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2012 CCU Competency Heart Failure Module 1: Medical Management Issues Heart failure is our disease specific focus area for 2012 competency. There will be 2 modules, each with a specific focus. ◦ Medical Management Issues ◦ Nursing Driven Care ◦ Quality Outcome Assessment Heart Failure Focus for 2012 The purpose of this module is to review key medical management areas where there is opportunity for improvement. As part of the interdisciplinary team a thorough understanding of medical treatment goals will allow you to optimally contribute to the treatment plan and advocate for your patients with heart failure. Purpose Stages of Heart Failure ACC / AHA Stage A Stage B Stage C Stage D At high risk for HF but without structural heart disease or symptoms of HF. Structural heart disease but without signs or symptoms of HF Structural heart disease with prior or current symptoms of HF. Refractory HF requiring specialized interventions. Previous MI LV Remodeling including LVH and low EF Asymptomatic valvular disease Known structural disease and SOB, fatigue, reduced exercise tolerance. Marked symptoms of HF at rest despite maximal medical therapy. HTN CAD DM Obesity Metabolic syndrome Family HX CM 4 Classification of Heart Failure: New York Heart Association Class I Class II Class III Class IV Cardiac disease no resulting limitation in physical activity. Cardiac disease with slight limitation of physical activity. Cardiac disease with marked limitation on physical activity. Cardiac disease resulting in inability to carry out any physical activity without discomfort. Ordinary activity free of fatigue, palpitation, dyspnea or anginal pain. Comfortable at rest but ordinary activity results in fatigue, palpitations, dyspnea, or anginal pain. Comfortable at rest but less than ordinary activity results in fatigue, palpitations, dyspnea, or anginal pain. May have symptoms of cardiac insufficiency at rest. 5 Systolic Dysfunction (Reduced EF) Diastolic Dysfunction (Preserved EF) 6 Although the commonly used terms are systolic and diastolic heart failure, the current recommended terms are heart failure with preserved left ventricular function and heart failure with reduced left ventricular function. The reason for the clarification is because most patients with “systolic heart failure” also have some abnormalities during diastole, and patients with “diastolic heart failure”, although their overall EF is normal do not have completely normal systolic function. Heart failure with preserved or reduced left ventricular function. There are evidence based guidelines for the management of patients with heart failure with reduced LV function. ◦ ◦ ◦ ◦ ACE-I (or ARB) Beta blocker Aldosterone antagonists (NYHA Class III or IV HF) Hydralazine / Nitrate combination (for African Americans - in addition to standard therapy) ◦ Cardiac resynchronization therapy if BBB (especially LBBB) and EF < 35% ◦ Referral for ICD therapy if EF < 35% Evidence Based Guidelines for Heart Failure with Reduced LV Function There are only three beta-blockers that are recommended for use in patients with reduced LVEF (<40%) These are considered evidence based beta blockers ◦ Carvedilol (Coreg) ◦ Metoprolol succinate (long acting metoprolol) (ToprolXL) ◦ Bisprolol (Zebeta) This is the reason you may see patient’s switched from Lopressor, which is metoprolol tartrate (short acting metoprolol) Quality Indicator: In 2011 evidence based beta blockers were only prescribed 84.7% of the time. More on Beta-Blockers In HF patients with preserved LVEF (diastolic dysfunction) the focus is on managing the patient’s comorbid conditions. This means rate control in atrial fibrillation, treatment of hypertension, and diagnosis and treatment of obstructive sleep apnea. Note: There are no clear evidence based guidelines for patients with preserved LVEF. Our quality data indicates that only 60-65% of potentially eligible patients have documentation regarding counseling or referral for cardiac resynchronization therapy and / or ICD. When caring for a heart failure patient with an EF < 35% ask / discuss during rounds if this patient is a candidate for CRT and / or ICD therapy. Focus areas to improve outcomes. Cardiac Resynchronization Therapy (CRT) Treatment modality for heart failure not just pacing ◦ Used in patients with dysynchrony (QRS > 120 msec) Used in conjunction with optimal drug therapy In addition to the atrial lead there are two ventricular leads ◦ RV Apex ◦ LV lateral wall Goal: Force biventricular pacing Goal: Ventricular Pacing 90% of time or greater Anticipated Outcomes: ◦ Improve hemodynamics by restoring synchrony of ventricular contraction ◦ Improve quality of life ◦ Decrease mortality and morbidity 12 Implantable Cardiovertor Defibrillator - Indications Secondary Prevention (Class IA Recommendation) ◦ Symptoms of HF ◦ History of cardiac arrest, VF, or hemodynamically destabilizing VT Primary ◦ ◦ ◦ ◦ Prevention (Class IA Recommendation) Non-ischemic dilated myopathy or ischemic heart disease > 40 days post-MI or > 90 days post intervention EF < 35% NYHA class II or III in optimal medical therapy Not recommended in Stage D 13 Recognizing Potential Obstructive Sleep Apnea Another Important Opportunity for Improvement Approximately 1 in 5 adults: mild Approximately 1 in 15 adults: moderate / severe 15 million Americans > 85% have not been diagnosed Adverse consequences may be greater in those < 50 years. High prevalence of pathological daytime sleepiness in OSA Almost all with OSA snore but not all snorers have OSA Obstructive Sleep Apnea 15 Reflex muscle • Airway narrowing or collapse activity is reduced / lost Apnea or hypoapnea occurs • Hypoxia and hypercapnea stimulate ventilatory effort and arousal occurs During Sleep 16 Hemodynamic Instability Increased negative intrathoracic pressure Increased transmural gradient Increased Afterload Increased atrial size Autonomic Instability Aortic dilation Diastolic dysfucntion Ventricular Dysfunction Physiological Impact of Obstruction 17 The prevalence of sleep apnea in heart failure has been reported to be approximately 50%. ◦ This includes both obstructive and central sleep apnea. In this study of 30,719 Medicare HF patients only 2% were tested for sleep apnea. Those who were tested, diagnosed and treated had improved survival compared to those who were not. Source: Javaheri, et al. (2011). American Journal of Respiratory Critical Care Medicine, 183, 539-546. Answer each of the following yes or no: 1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? 2. Do you often feel TIRED, fatigued, or sleepy during daytime? 3. Has anyone OBSERVED you stop breathing during your sleep? 4. Do you have or are you being treated for high blood PRESSURE? 5. BMI more than 35? 6. AGE over 50 years old? 7. NECK circumference > 15.75 inches? 8. Male GENDER? ≥3 yes answers: High-risk for OSA <3 yes answers: Low-risk for OSA The STOP-BANG Screening Tool for Obstructive Sleep Apnea. Our focus is linking knowledge to practice and practice to patient outcomes. For this module we want to increase awareness of our practice patterns in the care of HF patients. Find one patient in CCU admitted with HF with a reduced LVEF: ◦ Does the patient have a LVEF of < 35% If yes - does the patient have an ICD? If not – is there a notation regarding contraindication? ◦ Does the patient have a LBBB and a LVEF of < 35% If yes – does the patient have a CRT device? If not is there a notation regarding contraindication? ◦ What is the patient’s STOP BANG Score? Is the patient being treated for sleep apnea? If not has the patient ever had a sleep study? To Complete this Module: Document the answers to the above patient questions in QUIA. Put the date, room number and initials of the patient you assessed. For your Portfolio. Please include any examples of your input into rounding or collaborative discussion where you have identified potential candidates for ICD/CRT or sleep apnea testing. Thank you. Your commitment to excellence makes a difference!