Disclosures. Objectives. What is Heart Failure? Best Practices for Managing Patients

Transcription

1 Disclosures Best Practices for Managing Patients with Advanced Heart Failure I have no financial disclosures Site PI for observational heart failure study sponsored by Thoratec James O. Mudd, MD Assistant Professor of Medicine Director, Heart Failure, Heart Transplantation and Advanced Cardiac Devices Knight Cardiovascular Institute Oregon Health and Sciences University Objectives Review Pathophysiology of Heart Failure Heart Failure Epidemiology Bedside Clinical Assessment Treatment strategies for patients with Advanced Heart Failure Best Practices and Readmissions What is Heart Failure? Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood to meet the metabolic demands of the body. There is no single diagnostic test for heart failure because it is largely a clinical diagnosis based on a careful history and physical examination ACC/AHA Guidelines. J Am Coll Cardiol 2009;53:e1 90.

2 Heart Failure Pathophysiology Myocardial injury Myocardial toxicity Morbidity and mortality Activation of RAAS, SNS, ET, and others Adverse Remodeling and progressive worsening of LV function Fall in LV performance ANP BNP Peripheral vasoconstriction Hemodynamic alterations Heart failure symptoms Risk of Developing Heart Failure 75% of HF cases have antecedent hypertension. At age 40, the lifetime risk of developing heart failure for both men and women is 1 in 5. At age 40, the lifetime risk of heart failure occurring without an MI is 1 in 9 for men and 1 in 6 for women. The lifetime risk for people with BP >160/90 mm Hg is double that of those with BP <140/90 mm Hg. Roger V L et al. Circulation 2011;123:e18-e209 Heart Failure Resource Utilization In the U.S., ~ 6.6 million adults with heart failure 670,000 new diagnoses age > million office visits each year Over 1 million hospitalizations 2009 $39.2 billion in health care services, medications, lost productivity Heart Failure Survival Approximately 50% of individuals diagnosed with heart failure will die in 5 years Hunt et al ACC/AHA Guidelines. J Am Coll Cardiol 2009;53:e1-90. Heart Disease and Stroke statistics update. Circulation 2012;125:e12 NEJM 2002;374:1397

3 COPERNICUS carvedilol vs. placebo, NYHA III-IV IV Cardiac Resynchronization in Class III-IV IV Heart Failure: CARE-HF Predominantly males, ICM, 65% digoxin, 97% ACE, 20% aldactone Packer M, et al. NEJM 2001;344:1651 Mortality medical vs CRT, 1 yr: 12% vs 9% 2yr: 25% vs 18% NEJM 2005;352:1539 Outcomes Compared to Cancer The Greatest Challenge in Managing Heart failure.. Making the Diagnosis and Bedside Hemodynamic Assessment European Journal of Heart Failure 2001:3;315

4 Physical Exam Findings Blood pressure, heart rate, respirations, orthostatic vitals Pulse pressure JVP, JVP, JVP!!!! Hepatojugular reflex Presence or Absence of S3, and or S4 Valvular Murmurs Skin, hair, nails Thyroid disease, occult diabetes, amyloidosis Pulmonary Chronic CHF may have clear lungs and little or no peripheral edema Perfusion: warm, lukewarm, cool extremities Clinical Assessment of Hemodynamic Status Low Perfusion at Rest N O Y E S Congestion at Rest NO A Warm & Dry (Low Profile) L Cold & Dry C YES B Warm & Wet (Complex) Cold & Wet Signs/Symptoms of Congestion: Orthopnea / PND Cough Dyspnea Elevated JVP Hepatomegaly Edema Rales Possible Evidence of Low Perfusion: Cool extremities/poor pulses Hyponatremia Decreased mental status Hypotension Narrow pulse pressure Renal dysfunction Nohria A et al., JAMA 2002 Prognostic Value of Clinical Classification Bedside Determination of Cardiac Index Proportional Pulse Pressure Systolic Pressure Diastolic Pressure Systolic Pressure Nohria A et al., JACC 2003 JAMA 1989;261:884

5 Abdominojugular Test Bedside maneuver to determine right and left heart filling pressures Elevated sympathetic system and catechols in heart failure are thought to decrease venous compliance resulting in reflection of waves to the IJ. 10 seconds of sustained mid abdominal pressure Make sure patient breathes normally and does not valsalva Abdominojugular Test: Response patterns Negative Positive pressure pressure Abdominojugular Test Utility of AJT 52 pts with chronic heart failure, NYHA III, EF 18 ± 6% Sensitivity Specificity Predictive Accuracy Rales JVD AJT or JVD S X-ray Ann Intern Med 1988;109:456 JACC 1993;24:986

6 Venous Pressure Estimates in Chronic Heart Failure -JVD -AJT -JVD +AJT +JVD +AJT # Patients Right atrial and Wedge Pressure Physical Exam Estimates in ESCAPE AUC 0.74 for estimated RAP>8 vs. measured >8 AUC 0.68 for estimated PCW>22 vs. measured >22 AUC 0.55 for BNP detecting an elevated PCW >22 Mean RA 4 ± 3 8 ± 5 13 ± 5 Mean PCW 15 ± 9 22 ± 5 27 ± 6 JACC 1993;24:986 Circ Heart Fail 2008;1:170 Cardiac Index Estimates in ESCAPE PPP had Sens 10%, Spec 96%, PPV 87%, but was not significantly associated with low CI. cold profile was associated with a low measured CI <1.8 (OR 2.7, p=0.004) Median measured CI in cold vs warm 1.75 (1.5, 2.05) vs. 2.0 (1.7, 2.3) L/min/m 2, respectively, P=0.004 Circ Heart Fail 2008;1:170 ACC/AHA Heart Failure Classification Stage A High risk without structural disease Stage B Structural disease without symptoms Stage C Structural disease with symptoms Stage D Refractory, end stage heart failure NYHA Class I II III IV Main goals: Relieve symptoms, prevent progression, reduce mortality Stages: complement, do not replace NYHA 2009 ACC/AHA Guidelines. J Am Coll Cardiol 2009;53:e1 90.

7 Heart Failure Treatment late: 1800s Stage of Compensation Medicinal treatment at this period is not necessary and is often hurtful. A very common error is to administer cardiac drugs, such as digitalis, on the discovery of a murmur or of hypertrophy. If the lesion has been found accidentally, it may be best not to tell the patient, but rather a intimate friend Stage of Broken Compensation 1. Rest 2. Relief of the embarrassed circulation By venesection By depletion through the bowels 3. The use of remedies which stimulate the heart's action Stage A No symptoms or structural heart disease, but high risk features for the development of HF. Risk factor targeted drug therapy ACEI, ARBs, Diuretics, Beta blockers, Statins Avoiding behaviors increasing risk (i.e., smoking excessive alcohol, illicit drug use) Periodic evaluation for signs and symptoms of HF Evaluation of LV function in those with a strong family history cardiomyopathy or receiving cardiotoxic medications William Osler, M.D., The Principles and Practice of Medicine ACC/AHA Guidelines. J Am Coll Cardiol 2009;53:e1 90. Stage B Heart Failure Asymptomatic LV dysfunction Aggressive risk factor modification All stage B patients should receive: ACEI or ARB Beta Blocker ICD in selected patients Coronary revascularization if evidence of ischemia and viable myocardium Valve replacement or repair in selected patients 2009 ACC/AHA Guidelines. J Am Coll Cardiol 2009;53:e1 90. Stage C Heart Failure Reduced ejection fraction and symptoms of HF Ongoing risk factor modifications Drug therapy for all patients Diuretics for fluid retention ACEI or ARBs Beta blockers Drug therapy for selected patients Aldosterone antagonists Digitalis Hydralazine/nitrates ICDs in appropriate patients Cardiac resynchronization in appropriate patients Exercise Testing and Training Hunt et al ACC/AHA Guidelines. J Am Coll Cardiol 2009;53:e1 90.

8 A Case of the Walking Wounded 64 yo man with chronic nonischemic cardiomyopathy since 2005 on optimal medical therapy. Transferred from local hospital for VT October 2011, controlled with antiarrhythmics and volume overload managed and optimized, creatinine 1.2 Challenges coming to clinic, no license, no car, used public transportation But I really feel fine! October 2012 admitted with fluid overload Creatinine 1.4, diuresed 6 liters, on guideline based therapies but a low doses. Stressed importance of clinic follow up which he did and county based transportation arranged for him with nursing home visits. Weighing himself daily with good documentation Readmitted December 2012 without obvious precipitant. Diuresed 8 liters on bumex gtt, creatinine now 2.0, Na 138 after diuresis, JVP about cm on exam, positive AJT, no peripheral edema clear lungs. Feeling better, walking around the hospital What now?... Right Heart Catheterization The routine use of invasive hemodynamic monitoring in patients with ADHF is not recommended. (Strength of Evidence = A) Invasive hemodynamic monitoring should be considered in a patient: who is refractory to initial therapy, whose volume status and cardiac filling pressures are unclear, who has clinically significant hypotension (typically SBP < 80 mm Hg) or worsening renal function during therapy, or who is being considered for cardiac transplant and needs assessment of degree and reversibility of pulmonary hypertension, or (Strength of Evidence = C)

9 67/33/ CO 2.5/1.4 65/13 Circulation 2012;125: I I feel fine.but you re really not When to Refer to a Heart Failure Team Functional tolerance less than one block Walking wounded, Housebound Hyponatremia, (< 136) BUN > 40, Crt > 1.8 Diuretic needs > 1.5 mg/kg/day Titrating down medications due to intolerance Unexplained slight increases in LFTs Heart Failure hospitalization in last 6 months Non responder to cardiac resynchronization therapy Stage D: Refractory End Stage HF Strict Na+ and fluid restriction Referral to HF center for selected patients Is patient a transplant candidate? Yes Continuous home inotropes as bridge to Tx LVAD as bridge to Tx No Continuous home inotropes for palliation LVAD as destination therapy End of life discussion Discussion to turn off ICD Hospice care

10 NUMBER OF HEART TRANSPLANTS BY YEAR AND LOCATION HEART TRANSPLANTS January 1982 June 2010 N = 96,273 N at risk at 25 years = 112 ISHLT J Heart Lung Transplant. 2012;31: ISHLT J Heart Lung Transplant Oct; 31(10): Candidate Selection for Ventricular Assist Device Transplant eligibility for BTT Co morbid disease Right ventricular function Coexistent valvular disease Anatomical Considerations Nutritional status Renal Function Hepatic Function Social support Compliance Age? What Do Patients Want? Threshold for considering a VAD: quality vs. quantity J Heart Lung Trans 2009;28:863

11 What Do Patients Want? Threshold for considering a VAD: life expectancy What Do Patients Want? Threshold for considering a VAD: functional status J Heart Lung Trans 2009;28:863 J Heart Lung Trans 2009;28:863 LVAD Outcomes ISHLT 2013:32;141 Preparedness Planning in Advanced Heart Failure Shared decision making: clinicians and patients share information with each other and work toward decisions about treatment chosen from medically reasonable options aligned with the patients' values, goals, and preferences. Difficult discussions early will simplify difficult decisions in the future. Attention to the clinical trajectory is required to calibrate expectations and guide timely decisions, prognostic uncertainty is inevitable and should be included in discussions. An annual heart failure review with patients should include discussion of current and potential therapies for both anticipated and unanticipated events. Discussions should include outcomes beyond survival, including major adverse events, symptom burden, functional limitations, loss of independence, quality of life, and obligations for caregivers. As the end of life is anticipated, clinicians should take responsibility for initiating the development of a comprehensive plan for end of life care consistent with patient values, preferences, and goals. Circulation 2012;125:

12 I IIa IIb III Transition from Inpatient to Outpatient Post discharge systems of care, if available, should be used to facilitate the transition to effective outpatient care for patients hospitalized with HF. Patient Self Care Challenges Self Care Behaviors Medications Dietary adherence Tobacco cessation Weight loss Exercise Self care influences Depression Sleep disordered breathing Impaired cognition Age (young/old) Literacy Complex health system Circulation 2012:125;2382 Heart Failure Performance Measures What is so Magical about 30 days? Inpatient Measures LVEF Assessment Beta Blocker ACEI/ARB Post Discharge appt Outpatient Measures LVEF Assessment Beta Blocker ACEI/ARB Symptom and activity assessment Symptom Management Patient Self Care education ICD counseling for pts with LV dysfunction 25% of heart failure discharges are readmitted within 30 days but 58% occurred after 60 days No clear benefit that evidence based therapies reduce readmissions within 30 days Continuous period of vulnerability Circulation 2012:125;2382

13 Heart Failure Readmissions 30 Day Readmissions for Heart Failure Most common reason for readmission was heart failure and renal disorders Readmission diagnosis and timing did not change by sex, race or age Circulation: Heart Failure2012; 5: JAMA 2013;309:355 Challenges in Limiting Readmissions for Heart Failure Competing risks Dead patients can t be readmitted: hospitals with higher adjusted mortality have lower adjusted readmissions Hospitals with high readmissions may have low post discharge mortality Fixed socioeconomic factors may impact readmissions Patients who may need readmission may be diverted to other pathways to avoid penalties Variability in heart failure phenotype OHSU Heart Failure Best Practices Quarterly meeting Cardiology, IM, FP, nursing, quality, informatics Review readmission data Root cause analysis Weekend discharges Advanced heart failure patients Education plans by hospital unit JAMA 2013;309:354 NEJM 2012;366:1366

14 Important Considerations for Optimal Care Transitions Patient education on importance of self care Optimal documentation and communication with outpatient team Minimize Medication Errors Follow up appointments Primary Heart Failure Admissions Daily heart failure education Heart failure handbook given to all patients Provide scale and patients required to monitor their weight during their hospitalization Streamlining of DC paperwork Hot spot teams for frequent flyers Clinic follow up within one week of discharge with time and date on DC instructions Local or with referring physician Phone call within 2 days Concierge pharmacy services Heart Failure Readmissions Robert Wood Johnson AF4Q Stages in the Evolution of Heart Failure Stage A High risk without structural disease Stage B Structural disease without symptoms Stage C Structural disease with symptoms Stage D Refractory, end-stage heart failure Goals: RF modification Diet/exercise Therapy: ACEI, ARB in appropriate pts. Goals: RF modification Therapy: ACEI, ARB, Beta Blocker ICD HF Clinic Goals: RF modification Fluid/salt restriction Therapy: ACEI, ARB, Beta Blocker Aldosterone blocker Digitalis, Nitrates/hydralazine ICD/CRT HF Clinic Goal is to prevent progression Same as Stage C Hospice Inotropes Heart transplant LVAD Surgery Experimental therapies 2009 ACC/AHA Guidelines. J Am Coll Cardiol 2009;53:e1 90.

15 Best Practices for Advanced Heart Failure Patients Disease recognition and hemodynamic status Evidence based therapies Patient education and preparedness planning: its more than salt and fluid Early discharge follow up and identifying factors that may lead to a prolonged vulnerable period Team based care: Nursing, physicians, pharmacy, home health