Heart Failure This is not a virus. It doesn t go away Shelley Wojtaszczyk, FNP-C, CHFN Heart Failure Program Coordinator Mercy Hospital of Buffalo none Disclosures Objectives: Defining and identifying the etiology and pathophysiology of Heart Failure Define and classify HFrEF, HFpEF and Stages of HF Understand the ACCF/AHA Guidelines for Management of HF including Evidence Based Medical Therapy and use of Biomarkers Post hospital follow up and HF patient management in the outpatient setting Resources available for ongoing provider education and available Patient Education 1
Outline: HF Facts and definitions Trajectory of HF Staging of HF ACCF/AHA Classification of Recommendations (Class) and Level of Evidence (LOE) Medical therapy for Stage C HFrEF Biomarkers Post Hospital Follow-up appointments Up titration guidelines for EBMT Resources for Provider and Patient Education Heart Failure Facts Heart Failure isn t going away: It affects 6.5 million Americans and accounts for the number one admission DRG in our hospitals. 960,000 new cases are reported annually One in eight deaths include HF as a contributing cause Half of all HF patients die within 5 yrs of diagnosis An estimated 25% of Medicare patients with HF are readmitted within 30 days of a HF discharge. HF is responsible for 11 million provider visits yearly and more hospitalizations than all forms of cancer combined Latest statistics show heart failure on the rise; cardiovascular diseases remain leading killer Heart News, Stroke News DALLAS, January 26, 2017 The number of adults living with heart failure increased from about 5.7 million (2009-2012) to about 6.5 million (2011-2014), according to the American Heart Association s 2017 Heart Disease and Stroke Statistics Update. Based on the latest statistics, the number of people diagnosed with heart failure is projected to rise by 46 percent by 2030, resulting in more than 8 million people adults with heart failure. Heart Failure Facts Studies indicate that patients often don t have adequate knowledge about causes, symptoms and effects of HF Providers in the outpatient settings are pivotal in improving HF patients outcomes and prevent rehospitalizations. A vast majority of HF patients are managed by noncardiologists in the outpatient setting It is key that all providers understand and use the latest established guidelines for HF treatment 2
Heart Failure Facts Heart Failure doesn t just happen. Heart Failure is complex It results from structural or functional impairment of the ventricular filling or squeezing Occurs over time as the comp Most common predisposing factors CAD HTN DM Valve disorders Arrhythmias Metabolic disorders Renal disease Pulmonary diseases Goals of treatment: Heart Failure Facts Address and treat the underlying comorbidities Address and treat modifiable risk factors Recognizing and addressing early signs and symptoms of exacerbation Definitions AHA American Heart Association ACC American College of Cardiology HFSA Heart Failure Society of America EBBB Evidence Based B-Blockers (carvedilol, metoprolol succinate, bisoprolol) EBMT Evidence Based Medical Therapy EF Ejection Fraction, normal 55-70% HFrEF HF reduced Ejection Fraction (EF <40%) HFpEF HF preserved Ejection Fraction (EF >50% with diastolic dysfunction) HFpEF Borderline: EF 41-49% HFpEF Improved: EF was < 40%, now >40% 3
Trajectory of Heart Failure Staging of HF Interventions at each stage are aimed at: Modifying risk factors Treating structural heart disease Reducing morbidity and mortality Goal: Live longer, feel better Prevent exacerbations that result in hospitalization 4
ACCF/AHA Classification of Recommendations and Level of Evidence ACCF/AHA Classification of Recommendations Just Do It Better to do it than not Don t do it ACCF/AHA Level of Evidence Highest Moderate Limited 5
ACC/AHA General Guidelines Class 1 LOE A Stage A treatment should focus on reducing modifiable risk factors HTN, DM, obesity, OSA, dyslipidemia Stage B or C with reduced EF (HFrEF) introduce EBMT with ACEI/ARB, EBBB up-titrating to maximum tolerable dosing. Stage C with congestion (fluid retention) the addition of loop diuretic. Stage C African American Hydralazine and Nitrate Stage C with an EF <35% [HFrEF] and no contraindications aldosterone antagonist Medical Therapy for Stage C HFrEF: Magnitude of Benefit Demonstrated in RCTs GDMT ACE inhibitor or ARB RR Reduction in Mortality NNT for Mortality Reduction (Standardized to 36 mo) RR Reduction in HF Hospitalizations 17% 26 31% Beta blocker 34% 9 41% Aldosterone antagonist 30% 6 35% Hydralazine/nitrate 43% 7 33% Biomarkers: BNP / NT-proBNP Beta naturetic peptide Excreted as a result of cardiac stretch. Promotes naturesis Biomarker that can indicated the presence of congestion in a HF patient Confounding issues Renal status PE or pneumonia Age Obesity 6
Biomarkers: BNP 0-100 pg/ml normal 101-399 equivocal 400-600 indicates higher likelihood HF >600 mod-severe HF >2000 end stage CHF or Renal failure Higher in pulmonary emboli, PNA, elderly females (>80y.o), concomittent renal failure Lower in obese patients?what is the patient s baseline? Biomarkers 2017 Guidelines for: Prevention: (Class IIa, LOE B-R): use of a BNP screening for those at risk of developing HF., followed by team-based care including cardiology consult, GDMT, to prevent the development of LV dysfunction or new-onset HF. Diagnosis: (Class I LOE A) for measurement of BNP in patients presenting with dyspnea, to support a diagnosis of exclusion of HF. Prognosis or added risk stratification: (ClasssI LOE A) for measurement of BNP in establishing prognosis or disease severity in chronic HF as well as on admission to the hospital for acute decompensated HF. Importance of post-hospital follow up appointment Reviewed 11,855,702 Medicare beneficiaries claims. Findings: 50.2% of patients readmitted within 30 days of a medical discharge had no claim for a physician s office visit between discharge and rehospitalizations. 7
What to look for in a post hospital follow up appointment The assumption is that there is a Discharge Summary available-- Medication Reconciliation bring all medication bottles in from home. Review all hospital discharge instructions Review signs and symptoms that prompted the trip to the hospital. Review daily weight logs, BP logs, BG logs Review understanding of dietary restrictions (Na+, K+, fluid restrictions) Post hospital home care or supports in place. Anticipated follow up visits --remembering the trajectory-- Front load for close follow up 3-5 days, once weekly, bi-weekly, monthly Up titration of EBMT Lab surveillance BMP, INR, imaging, etc. Specialist follow ups: Cards, Nephrology, Pulm., Endo., etc. This is a team effort. Plan for exacerbations: Symptomatic what to do next Asymptomatic but warning signs Advanced Planning if not in place. EBMT Titration ACEI o Lisinopril 20 mg daily Captopril 50mg tid Enalapril 20mg bid Quinapril 20mg tid Ramipril 10mg bid Benazepril 40mg daily ARB Losartan 50mg bid Valsartan 160mg daily (80 mg if hepatic impairment) Irbesartan 300mg daily EBBB Carvedilol 25mg bid Metoprolol succinate 200mg daily Bisoprolol 10mg daily Aldosterone Antagonist Spironolactone 25mg daily or bid Eplerenone 50mg daily ARNI Valsartan/sacubitril (Entresto) 97/103mg bid (ONLY after 36hr washout of ACEI/ARB) S-A Node Modulator Ivabradine 8
Renin-Angiotensin System Inhibition With ACE Inhibitor or ARB or ARNI (Entresto) 2017 ACCF/AHA LOE Recommendations The clinical strategy of inhibition of the reninangiotensin system with ACE inhibitors (Level of Evidence: A) ARBs (Level of Evidence: A) ARNI (Level of Evidence: B-R) (Entresto) In conjunction with- Evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic HFrEF to reduce morbidity and mortality. Conclusion HF is not a virus and it is not going away Prevalence and incidence of HF is growing as the population ages Knowing the ACCF/AHA Guidelines for the Management of HF is crucial for Best Care. Close post-hospital follow up and active management of the HF patient in the outpatient setting is critical. We want our HF patients to: FEEL BETTER. LIVE LONGER Resources to access The full-text guidelines are also available on the following Web sites: American College of Cardiology (www.acc.org) American Heart Association (professional.heart.org) Heart Failure Society of America(www.hfsa.org) Yancy, et. al. ACC/AHA/HFSA 2017 Heart Failure Focused Update ACCF/AHA/HFSA Focused Update for the management of HF (http://circ.ahajpurnals.org/content/early/2017/04/26/ci R.0000000000000509) www.heart.org/hf Guidelines Toolkit 9
Citations 2017 ACC/AHA/HFSA Focused 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., J Am Coll Cardiol 2017; Apr 28:[Epub ahead of print]. ACCF and AHA Release Guidelines on the Management of Heart Failure ACCF and AHA Release Guidelines on the Management of Heart Failure, Am Fam Physician. 2014 Aug 1;90(3):186-189. Latest statistics show heart failure on the rise; cardiovascular diseases remain leading killer, AHA January 26, 2017: Heart News, Stroke News Korczyk, D., Marwick, T., Kaye, G. (2012). Fast Facts: Heart Failure. Health Press Ltd. Oxford UK. Similar guidelines for target dosing are available in additional resources such as: i) 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the diagnosis and management of heart failure in adults and ii) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 Source: www.hrartonline.org.au/resources Kotecha, et al, Heart Rate, Heart Rhythm, and Prognostic Benefits of Beta-Blockers in Heart Failure: Individual Patient-Data Meta-Analysis, JACC April 2017 See the Online Data Supplement for evidence supporting recommendation of Ivabradine: and ARNI in HFrEF patients on target EBMT: (http://circ.ahajournals.org/lookup/suppl/doi:10.1161/cir.0000000000000435/- /DC2) 10