HEART FAILURE KEEPING YOUR PATIENT AT HOME

Transcription

1 HEART FAILURE KEEPING YOUR PATIENT AT HOME SUZANNE FRAZIER MS, CRNP, NP-C, CHFN HEART FAILURE DISEASE MANAGEMENT COORDINATOR PENN STATE HERSHEY HEART & VASCULAR INSTITUTE

2 IMPACT OF HEART FAILURE In 2010, 6.6 million US adults 18 years of age (2.8%) had HF It is estimated that by 2030, an additional 3 million people will have HF, a 25.0% increase in prevalence from 2010 In 2010, estimated heart failure costs the United States 34.4 BILLION dollars Heart Disease and Stroke Statistics-2012 Update January 2012 Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association 2011

3 YOU will treat patients with heart failure. As our population ages, this epidemic of heart failure will only continue to grow. The cost of providing heart failure ranks among the leading U.S. healthcare expenditures. Additionally, the toll of heart failure on life, both in quality and longevity, is sobering. 2010, American Heart Association

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6 Healthcare Reimbursement: A Changing Paradigm Center for Medicare & Medicaid Shift from pay-for service Now based on outcomes with possible penalties Pay-For Performance Private insurers monitor quality benchmarks Apply incentives and penalties

7 CMS Bundled Care Payments 2013 Bundled Payments for Care Improvement initiative: Organizations enter into payment arrangements that include financial and performance accountability for episodes of care (90 days). These models, it is speculated, lead to higher quality, more coordinated care at a lower cost to Medicare.

8 What can you do? Apply evidence based care Support self care management Treat volume overload Use community resources Recognize advanced HF and palliate

9 HF Evidence Based Therapies & Medications Classifications of Recommendations Levels of Evidence

10 Types of Heart Failure HF with Reduced EF (HFrEF) 40% Systolic HF with Preserved EF (HFpEF) >50% Diastolic

11 Approach to Treatment of HFrEF Assessment of EF Assessment of fluid volume status Signs and symptoms of fluid retention Diuretic EF 40% Stop aggravating meds Select anti-arrhythmics Calcium channel blockers NSAIDS Apply evidence-based medications Titrate ACEI/ARB/ARNI & Beta-blocker Therapy In selected patients: aldosterone antagonists, digoxin ICD NYHA Class II-IV, EF<35% EF still 35% Transplant LVAD Palliative Care NYHA Class III-IV, EF<35%, QRS>120 ms CRT-P/CRT-D Cardiac Resynchronization Therapy

12 Beta Blockers **Metoprolol Succinate(Toprol XL): Start 12.5 mg daily Titration Schedule: Double the dose every 2 weeks as tolerated until reach target dose 200 mg daily (Target) Carvedilol (Coreg): Start mg BID Titration Schedule: Double the dose every 2 weeks until at target dose25 mg BID (Target) for patients <187 lbs or 50 mg BID (Target) for patients >187 lbs **Bisoprolol (Zebeta): Start 1.25 mg daily Titration Scheduled: Double the dose every 2 weeks as tolerated until reach target dose 10 mg daily (Target) **cardio selective

13 Angiotensin Converting Enzyme Inhibitors (ACE-i) Lisinopril: ( Prinivil, Zestril): Start 2.5 mg 5 mg daily Titration Schedule:5 mg daily for 1 week10 mg daily for 2 weeks 20 mg daily for 2 weeks(target) 40 mg daily if needed for BP control (Max dose) Enalapril (Vasotec): Start 2.5mg Bid Titration Schedule:2.5 mg BID for 2 weeks 5 mg BID for 2 weeks10 mg BID for 2 weeks (Target)20 mg BID if needed for BP control (Max dose) Captopril (Capoten):Start 6.25 mg TID Titration Schedule:6.25 mg TID for 2 weeks12.5 mg TID for 2 weeks25 mg TID for 2 weeks (Target)50 mg TID if needed for BP control (Max dose) *BMP and BP check before initiation and with each med adjustment* Use cautiously in patients with chronic renal insufficiency (Creatinine > 2.5) or K+ > 5.0) If cough occurs, consider 3-5 day trial off med or try ARB Avoid taking NSAID s

14 Angiotensin Receptor Blockers (ARB) Valsartan (Diovan): Start mg BID Titration Schedule:80 mg BID (Target)160 mg BID if needed for BP control (Max dose)losartan Losartan(Cozaar): Start mg daily Titration Schedule:50 mg daily (Target)100 mg daily if needed for BP control (Max dose) *Used for those who are intolerant to ACE-I, typically due to cough *BMP and BP check before initiation and with each med adjustment *Used cautiously in patients with chronic renal insufficiency (Creatinine > 2.5)or K+ > 5.0

15 Angiotensin Receptor-Neprilysin Inhibitor (ARNI) sacubitril/valsartan(entresto) Dosages: 24/26 mg tab 49/51 mg 97/103 tab Titration: lisinopril or enalapril 10 mg daily or No ACE - start 24/26 mg BID valsartan or losartan 160 mg daily - start 24/26 mg BID lisinopril or enalapril 10 mg daily start 49/51 mg BID valsartan or losartan 160 mg daily - start 49/51 mg BID Double dose every 2-4 weeks; monitor for renal dysfunction & hyperkalemia Severe renal impairment (gfr<30) or moderate liver impairment (Child Pugh B) start at lowest dose MUST stop ACEi 36 hours before starting ARNI - need washout period to avoid chance for angioedema

16 ARNI Mechanism of Action: 1) Inhibits overactive RAAS 2) Inhibits breakdown of vasoactive peptides which in return promotes Vasodilation Natriuresis Renin/aldosterone suppression Monitor: Hypotension Angioedema Hyperkalemia Impaired renal function

17 Aldosterone Antagonists Spironolactone/ eplerenone: Start mg daily Titration Schedule:25 mg daily (Target) 25 mg BID (Max dose) Cautions: **Contraindicated in patients with serum K+ > 5.0 or creatinine > 2.5 **BMP weekly x 3 and following any dose adjustment **If gynecomastia switch to epleronone **K+ supplements should be discontinued or reduced ** NSAID s, lithium, or digoxin should be avoided **Side effects: hyperkalemia, worsening renal function, hypotension, hypovolemia

18 Approach to Treatment of HFpEF Assessment of EF Assessment of fluid volume status EF > 40% Control DBP and SBP Can use BB,CCB,ACE,ARB Signs and symptoms of fluid retention Diuretic Use cautiously NSAIDS Steroids (cause fluid retention) Control HR Tachy-arrhythmias such as atrial fibrillation or atrial tachycardia (decrease diastolic filling) Optimize treatment of co-morbidities Diabetes CAD Sleep apnea COPD Obesity Smoking cessation

19 HF Self Care Management DAILY WEIGHTS weight everyday after AM voiding; in the same amount of clothing. Place scale on a hard surface, not on carpeting. Record weights and compare day-to-day. Look for weight gains of 2-3 pounds overnight or a 4-5 pound weight gain in one week. Also look for quick weight loss. Every HF patient needs an Action Plan 2000 mg SODIUM DIET FLUID GUIDELINE: No more than two (2) quarts daily / 64 ounces ENERGY-CONSERVING ACTIVITIES: Progressive walking program CARDIAC REHABILTATION PROGRAM: Start 6 weeks after discharge

20 Fluid Retention.Why? Diet indiscretion Medication non-adherence Use of NSAIDS Prednisone TZDs Diuretic resistance Advancing disease

21 Diuretic Action Plan Double daily oral diuretic Transition to different loop diuretic Add a thiazide PRN Office IV diuretics Fluid retention in abdomen can affect choice of diuretic Need BMP and magnesium monitoring Overuse of thiazides can result in hyponatremia and hypomagnesia BNP level can act as marker for treatment

22 Diuretics furosemide (Lasix):PO: Start at mg daily or BID; 400 mg daily (Max dose ) bumetanide (Bumex):PO: Start at 0.5 to 1.0 mg daily or BID; 5 mg BID / 10 mg daily(max dose) torsemide (Demadex):PO: Start at mg daily; 200 mg daily (Max dose) metolazone (Zaroxolyn):PO: Start at 2.5 mg daily; 20 mg daily (Max dose) hydrochlorothiazide (Microzide):PO: Start at 25 mg daily or BID; 200 mg daily (Max dose) *Titrate quickly: Goal kg/day (3-4 lb/day) weight loss *Monitor K+, Mg, & Creatinine until goal weight achieved *Torsemide: greater bio-availability and longer half-life

23 Diuretic Pharmacokinetics Product Furosemide (Lasix) Bioavailability of oral tablets 47-64% PO: 6-8 hrs IV: 2 hrs Duration of effect after single dose Bumetanide (Bumex) 59-89% PO: 4-6 hrs IV: 4-6 hrs Torsemide (Demadex) 80-90% PO: 6-12 hrs IV: 6 hrs Ethacrynic Acid (Edecrin) * For sulfa allergy * 100% Po: 4-8 hrs IV: 15 min-3 hrs Conversion Equation: Lasix 40 mg = Bumex 1 mg = Demadex 20 mg

24 Coming Soon. Subcutaneous furosemide

25 From Hospital to Home Transitioning requires good hand-off communication to PCP and 7 day follow-up. Use outpatient resources Medical Home Care Managers Hospital-based programs Home health services- tele health Medical Home Model -Case managers Remote monitoring resources

26 Remote Monitoring

27 Resources Patient: AHA online support group for HF patients/families Low salt cookbooks / website recipes Phone apps Pharmacy dietary/medication free counseling services Grocery Store- 1:1 grocery shopping counseling Healthcare Providers:

28 Time for Palliation?

29 Identifying Patients with Advanced HF Two or more hospitalizations / ED visits for HF in the past year Progressive deterioration in renal function Weight loss without other cause (cardiac cachexia) Intolerance to ACE inhibitors due to hypotension and/or worsening renal function Intolerance to beta blockers due to worsening HF or hypotension Frequent systolic blood pressure <90 mm Hg Persistent dyspnea with dressing or bathing requiring rest Inability to walk 1 block on the level ground due to dyspnea or fatigue Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapy Progressive decline in serum sodium, usually to <133 meq/l Frequent ICD shocks Adapted from Russell et al. Congest Heart Fail. 2008;14: Yancy, CW et al ACCF/AHA Heart Failure Guideline.

30 It takes a village to treat HF. OK maybe not this village!

31 Help your patients be.. Heart Strong!