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Maximizing Treatment Options with Congestive Heart failure David Wolinsky FACC Prime Care Physicians Jan 31, 2009 CHF Magnitude in the US • 5 million have CHF (prevalence)1 • 550,000 new cases annually (incidence)1 • HF most common cardiovascular discharge in elderly patients2 • 25% probability of dying over 2.5 years3 – 50% of these deaths occur suddenly Heart Association. Heart Disease and Stroke Statistics – 2005 Update. NHLBI, CHF Data Fact Sheet, September 1996. 3 Sweeney MO. PACE. 2001;24:871-888. 1 American 2 Classification of Heart Failure: ACC/AHA Stage vs NYHA Class Heart Failure Treatment Algorithm CHF Patients Survival Results1 Women (N = 230) Probability of Survival (%) 100 Men (N = 237) 90 80 80% of men and 70% of women who have CHF will die within 8 years.2 70 60 50 40 30 20 10 0 0 1 2 2 4 6 8 Time After CHF Diagnosis (Years) Framingham Heart Study (1948-1988) in Atlas of Heart Diseases. American Heart Association. Heart Disease and Stroke Statistics—2005 Update. 10 Hospitalization for Congestive Heart Failure is a Sentinel Event Paradigms of CHF Management • Patient Based management • ADHF • Chronic Heart Failure • Patient Based approach • CORE Measures • ACC/AHA/HFSA Guidelines • Systems Based Approach • Inpatient Therapy • Outpatient Therapy • Transitional Care • Measured by Readmission and Mortality Rates • Benchmarks? Adjusted* hazard ratios (95% CI) for oneyear outcomes, beta blocker therapy vs no beta blocker therapy, by LV functional status End point LV systolic dysfunction, n=3001 Preserved LV systolic function, n=4153 Mortality 0.77 (0.68–0.87) 0.94 (0.84–1.07) Readmission 0.89 (0.80–0.99) 0.98 (0.90–1.06) Mortality or readmission 0.87 (0.79–0.96) 0.98 (0.91–1.06) *Adjusted for baseline age, sex, race, HF etiology, LVEF, systolic blood pressure, smoking, signs of congestion, laboratory values, discharge medications, in-hospital invasive procedures, and history of diabetes and cardiovascular, neurological, pulmonary, and renal diseases Hernandez AF et al. J Am Coll Cardiol 2009; 53:184192. Beyond CORE Measures • • • • Reduce readmission rate at 30 days Reduce 30 day and 180 day mortality Improve documentation Incorporation of transitional care i.e. redefine ‘home care” • Identlify endstage patients early on and enroll into appropriate care algorithms • Implications of outcomes to patients, physicians, and hospitals Neurohormonal Activation in Heart Failure Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease) Initial fall in LV performance, wall stress Activation of RAAS and SNS Remodeling and progressive worsening of LV function Fibrosis, apoptosis, hypertrophy, cellular/ molecular alterations, myotoxicity Morbidity and mortality Arrhythmias Pump failure RAS, renin-angiotensin system; SNS, sympathetic nervous system. Peripheral vasoconstriction Hemodynamic alterations Heart failure symptoms Fatigue Activity altered Chest congestion Edema Shortness of breath JCAHO: Quality-of-Care Indicators for HF HF-1: Discharge Instructions 1. Daily weights 2. 2 gram sodium diet 3. Activity Rx 4. What to do if Sx worsen 5. Follow-up appointment 6. List of medications HF-2: Assessment of LV Function HF-3: ACEI or ARB at Discharge in Appropriate Patients HF-4: Smoking Cessation Advice/Counseling www.jcaho.org Heart Failure Core Measure Outcomes 2006-1st Q 2008 120.0% 100.0% Percentage 80.0% 60.0% 40.0% 20.0% 0.0% Written D/C instructions (activity level, diet, d/c medications, f/u apt., wt. monitoring, worsening symptoms) LVF assessment ACEI/ARB Smoking cessation advice/counseling Quality Indicator 1st Q 06 2nd Q 06 3rd Q 06 4th Q 06 1st Q 07 2nd Q 07 3rd Q 07 4th Q 07 1st Q 08 Heart Failure Appropriate Care Measure 2006 - 1st Q 2008 120.0% 97.6% 100.0% 90.8% 94.4% 90.1% 80.0% Percentage 82.4% 85.1% 81.7% 68.0% 60.0% 71.8% 40.0% 20.0% 0.0% 1st Q 06 2nd Q 06 3rd Q 06 4th Q 06 1st Q 07 Time Period 2nd Q 07 3rd Q 07 4th Q 07 1st Q 08 Health Grades CHF Goals for Patients Hospitalized With HF Relieve symptoms rapidly Reverse hemodynamic abnormalities Prevent end-organ dysfunction Initiate patient education and survivalenhancing medications before discharge Optimize survival-enhancing oral medications (ACE inhibitor, beta blocker, aldosterone receptor antagonist) Optimize patient education and HF disease management Case History • 73 yo moved up from Fla and presented to SPH via car in acute CHF • Past HX remote MI, remote CABG,Hx ICD, Hx chronic CHF, AFib EF less than 30 • COPD, OSA, DM, Hx carotid stent • Non compliance felt to be component • Initial BP 130/70 BUN 58 CR1.9 • ECG : Afib LBBB Hospital Course • Diuresed with bolus IV Bumex 2mg IV BID • Seen by cardiology for CHF x3 days • Seen by EP for evaluation of rhythm- active GI bleed precludes TEE cardioversion. Later consider upgrade to Bivent device. Maintain rate control • Discharged with BUN 34 and Cr 1.7 • Meds Bumex 2 PO BID , Imdur 30QD, Coreg 25 BID, Hydralazine 25 TID Readmitted 8 days later with sob • • • • “I told them I didn’t have enough diuretics” Placed on hosp service boarded in PCU Seen by cardiology 3 days later Moved to CCU started on Nesiritide and Lasix gtts • Diuresed 30 #, BUN 24 CR 1.4 • Repeat EP evaluation BiV IVD already in place • MEDS: Lasix 80 BID, Coreg 25 BID, Coumadin, Accupril 20, Hospitalizations for Acute Decompensated Heart Failure • Congestion is the primary reason for heart failure admissions • This may be associated with systolic or diastolic dysfunction • Low cardiac output and associated signs/ symptoms are uncommon. • Sub-optimal weight reduction during hospitalization. • Although appear improved clinically, many patients are discharged with persistent fluid overload (related to pulmonary congestion that is not being identified clinically). Can we Risk Stratify Patients • Early determination of level of care needed • Determination of short term risk and needs • Predict long term risk to guide adjunct therapy- ICD, CRT, Transplant , Hospice Therapeutic Challenges • Decongest organs • Diurese • Win the Battle with the Kidneys • Cardiac Decompensation urges the kidneys to play unfairly Cardiorenal Syndrome • Worsening renal function in CHF patient who remains congested despite increasing doses of diuretics • Increased venous pressure with ”choked kidneys” and decreased cardiac output • Neurohormonal activation • Decreased renal perfusion • Fluid retention • Worsening cardiac performance • POOR PROGNOSIS Prognostic /Therapeutic Targets • • • • • • Blood Pressure Body Weight Serum Na Renal Function QRS Duration CAD High PCWP at Hospital Discharge is Associated with Higher Long-Term Mortality 60 60 Mortality (%) Mortality (%) 50 50 PCWP > 16 mmHg N=199 40 40 P = 0.001 30 20 CI > 2.6 L/min/m2 N=236 30 P = NS 20 PCWP < 16 mmHg N=257 10 CI < 2.6 L/min/m2 N=220 10 0 0 0 6 12 18 24 Time (months) Fonarow GC et al. Circulation 1994; 90: I-488 0 6 12 18 Time (months) 24 Predictors of Mortality Based on Analysis of ADHERE Database Classification and Regression Tree (CART) analysis of ADHERE data shows: Three variables are the strongest predictors of mortality in hospitalized ADHF patients: BUN BUN>>43 43mg/dL mg/dL Systolic Systolicblood bloodpressure pressure<<115 115mmHg mmHg Serum Serumcreatinine creatinine>>2.75 2.75mg/dL mg/dL Fonarow GC et al. JAMA 2005;293:572-80. ADHERE® CART: Predictors of Mortality Less than BUN 43 Greater than N=33,324 2.68% n=25,122 8.98% n=7,202 SYS BP 115 SYS BP 115 n=24,933 n=7,150 5.49% n=4,099 15.28% N=2,048 2.14% n=20,834 Cr 2.75 Highest to Lowest Risk Cohort OR 12.9 (95% CI 10.4-15.9) 2,045 12.42% n=1,425 Reference: 6.41% n=5,102 21.94% n=620 Fonarow GC, et al. Risk stratification for in-hospital mortality in heart failure using classification and regression tree (CART) methodology. JAMA. 2005;293:572-580. Primary Prevention of Sudden Cardiac Arrest in Heart Failure Patients with LV Dysfunction SCD in Heart Failure • Despite improvements in medical therapy, symptomatic HF still confers a 20-25% risk of premature death in the first 2.5 years after diagnosis1-4 • 50% of these premature deaths are SCD (VT/VF)1-4 1 SOLVD Investigators. N Engl J Med 1992;327:685-691. Investigators. N Engl J Med 1991;325:293-302. 3 Goldman S. Circulation 1993;87:V124-V131. 4 Sweeney MO. PACE. 2001;24:871-888. 2 SOLVD Severity of Heart Failure Modes of Death NYHA II 12% 64% 24% NYHA III CHF CHF Other 26% Sudden Death 59% 15% (N = 103) Other Sudden Death (N = 103) NYHA IV CHF 33% Other 56% 11% 1 MERIT-HF Study Group. LANCET. 1999;353:2001-2007. Sudden Death (N = 27) Relation of Time from MI to ICD Benefit in the MADIT-II Trial % Mortality for Each Time Period 16 Conv ICD 14 14 11.6 12 10 8 7.8 8.4 8.2 9 7.2 6 4.9 4 2 0 1-17 mo 18 - 59 mo 60 - 119 mo > 120 mo Time from MI (n = 300) Hazard Ratio .98 (p = 0.92) Wilber, D. Circulation. 2004;109:1082-1084. (n = 283) 0.52 (p = 0.07) (n = 284) 0.50 (p = 0.02) (n = 292) 0.62 (p = 0.09) HFSA 2006 Practice Guideline (9.1, 9.4) Device Therapy: Prophylactic ICD Placement In patients on optimal medical therapy (ideally 3-6 months) with or without concomitant coronary artery disease (including a prior MI > 1 month ago): Prophylactic ICD placement should be considered in those with NYHA II-III HF (LVEF 30%) Prophylactic ICD placement may be considered in those with NYHA II-III HF (LVEF 31-35%) Strength of Evidence = A Concomitant placement should be considered in NYHA IIIIV patients undergoing implantation of a biventricular pacing device. Strength of Evidence = B Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122. Disease Management Program for Congestive Heart Failure HFSA 2006 Practice Guideline (8.7) Heart Failure Disease Management Patients recently hospitalized for HF and other patients at high risk should be considered for referral to a comprehensive HF disease management program that delivers individualized care. Strength of Evidence = A Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122. 1 of 2 HFSA 2006 Practice Guideline Patient Education Recommendation 8.1 (1 of 2) It is recommended that patients with HF and their family members or caregivers receive individualized education and counseling that emphasizes self-care. This education and counseling should be delivered by providers using a team approach in which nurses with expertise in HF management provide the majority of education and counseling, supplemented by physician input and, when available and needed, input from dietitians, pharmacists and other health care providers. Strength of Evidence = B Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122. HFSA 2006 Practice Guideline Patient Education Recommendation 8.6 During acute care hospitalization, only essential education is recommended, with the goal of assisting patients to understand: Heart failure The goals of its treatment Post-hospitalization medication and follow up regimen. Education begun during hospitalization should be: Supplemented and reinforced within 1-2 weeks after discharge Continued for 3-6 months Reassessed periodically Strength of Evidence = B Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122. HF Disease Management and the Risk of Readmission 1.1 Risk Ratio Ekman 1 0.9 0.8 Jaarsma 0.7 Cline Lasater Stewart Rich Rauh Venner 0.6 Naylor 0.5 Fonarow Summary RR = 0.76 (95% CI .68-.87) Summary RR for randomized only = 0.75 (CI = .60-.95) Transitional Care for Heart Failure • May assist in device guided monitoring of volume status • May determine needs for supplemental oxygen therapy Involve Palliative care/ Hospice • Effective reporting to all appropriate physicians • Goal is to reduce rehospitalization and mortality • If patient is readmitted maintain transparency of care allocation CHF Education and Rehab • Cardiac Rehab not approved by CMS for CHF • Recovery from AHDF is slower than from acute coronary event • More likely to have repeat setbacks over first 180 days than from CAD • Heart Failure Monitoring can be accomplished how? Post Discharge Vulnerable Period • Two period of neurohormonal modification which are crucial to prognosis and survival • Changes in renal and hepatic function worsening signs and symptoms were predicitive of early events • BEST PREDICTORS : rising BUN and rising body weight cTHESE PEOPLE NEED CLOSE COMPETENT FOLLOWUP MONITORING OUTPATIENT THERAPY TIME-CHF 1. To compare intensified BNP-guided therapy to standard symptom-guided therapy on 18month outcome. 2. To assess if there is a difference in response to such therapy in patients ≥75years of age compared to those <75years of age, previously included in large heart failure trials. 3. Can monitoring of BNP reduce hospitalization in high risk patients? TIME-CHF Intensified, BNP-guided therapy did not improve the primary endpoint of all-cause hospitalisation free survival overall However, it improved the more disease-specific endpoint of heart failure hospitalisation free survival Response to therapy differed significantly between age groups Patients age 60-74 years Reduced mortality Improved HF hospitalisation free survival Patients aged ≥75 years No benefit on outcome Less improvement quality of life in Sleep Related Breathing Disorder • Affects 40-50% of pts with systolic HF • Central sleep apnea Cheyne Stokes respiration • Does not correlate with ejection fraction • Overnight oximetry- easy diagnostic test • Treatment with supplemental oxygen • May also need mild sleeping pills, acetazolamide • May need Full sleep study -BiPap • Nocturnal 02 lowers BNP and catecholamine levels Central Sleep Apnea and CHF • Withdrawal of central respiratory drive to respiratory muscles during sleep • Usually more than five events per hour of more than 10 seconds of apnea • Disrupted sleep • Hypersomnia during the day • CHF- often associated with hyperventilatory events- hypocapnia Relationship of Sleep Apnea to CHF • Epiphenomenon vs Risk predictor • Lanfranchi Apnea index of nonsurvivors twice that of survivors • AHI> 30 worst prognosis • Treatment includes • -treat underling decompensated HF • -Positive airway pressure • -nocturnal oxygen Impedance Monitoring Bi-V devices Pulmonary Congestion As fluid accumulates in the lungs, intrathoracic impedance decreases OptiVol Fluid Trends OptiVol Threshold OptiVol Fluid Index: Accumulation of the difference between the Daily and Reference Impedance Reference Impedance adapts slowly to daily impedance changes Daily impedance is the average of each day’s multiple impedance measurements Types of Chronic Heart Failure The use of the term “Diastolic Heart Failure” is controversial Some experts prefer the terms “Heart Failure with Preserved Ejection Fraction” or “Heart Failure with Preserved Systolic Function” The term diastolic heart failure is used to describe patients with the signs and symptoms of heart failure, a normal EF, and LV diastolic dysfunction It is not simply LVH Aurigemma N Engl J Med 355 (2006) 308-310 60 Treatment Options for Diastolic Heart Failure • Diuretics Hazard ratios (95% CI) for outcomes in I-PRESERVE, irbesartan vs placebo, over a mean of 50 months End point HR (95% CI) p Primary end point* 0.95 (0.86–1.05) 0.35 CV mortality 1.02 (0.87–1.19) 0.85 HF death or hospitalization 1.01 (0.88–1.16) 0.89 *Composite of death from any cause or hospitalization for heart failure, MI, unstable angina, arrhythmia, or stroke Massie BM, Carson PE. American Heart Association 2008 Scientific Sessions; November 11, 2008; New Orleans, LA. Advanced Glycation End-products (AGEs) in Heart Failure Advanced Glycation End-products (AGEs) have been proposed as a novel factor involved in the development and progression of chronic heart failure Pathways involved include cross-linking of extra cellular matrix as well as enhanced stimulation of AGE receptors leading to (prolonged) cellular activation and release of inflammatory cytokines The clinical and prognostic value of AGEs in patients with CHF remains largely unproven. Hartog et al. European Journal of Heart Failure 9 (2007) 1146–1155 63 Alagebrium: Effects in Reversing Cardiac Pathology arterial stiffness left ventricular stiffness end diastolic volume diastolic compliance stroke volume fractional shortening pulse wave velocity Prevents increase in cardiac A.G.E.s, BNP, CTGF, collagen III Restoration of collagen solubility Optimized ventriculo-vascular coupling 64 HFSA 2006 Practice Guideline (8.13) End-of-Life Care in Heart Failure End-of-life care should be considered in patients who have advanced, persistent HF with symptoms at rest despite repeated attempts to optimize pharmacologic and nonpharmacologic therapy, as evidenced by one or more of the following: Frequent hospitalizations (3 or more per year) Chronic poor quality of life with inability to accomplish activities of daily living Need for intermittent or continuous intravenous support Consideration of assist devices as destination therapy Strength of Evidence = C Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122. The Clinician Perspective What the palliative care team can do for clinicians: Save time by helping to handle repeated, intensive patient-family communications, coordination of care across settings, comprehensive discharge planning. Bedside management of pain and distress of highly symptomatic and complex cases, 24/7, thus supporting the treatment plan of the primary physician. Promote patient and family satisfaction with the clinician’s quality of care. The Hospital Perspective For hospitals, a palliative care team can help - Effectively treat the growing number of people with complex advanced illness. Provide service excellence, patient-centered care. Increase patient and family satisfaction. Improve staff satisfaction and retention. Meet JCAHO quality standards. Rationalize the use of hospital resources. Increase capacity, reduce costs. 30 Day Mortality Tracking