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Shared System of Care
COPD/Heart Failure
Learning Session 1
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Agenda
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Welcome and Introductions (15)
Video Clip or Patient Story (15)
COPD 101 (70)
Local respiratory services
COPD-6 training
QuitNow
Integrate into Practice Workflow
Break (15)
Heart Failure 101 (65)
Local HF clinic services and cardiologist referral
Integration of HF into practice workflow
Action Planning Expectations (5)
Planning for action Period (25)
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CME Accreditation
Choice of:
 10.5 Mainpro Plus credits IF post reflective activity submitted 2-3
months after module completion and at least one action period
completed
 10.5 Maincert Section 1
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Module Structure
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How is a collaborative different than CME?
 Action-oriented: try what you learn – “What are you going to do
next Tuesday?”
 Test change on small population
 Track data to evaluate changes
 When satisfied spread to the larger population
 Discussion with colleagues
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AIM
To create a system of care that improves the
quality of care and experience for patients at
risk for and living with COPD and/or HF
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How will we achieve this aim?
 Identifying patients earlier who have COPD and/or HF using a
case-finding approach
 Developing relationships and care plans amongst family
physicians, specialists, patients, and community services
 Implementing more standardized referral and consult letters, and
improving relationships, hand offs, and communication between
GPs and specialists
 Improving the management of COPD and HF by applying
evidenced based practices
 Supporting patients to quit smoking
 Enhancing patient self-management skills for patients to manage
their condition
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Action Period 1 Measurement
 Develop patient registries for COPD and HF.
 Case-finding and testing with COPD-6 device
 Referred for Spirometric Diagnostic testing for COPD patients
 Referred for Ejection Fraction or Brain Natriuretic Peptide (BNP)
Diagnostic testing for Heart Failure patients
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Patient Story
(15 minutes)
Our Aims
 To foster a shared system of care that improves the quality of
care and experience for patients at risk for and living with COPD
and Heart Failure by:
› Identifying subjects with COPD and Heart Failure earlier
› Using a team-based approach
› Improving communications between patients and care team
as well as within the care team
› Developing strategies to prevent progression of COPD or
Heart Failure as well as its optimal Improving management
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How will we achieve this aim?
In the FP practice:
 Enhanced identification and diagnosis of COPD & HF
 Appropriate risk stratification based on level of airflow
obstruction or cardiac output, and symptoms and
exacerbation history – followed by review of
prescriptions and including a flare-up plan
 Appropriate use of evidence-based therapies for
COPD & HF based on current best evidence, including
the development of a flare-up plan
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How will we achieve this aim?
Across the continuum
 Supporting subjects to quit smoking.
 Enhancing patient self-management skills to allow
better management of their lung health.
 Improving the patient experience within the system of
care.
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Approach to Dyspnea: COPD/HF
 Similar clinical presentation
 Both may be present in the same person
 Diagnostic confirmation of disease needed
 What condition is contributing to the dyspnea?
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COPD/Heart Failure
 25-30% HF patients have COPD
 20-40% COPD patients have HF
 “Common partners, common problems”
 Presence of each other predicts
increased mortality
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Look for clues!
1. Initial clinical judgement
2. Risk factors for heart increase likelihood of HF
3. Symptoms of PND, orthopnea or edema increase likelihood
of HF
4. Signs for HF include:
› 3rd heart sound, arrythmia or murmur
› ↑ JVP
› Crackles
› Edema
5. Signs for COPD or AECOPD
› Air-trapping, wheezing, quiet lungs, prolonged expiration
› Worsened cough with increased or purulent phlegm
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A Case of Dyspnea
Postbronchodilator
FEV1/FVC 48%
FEV1 55%
Echo 2
years prior
showed EF
45%
 Shortness of breath has worsened in past
week
WHY?
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Approach to Dyspnea: Diff Dx
Respiratory
• Airway disorders
•COPD/AECOPD
•Asthma
• Parenchymal
• Cancer
• ILD
• Pneumonia
• Pleural or chest wall
disorders
• Vascular
• Central
Cardiac
• CHF
• Arrhythmia
• Ischemia
• Valvular
• Pericardial
Systemic
• Anemia
• Acidosis (numerous
causes eg renal)
• Liver disease
• Thyroid
• Pregnancy
• Anxiety
Schwartzstein RM. UpToDate: January 2014.
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Approach to Dyspnea
 Onset of symptom
› Gradual vs sudden, rest or exertion?
Think:
CARDIAC,
RESP,
SYSTEMIC
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Approach to Dyspnea
 Associated symptoms
› Cough, sputum, wheeze
› Chest pain: pleuritic versus exertional
› Palpitations, dizziness
Think:
› Edema, orthopnea, PND
CARDIAC,
RESP,
› Bleeding causing anemia
SYSTEMIC
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Approach to Dyspnea
 Associated signs
› Pallor
Think:
› Tachycardia or arrhythmia
CARDIAC,
› Crackles vs wheeze
RESP,
› Hyperinflation vs chest restrictionSYSTEMIC
› Edema
› ↑JVP, S3, murmur
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Examination in 2 minutes
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General appearance
Heart Rate
Rhythm
BP
(O2 sat)
Listen to chest
Listen to heart
JVP assessment
Edema
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Diagnostic Tests
 O2 sat: rest and on exertion
 EKG
 CXR
 Hb, BNP, LYTES with anion gap, TSH, troponin,
renal, liver,
 PFTS
 ECHO
 Other tests:
› PE Protocol CT
› High resolution CT
› Stress test or MIBI, MUGA
› ABG
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Case continued
 Current inhalers include an lone ICS inhaler and short
› Has not followed up with you recently
› Renews her prescriptions intermittently
 Other Rx: rosuvastatin, HCTZ, amlodipine, metformin,
daily ASA
 Exam reveals decreased breath sounds bilaterally,
wheeze,
Heart rate of 90, JVP of 4 cm, pitting edema to shins
and BMI 36
 How would you proceed with this case?
ICS (inhaled corticosteroid), LABA (long-acting ß-agonist), LAMA (longacting muscarinic antagonists),
JVP (jugular venous pressure), HCTZ (hydrochlorothiazide)
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What tests could be ordered from your office to sort
this patient out?
Respiratory
• CXR
• CT scan
• Repeat
spirometry
Cardiac
• ECG
• CXR
• BNP
• ECHO
• Stress test
Systemic
• CBC
• Electrolytes,
• Urea, Cr
You may start by sending this patient to lab
for an ECG, CXR and Blood work
Schwartzstein RM. UpToDate: January 2014.
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Diagnostic tests have limitations:
 Spirometry best done when patient stable
› HF can reduce FEV and FVC
 Echo is technically difficult if Afib or COPD
› Reduced EF does not necessarily mean that
decompensation is acute HF
 BNP has good negative and good positive
predictive values
› <100 = not acute HF
› >200 = possible HF
› >500 = definite HF
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β-blocker therapy is safe in COPD¹ ² ³
 Selective β1-blockers
 Metoprolol
 Atenolol
 Bisoprolol
 Non-selective α (alpha) and β-blockers used in
CHF that are found to be safe in COPD
 Carvedilol
 These agents should not be withheld from
patients with COPD and cardiac disease
1. Camsari A, Heart Vessels 2003;18:188–192. 2. Salpeter SRAnn Intern Med
2002;137:715–725. Salpeter SR, Respir Med 2003;97:1094–1101. 3. GOLD
guidelines 2013
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COPD 101
(25 minutes)
Definition of COPD
 COPD is a preventable and treatable disease
with some significant systemic effects
that may contribute to the severity in
individual patients.
 Its pulmonary component is characterized by airflow limitation
that is not fully reversible. This leading to significant exercise
limitation.
 The airflow limitation is usually slowly progressive over time.
This is accelerated in cases of continued smoking, frequent ‘lung
attacks’ or with AAT deficiency.
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Asthma
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Clinical Course of COPD
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Prevalence and Burden of COPD
Global Disease Burden
 1990 : COPD was 6th leading cause of death
 2001: Approx. 2.7 million deaths from COPD (more
than 5% of total death worldwide)
 2020: COPD is projected to be the 3rd leading cause of
death (approx 4.5 million deaths) only after Ischemic
Heart Disease and Cerebrovascular Disease
Murray and Lopez. Lancet 1997
WHO Report 2002
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COPD is Under-diagnosed in Canada
 Patients >40 yrs + 20 pack-year history
of smoking visiting a primary care
physician for any reason
 1,003 patients underwent spirometry:
Diagnosis of
COPD
Spirometry
results
Normal
79.3%
Criteria
for COPD
20.7%
No
67.3%
Yes
32.7%
Hill K, et al. CMAJ 2010182:673-678
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Hill K, et al. CMAJ 2010, 182;673-678
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Case Finding
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Diagnosis
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Key Message
“Most patients with COPD are not diagnosed until the
disease is well advanced. Spirometry targeted at
individuals who are at risk for COPD can establish an
early diagnosis.”
Can Respir J 2008;1 5 (Suppl A):1A-8A
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Fletcher Curve - the Effect of Smoking on FEV1
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Local respiratory services
COPD-6 training
The COPD6
 If you have a normal result has the potential to rule
out COPD
 May have some false positives due to 6 second
exhalation time reducing the denominator ie
FEV1/FEV6.
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 If FEV1/FEV6 is low ,<0.7 ,then refer to accredited
lab for definitive diagnosis
 Walk in spirometry clinics
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COPD-6
Accurate enough for FEV6 & Ratios
(And multi-patient use. Exceeds ATS/ERS guidelines)
Simple to use – just turn unit on
(enter Age, Height; Sex and blow for 6 seconds
Press Enter to view best)
Detach flow
head
for cleaning
Includes predicted value sets
Built-in quality of blow indicator
Large easy to read display
Displays FEV1 and % predicted
Displays FEV6 and % predicted
Displays FEV1/FEV6 and % predicted
Lung Age indicator
Obstructive Index and
displays degree of obstruction
Provides GOLD COPD classification
(Class I; II; III; IV)
AAA Batteries
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COPD-6 (continued)
Built-in quality of blow indicator
Slow Start Warning: Vext >5% or 150mL of FEV6
Abrupt End: Change of volume is > 25mL in the last sec
No coughing: 50% drop & recovery in flow in the 1st sec
If Blow <1 sec FEV1 = 0.00
Result out of Range FEV6 (0-8L)
Obstructive Index (Measured FEV1/Pred FEV1)
& COPD Stage I - IV (with ratio FEV1/FEV6 >
70%)
AAA batteries
Turns off after 4 minutes
Low battery indicator
Green ≥ 80% + ratio > 0.70
Green ≥ 80%
Yellow = 50 - 80%
Orange = 30 - 49%
Red
< 30%
= Not COPD
= STAGE I
= STAGE II
= STAGE III
= STAGE IV
All boundaries can be reset
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COPD-6 (continued)
1. Turn on
(Age Symbol and 50 appears on
screen)
2. Scroll up/down
To adjust age (if the buttons are kept
depressed, the values will scroll faster)
3. Press Enter
(Height Symbol and 60 appears on
screen)
4. Scroll up/down
To adjust height in inches
5. Press Enter
(Male Symbol appears on screen)
6. Scroll up/down
For Female symbol
7. Press Enter
(Population Group Symbol appears on
screen)
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Entering subject data continued
8. Scroll up/down to select:
 C - Caucasian
 AA - African-American
 HA - Mexican-American
 Note: use C for all other races
9. Press Enter
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Copd-6 is now ready for blow
• Place the Mouthpiece into the
Copd-6
• Hold your head up, breathe in as
deeply as possible, place the
mouthpiece in your mouth, biting
it lightly while sealing your lips
firmly around it.
• Blow out as HARD and FAST as
you can for a full 6 seconds.
• Repeat 2 more times when the
blow icon appears.
• Hold down the enter key to bring
up the last session results
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Results of blow
Blow is classified as Green, Yellow, or Red
Obstructive Index (Measured FEV1/Pred FEV1) &
COPD Stage I - IV (with ratio FEV1/FEV6 > 70%)
Green ≥ 80% + ratio > 0.70
Green ≥ 80%
Yellow = 50 - 80%
Orange = 30 - 49%
Red
< 30%
= Not COPD
= STAGE I
= STAGE II
= STAGE III
= STAGE IV
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Indication of bad blow

The blow icon with an
exclamation point indicates a
bad blow.

Possible reasons are coughing,
slow start, blow less than 3
seconds in duration, abrupt
stop, or blocking the back of
copd-6 unit with hand.
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Test results after three blows
Press Enter to display the best of the
session
 Press enter to display the best FEV1
and percent predicted of all blows
 Press the down arrow to see Lung Age
 Press the down arrow again to see
FEV1/FEV6 Ratio & percent predicted
 Press the down arrow again to see
FEV6 & percent predicted
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The Copd-6 USB version’s printed report
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Training
 http://www.youtube.com/watch?v=syXXEgZSTOQ
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1 (877) 455-2233
Progress in British Columbia
Progress in BC
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Intention to Quit
Intention to Quit
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Physicians discussing quitting
Physicians Discussing Quitting
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Effect of Physician intervention
Effect of Intervention
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What can Physicians do?
What can Physicians do?
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Strategies to help your patients quit
Complete Personal Risk Assessment for Rx for Health
Brief advice to quit smoking
Refer to behavioural support (like QuitNow)
Recommend patients call 8-1-1 for NRT
Order Buproprion or Varenicline (prescription)
Strategies
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What is QuitNow?
Behavioural quit smoking support
Provincially Funded
Managed by the BC Lung Association
Evidence-based
Free, confidential, 24/7
What is QuitNow?
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Fax Referral Forms
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[email protected]
Online Referral
online
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Integrate into the workflow
discussion
End
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Heart Failure 101
(40 minutes)
Definitions and Nomenclature
 Heart Failure
 A clinical diagnosis
 Inability for the heart to deliver sufficient blood/oxygen to
meet the demands of the peripheral tissues, or to do so at
abnormally high filling pressures, or both
 Characterized by signs and symptoms of decreased
cardiac output and/or volume overload
 Does not suggest a cause or underlying pathological state
 Cardiomyopathy
 Disease of the heart muscle due to any number of causes
 Clinically characterized by heart failure
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Definitions and Nomenclature
 Heart Failure with Decreased Ejection Fraction
 Poor systolic performance of the heart resulting in
decreased cardiac output and increased venous pressures
 Typically occurs in association with impaired left ventricular
systolic function due to any number of causes
 Left ventricular ejection fraction (LVEF) of <40%
 Heart Failure with Preserved Ejection Fraction (HF-PEF)
 Poor diastolic performance of the heart resulting in
decreased cardiac output and increased venous pressures
 May occur in association with preserved (LVEF >40%) or
decreased LVEF
 Systolic and Diastolic heart failure frequently co-exist
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Prevalence of Heart Failure
12
10
Patients in Millions
10.0
Incidence:
550,000 new cases/yr
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Prevalence:
6
2% in 40 – 60 year olds
4.8
4
10% in those aged 70+
3.5
2
0
1991
2001
2037
Year
adapted from McMurray and Pfeffer, 2003
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HF Readmissions
 Hospital readmission rates are high, and mainly
due to recurrent heart failure
Lee DS et al. Can J Cardiol 2004;20(6):599-607.
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Survival After Admission to Hospital for Heart
Failure in BC
Percentage Alive
100
80
50% survival at 30 months
60
40
20
0
0
5
10
15
http://www.healthservices.gov.bc.ca
20
25
30
35
40
45
50
Months
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NYHA Classification of Heart Failure
Classes
Description
1 Year
Survival Rate
Grade I
Early failure
no symptoms with regular exercise or restrictions
Grade II
Ordinary activity results in mild symptoms,
but comfortable at rest
Grade III
Advanced failure,
comfortable only at rest;
increased physical restrictions
Grade IV
Severe failure;
patient has symptoms at rest
> 95%
80 - 90%
55 - 65%
5 - 15%
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Important Causes of Cardiomyopathy and
Heart Failure
SYSTOLIC
DIASTOLIC
Myocardial Infarction
Myocardial Infarction
Mitral and Aortic Regurgitation
Aortic Stenosis
Alcohol
Hypertension
Thyroid Disease
Infiltrative Disorders
Chemotherapy
Radiation Therapy
Familial/Genetic Cardiomyopathies
Hypertrophic Cardiomyopathy
Nutritional Deficiencies
Amyloidosis
Systolic and Diastolic Dysfunction Frequently Co-Exist
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What tests could be ordered from your office to sort
the patient out?
Respiratory
• CXR
• CT scan
• Repeat
spirometry
Cardiac
• ECG
• CXR
• BNP
• ECHO
• Stress test
Systemic
• CBC
• Electrolytes,
• Urea, Cr
You may start by sending this patient to lab
for an ECG, CXR and Blood work
Schwartzstein RM. UpToDate: January 2014.
80
Diagnostic tests have limitations:
 Spirometry best done when patient stable
› HF can reduce FEV and FVC
 Echo is technically difficult if Afib or COPD
› Reduced EF does not necessarily mean that
decompensation is acute HF
 BNP has good negative and good positive
predictive values
› <100 = not acute HF
› >200 = possible HF
› >500 = definite HF
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BNP – B-type Natriuretic peptide or
NT-proBNP – N-terminal prohormone of BNP
• Biochemical test of choice for ruling-in or ruling-out the
diagnosis of HF and should be considered as part of
the initial evaluation of patients with dyspnea
suspected of having HF. [Amended, 2015]
• BNP (or NT-proBNP) testing should not be used
routinely for monitoring disease severity. [New, 2015]
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Local HF Clinic Services
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Referral Resources
Indications for
Referral
to a HFC
Heart
Function
Clinic
Referral
Form
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When and Who Should I refer to an
HF Clinic?
 New onset heart failure NYD
 Recurrent hospitalizations
 Difficult to manage using standard therapies
 Young age
 Advanced functional symptoms
 Consideration for aggressive therapies
 ICD or CRT
 Coronary angiography
 Surgery
 Consideration for cardiac transplant
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BC’s Heart Failure Website www.bcheartfailure.ca
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Local Heart Failure services
Integrate into the workflow
discussion
Action Period Planning
(20 minutes)
Action Period 1 Measurement
 Develop patient registries for COPD and HF.
 Case-finding and testing with COPD-6 device – Minimum 6 pts.
 Referred for Ejection Fraction or Brain Natriuretic Peptide (BNP)
Diagnostic testing - Minimum 2 patients.
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Questions