 1- to 2- year mortality or dependence on continuous parenteral inotropic support. Class IIa, level of evidence B: ndurable MCS (percutaneous and extracorporeal ventricular assist devices (VADs)) can be used as a bridge to recovery or bridge to decision for carefully selected patients with HFrEF with acute, profound hemodynamic compromise D: Class I, level of evidence C: stage D HF despite GDMT, device, and surgical management.

7 FOOTNOTE 2: ICD DEACTIVATION If not imminently dying but nearing end of life, preference is for the patient and/or decision makers to confer with the cardiologist/cardiac physiologist to discuss and plan for deactivation of ICD. If patient is imminently dying, emergency ICD deactivation can be performed by placing a magnet (such as the Medtronic Detection Donut Magnet) directly over the implant site (usually on L side of chest just below clavicle) and taping or attaching it in place until after death. REFERENCES: 1) Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128: ) Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos G, Fonarow GC,Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW,Westlake C ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016;13:e282 e293 3) Heidenreich PA, Fonarow GC. Quality indicators for the care of heart failure in vulnerable elders. J Am Geriatrics Soc 2007, 55:S30-S36. ) Schamp R, Tenkku L. Managed death in a PACE: Pathways in present and advance directives. JAMDA 2006;7:339-3 American Geriatrics Society. AGS Guidelines for improving the care of the older person with diabetes mellitus. J.Am. Geriatrics Soc 2003 May;51 (Suppl 5):S ) Ponikowski, P, Voors,A et al, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC European Heart Journal, Volume 37, Issue 27, 1 July 2016, Pages

8 APPENDIX 1 HEART FAILURE STAGING From 2013 ACCF/AHA guideline for the management of heart failure: (Reference 2, Yancy CW, et al) This table is a useful comparison of ACCF/AHA Stages of heart failure and can be found online at APPENDIX 2 HEART FAILURE DEFINITIONS From 2013 ACCF/AHA guideline for the management of heart failure: (Reference 2, Yancy CW, et al) The guideline could not be reprinted, definitions of HFrEF and HFpEF can be found at APPENDIX 3 APPROACH TO TREATMENT OF SYMPTOMATIC HF with reduced EF FROM 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: (REFERENCE 5, Piotr Ponikowski, Adriaan Voors, et al) An algorithm for the treatment of heart failure from the European Society of Cardiology can be viewed in Figure 7.1 at the following link: