Early Recognition & Management of Heart Failure in the Elderly ALMDA Winter 2015 Mid Winter Conference Gregory Payne MD, PhD Division of Cardiovascular Disease University of Alabama at Birmingham School of Medicine 1
Disclosures No Disclosures 2
78 year old man Presented to local ER with complaints of shortness of breath at rest and worsening dyspnea on exertion. History: Hypertension Chronic Kidney Disease Coronary Artery Disease s/p remote bypass surgery He currently lives alone and and states that he tries to stay compliant with all of his medications, but admits it is difficult He is hospitalized for heart failure exacerbation with echocardiogram that notes ejection fraction of 30% (he declines further invasive intervention). 3
78 year old man He is hospitalized for one week with successful diuresis and appropriate adjustments to his medications. He is discharged home, but. Re admitted within 2 weeks for heart failure exacerbation It is noted during this visit that he is deconditioned with significant cognitive impairment He ultimately is discharged to a nursing home for long term care. 4
An unprecedented epidemic National Vital Statistics System and the U.S. Census Bureau 5
An unprecedented epidemic Lifetime risk of heart failure (HF) is estimated to 20% for Americans over the 40 years of age While the incidence of new diagnosis remains flat (~650,000 annually) the prevalence continues to increase Incidence increases with age: 20 per 1000 individuals aged 65 to 69 years of age >80 per 1000 individuals aged 85 years of age Number of Americans with HF is expected to significantly worsen in the near future Konstam, MA. Circulation. 2012; 125: 820 827 6
An unprecedented epidemic Lifetime risk of heart failure is estimated to 20% for Americans over the 40 years of age While the incidence of new diagnosis remains flat (~650,000 annually) the prevalence continues to increase Incidence increases with age: 20 per 1000 individuals aged 65 to 69 years of age >80 per 1000 individuals aged 85 years of age Number of Americans with heart failure is expected to significantly worsen in the near future Konstam, MA. Circulation. 2012; 125: 820 827 7
Hospitalization & Heart Failure HF is the primary diagnosis in>1 million hospitalizations annually Patients hospitalized for HF are at high risk for all cause rehospitalization Of the $30 billion spent annually, >50% is spent in hospitalizations 1 month readmission rate of 25% 2013 ACCF/AHA Heart Failure Guidelines 8
Hospitalization & Heart Failure HF is significantly associated with functional impairment and poor quality of life (QOL) Lack of improvement of QOL (post discharge) is a powerful predictor of rehospitalization and mortality 2013 ACCF/AHA Heart Failure Guidelines 9
Heart Failure and Hospitalization Discharge to Post Acute or Long term Care facility Alabama 2005 Alabama 2009 National Vital Statistics System and the U.S. Census Bureau 10
Heart Failure and Hospitalization Early clinical deterioration is a common phenomenon among older patients with CHF after discharge S. Stewart, JD Horowitz / The European Journal of Heart Failure / 4 (2002) 345 351 11
The challenge ahead 12
Recognition & Management of Heart Failure in the Elderly Multidisciplinary Approach Identify High Risk Patients Optimal Medical Therapy Clinical Assessment Pathophysiology 13
ETIOLOGIES OF HEART FAILURE 14
Etiology of Heart Failure Complex Clinical Diagnosis Results from any structural or functional impairment of ventricular filling or ejection of blood Cardinal manifestations: Dyspnea fatigue exercise intolerance fluid retention congestive symptoms (orthopnea, cough, abdominal discomfort) 15
Etiology of Heart Failure Reduced Ejection Fraction (HFrEF) Left ventricular ejection fraction (LVEF) <40% Most studied group Goal directed therapy was designed for this patient population Randomized controlled trials (RCTs) Preserved Ejection Fraction (HFpEF) LVEF of 40%, Diastolic heart failure Very little evidence to support correct management No proven therapy Estimated 40 50% of clinical heart failure 16
Influence of EF on Survival in Patients with Heart Failure Vasan RS et al. J Am Coll Cardiol. 1999;33:1948-55 17
Heart Failure Etiology Ischemic Cardiomyopathy Chronic ischemia Sequela of Acute Coronary Syndrome Most prevalent within the aging population Non Ischemic Cardiomyopathy Very diverse list of causes Increasingly recognized within the aging population Valvular Heart Disease and Associated Cardiomyopathies Diseases of aging Aortic Stenosis Mitral Regurgitation 18
Prognosis depends on Etiology 1230 Patients referred for unexplained heart failure symptoms Felker GM. NEJM 2000;342:1077 19
Ischemic Cardiomyopathy 20
Non Ischemic Cardiomyopathies Non Ischemic Cardiomyopathy Endocrine Disorders Drug Induced HTN Arrhythmia Infiltrative Diabetes Thyroid Alcohol Drugs Chemo Afib Pacing Amyloidosis Sarcoidosis Also including inflammatory, malignant, infectious, etc. Large group of heterogeneous myocardial disorders Typically characterized by ventricular dilation and depressed contractility 21
Hypertensive Heart Failure Approximately 40% prevalence among elderly patients Sequelae: Accelerated coronary artery disease Left ventricular hypertrophy Diastolic Dysfunction and Heart failure (HFpEF) Left ventricular systolic dysfunction (HFrEF) Dilated Cardiomyopathy Chinnakali et al. Hypertension in the Elderly. N Am J Med Sci. Nov 2012. 22
Cardiac Amyloidosis Many variations of amyloidosis: Primary (AL amyloidosis) plasma cell dyscrasia leading to overproduction of Immunoglobulin light chains Secondary (AA amyloidosis) Deposition of fragments of serum amyloid A protein, an acute phase reactant Associated with chronic inflammatory disorders (eg RA). Senile systemic and Heritable amyloidosis Transthyretin (TTR) deposits Significant Cardiac involvement, but much slower time course than AL Later age at time of symptom development 23
Cardiac Amyloidosis Deposition of insoluble proteins as fibrils in the heart, resulting in HF Clinical manifestations: Nephropathy Neuropathy Organomegaly Purpura Apple green birefringence on biopsy Cardiac amyloid is increasingly recognized for causing HF in the elderly 24
Valvular Cardiomyopathy Aortic Stenosis Mitral Regurgitation Volume overload and heart failure 25
Aortic Stenosis Primarily degenerative valve disease in the elderly Typical presentation: Heart Failure (orthopnea, dyspnea) Angina Syncope Systolic Murmur on exam Valvular obstruction leads to cardiomyopathy and sudden death 26
2/3/2015 Aortic Stenosis 27
CLINICAL ASSESSMENT 28
Clinical Assessment Symptom Burden Functional / Medical Baseline Review & Management of Medications and Therapy Review of Laboratories & Diagnostic Studies Assessment of physical and social barriers (and support) Assessment of psychological status 29
Clinical Assessment: Symptoms & Exam Symptoms Baseline symptoms Dyspnea on exertion Orthpnea Peripheral Edema Physical Exam Volume status: Cardiac Auscultation (+S3) Jugular Venous Pressure Pulmonary edema Abdominal distention or ascites Hepatosplenomegaly Vital Signs Clues of decompensation Tachycardia Tachypneia Hypothermia Physical Exam Cognition Functional capacity 30
Estimation of Jugular Venous Pressure 31
Clinical Assessment Congestion Warm & Dry Warm & Wet Body Perfusion Optimal Hemodynamics: Focus on Disease progression and avoiding decompensation Cold & Dry Limited further options for therapy Diuresis Continuation of standard therapy Cold & Wet Diuresis and redesign of medical therapy 32
Clinical Assessment NYHA Functional Classification Class I: No limitation of physical activity. Ordinary physical activity w/o fatigue, palpitation, or dyspnea. Class II: Slight limitation of physical activity. Comfortable at rest, but symptoms w/ ordinary physical activity Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. Class IV: Unable to carry out any physical activity without discomfort. Symptoms include cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased. J Cardiac Failure 1999; 5:357 382 33
Clinical Assessment Goal Directed Medical Therapy (GDMT) Pharmacologic Therapy Primary therapy to delay disease progression Cardiac Rehabilitation Structured Exercise Nutritional Support Continued patient and family guidance Invasive therapies Implantable Cardiac Defibrillator (ICD) Cardiac Resynchronization Therapy (CRT) 34
GDMT: Pharmacologic Therapy J Am Coll Cardiol. 2013;62(16):1495 1539. doi:10.1016/j.jacc.2013.05.020 35
GDMT: Pharmacologic Therapy J Am Coll Cardiol. 2013;62(16):1495 1539. doi:10.1016/j.jacc.2013.05.020 36
GDMT: Pharmacologic Therapy Inappropriate Medications NSAIDs Calcium antagonists (Verapamil, diltiazem) TCAs Corticosteroids Class I antiarrhythmic drugs (flecainide) 37
GDMT: Cardiac Rehabilitation Several studies document clinical improvement Increased exercise capacity Improved Quality of Life Hospitalization and mortality HF Action Trial showed modest reductions with sponsored exercise HF ACTION RCT. JAMA April, 8 2009 38
GDMT: Cardiac Rehabilitation Cumulative incidence of death by number of cardiac rehabilitation sessions attended Increased physical activity trends towards improved outcomes Kwan G, and Balady G J Circulation. 2012;125:e369 e373 39
GDMT: Cardiac Resynchronization Therapy Grines CL, Circulation 1989;79: 845 853 Xiao HB, Br Heart J 1991;66: 443 447 Søgaard P, JACC 2002;40:723 730 Interventricular Intraventricular Atrioventricular LV Dyssynchrony Reduced diastolic filling time Weakened contractility Worsened global function Increased symptom burden 40
GDMT: Cardiac Resynchronization Therapy 41
GDMT: Cardiac Resynchronization Therapy Improved Hemodynamics Increased CO Reduced LV filling pressures Reduced sympathetic activity Increased systolic function The only proven therapy to significantly improve Quality of Life Available with or without defibrillator therapy 42
GDMT: Objective Studies Daily Weights (superior to ins and outs) Accurate input & outputs Measurement of BNP (or pro BNP) Most helpful as a comparison to when the patient was euvolemic Routine labs Basic Metabolic Panels (GFR and electrolytes) 43
HIGH RISK PATIENTS 44
Identifying High Risk Patients The Seattle Heart Failure Score Robust tool to predict the 1, 2 and 5 year survival of heart failure patients: Age Gender NYHA Class Weight Ejection Fraction Blood pressure Medical Therapy (including ICD and CRT) Lab Data Predicts anticipated changes in survival with adjustments to medical therapy Levy W C et al. Circulation. 2006;113:1424 1433 45
The Seattle Heart Failure Model Levy W C et al. Circulation. 2006;113:1424 1433 46
Identifying High Risk Patients Among patients 65 years old, the following were risk factors for all cause re admission: Krumholz et al. American Heart Journal. Vol 139, #1, Part 1 47
Identifying High Risk Patients Among patients 65 years old, the following were risk factors for all cause re admission: Systematic Reviews Duration of hospitalization Functional disability Other comorbid conditions Importantly, age and sex alone were not indicative of risk Physiologic vs. chronologic age Almost every patient requiring Post Acute or Long Term Care is therefore high risk L. Garcia Perez et al. Q J Med 2011; 104:639 651 48
MULTIDISCIPLINARY APPROACH 49
Multidisciplinary Approach Diagnosis and treatment strategies of heart failure are complex Significant co morbidities Alter the delivery, safety and efficacy of established therapies Nursing staff, social work, case management, general practitioners, geriatricians, cardiologists all need to cooperate 50
Multidisciplinary Approach Comprehensive discharge planning has long been known to decrease all cause readmission rates for heart failure Ideally initiated within the first 24 48 hours Within nursing homes, no generalizable proven strategies to date Naylor M et. al. Comprehensive discharge planning for the hospitalized elderly: A randomized clinical trial. Ann Intern Med. 1994 51
Strategic Approach Continue Goal directed therapy to the fullest extent With appropriate monitoring (i.e. BMP) Maintain Euvolemia Accurate daily weights Input and Outputs (if possible) Avoid intravenous fluids (especially continuous) Maintain physical activity / Maximize mobility Adequate pain control Adequate nutrition Adequate bowel and bladder function Foster care support from family and friends Special focus to those at highest risk 52
Strategic Approach: DEFEAT HF D Diagnosis E Etiology F Fluid volume status E Ejection A fraction T Therapy H identify High Risk F Fine tune based on comorbidities Ahmed Ali et al. J Am Med Dir Assoc. 2008 July; 9(6): 383 389 53
Summary Heart failure is a very common, disabling and costly disease Poor quality of life associated with a general poor prognosis Many of the highest risk patients require long term care facilities Heart failure management in long term care facilities is a unique challenge, that deserves unique approach. Early identification of these high risk patients may decrease rates of re admission, worsening morbidity and mortality 54
THANK YOU 55
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Cardiac Amyloidosis Surface electrocardiogram demonstrating atrial fibrillation with low-voltage in the limb leads. Two-dimensional (2D) echocardiographic image (parasternal long-axis view) from a patient with AL cardiac amyloidosis showing normal biventricular dimensions, granular "speckling" ventricular wall appearance, concentric left ventricular wall thickening, and thickened mitral valve leaflets suggesting infiltration 57