Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
2/7/2013 Robin Harris, PhD, ANP-BC Doctorate in Nursing, University of Tennessee Post-Master’s Certificate in Adult Health Nursing, University of Tennessee Master of Science in Nursing, University of Virginia Bachelor of Science in Nursing, East Tennessee State University Affiliations: American Association of Critical Care Nurses, American A ssociation of Heart Failure Nurses Locations: Kingsport, Bristol Heart Failure 2013 Update Wellmont CVA Heart Institute Thomas M. Bulle, MD, FACC Robin Harris, PhD, ANP-BC 1 2/7/2013 The diagnosis of heart failure is based on the presence of symptoms and/or signs of pulmonary and/or systemic edema, and/or low cardiac output manifested by organ hypo-perfusion in the presence of and due to structural heart disease. 2 2/7/2013 Not everyone who is short of breath or has edema has heart failure! Biological Changes of the Failing Cardiac Myocyte Cellular hypertrophy Altered Excitation-Contraction coupling Myofilament loss Beta Adrenergic desensitization Mitochondrial & substrate metabolic change Abnormal myocyte energetics Myocyte cytoskeleton loss & disarray 3 2/7/2013 Ventricular Geometry Goals of therapy: •Live longer •Live better 4 2/7/2013 Patient Presentation 12.15.12 75 y/o male c/o Short of breath, dry cough, fatigue, chest pain; Seen in local Urgent Care Clinic; referred for further evaluation with Dx “Heart Failure” Hx: No prior cardiac history ◦ Prior HTN-ran out of meds & cannot recall ◦ No routine medical care Exam: BP 168/92 HR 130, BMI 38; warm extremities; JVP 14; S3; basilar rales; edema 1+ Critical Co-Morbidities in HF Acute myocardial ischemia/acute coronary syndromes Severe hypertension Atrial & ventricular arrhythmias Infections Pulmonary emboli Renal failure Medical or dietary non-compliance 5 2/7/2013 Appropriate Initial Studies Appropriate (guideline based) studies for this patient include: CBC, BMP, U/A TSH, HgA1C BNP FLP, LFT’s, FBS ECG, CXR Echo 2D/Dop Stress MPI or Echo Right & Left Heart Cath Appropriate Initial Studies Appropriate (guideline based) studies for this patient include: CBC, BMP, U/A, TSH, HgA1C or FBS, LFT’s, FLP (Class I) BNP-indicated when the etiology of symptoms of breathlessness is unclear and prognostically during hospital admission ECG, CXR (Class I) Echo 2D/Doppler (Class I) ”The single most useful diagnostic test in the evaluation of patients with HF” Stress MPI or Echo (Class IIB / LOE C) Right & Left Heart Cath (Class 1/ LOE B) “Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization of any kind.” Class I/ LOE B 6 2/7/2013 Accuracy of H&P to Detect PCWP > 22mmHG H&P Finding Sensitivity Specificity + Pred Value Rales 15 89 69 - Pred Value 38 S3 62 32 61 33 Ascites 21 92 81 40 Edema 41 66 67 40 Orthopnea 86 25 66 51 Hepatomegaly 15 93 78 39 HJR 83 27 65 49 JVP >11 65 64 75 52 JVP <8 4 81 28 33 Potential Screening & Prognostication Uses for Natriuretic Peptides Screening for Stage A HF Screening for Stage B HF R/O HF in primary care setting Risk prediction in stable CAD Risk prediction in unstable CAD Risk prediction in HF Pre-Operative risk prediction Risk prediction with chemotherapy JACC 2012;60:277 Predicting Risk http://depts.washington.edu/shf m/app.php 7 2/7/2013 http://depts.washington.edu/ shfm/app.php Patient Presentation 12.15.12 75 y/o male Short of breath, dry cough, fatigue, chest pain Rhythm-Afib; LBBB; HR 130 Hemodynamics-volume expanded; depressed CI Metabolic-Diabetes, kidney disease, anemia, dyslipidemia, hyponatremia 8 2/7/2013 First Things First ! Acute Stabilization priorities Education: Medication: ◦ ◦ ◦ ◦ ◦ ◦ ACE Inhibitor ARB Beta blocker? Aldosterone antagonist? Aspirin? Statin? Referral for device Rx? Patient Education in HF “Comprehensive written discharge instructions for all patients with a hospitalization for HF; special focus on: 1. Diet 2. Discharge medications, adherence, persistence, and up-titration of ACE/ARB & Beta Blocker Rx; 3. Activity level; 4. Follow up appointments including date, time & contact information; 5. Daily weight monitoring; 6. Response to clinical symptoms changes or development. Beta Blocker Rx in Acute HF If patients are already taking BB’s, these should be continued BB’s with demonstrated efficacy in HF should be prescribed (Bisoprolol, Carvedilol, Metoprolol succinate only) BB’s should be started ONLY after optimization of volume status and discontinuation of intravenous diuretics. BB’s should be started at low doses BB’s should be started in stable patients; particular caution should be used in patients who have required inotropic Rx during the hospitalization 9 2/7/2013 Aldosterone Blockade in HF (Spironolactone/Epleronone) “Recommended in patients with moderately severe or severe symptoms of HF with reduced EF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be </ 2.5 in men and 2.0 in women and K+ <5.0 Potential benefit in patients with low EF post MI and with recent decompensation with mild symptoms, in addition to loop diuretics, “however the writing committee strongly believes that there are insufficient data or experience to provide a specific or strong recommendation.” The combination of Aldosterone blocker Rx with combined ACE/ARB Rx “cannot be recommended.” Atrial Fibrillation in HF Restoration of sinus rhythm indicated if symptoms persist following heart rate control* *presuming effective anticoagulation control** or TEE-documented absence of LA thrombi ◦ **>3weeks of SEQUENTIAL effective anticoagulation with INR > 2.0 Given presence of important MR, this would be considered “valvular” atrial fibrillation and not an approved condition for Pradaxa or Xarelto Complimentary role of BP control ◦ Investigative role of renal artery denervation Cardiac Resynchronization (CRT) Patients with LVEF < 35% in sinus rhythm and symptomatic class III-IV HF on optimal medical therapy and QRS > 120 msec (Class I/LOE A) Patients with LVEF < 35% in atrial fibrillation and symptomatic class III-IV HF on optimal medical therapy and QRS >0.12msec (Class IIa/LOE B) 10 2/7/2013 “Maximal Medical Therapy” Angina: Limiting angina that interferes with the lifestyle the patient wishes to lead ◦ Maximally tolerated dose of at least 2 anti-anginal medications (BB’s, CCB’s, Nit’s) ◦ HR 50-60; ◦ SBP 100-115 Heart Failure: ◦ ◦ ◦ ◦ BB; ACE or ARB (if Creat < 2.5 Diuretic. CRT for patients with EF < 35% and NYHA Class II-IV Sx’s with QRS> 0.12msec Cardiac Resynchronization So…what?? Measurable clinical benefits Reimbursement tied to performance measures Financial penalties for failure to satisfy performance measures Consumer awareness 11 2/7/2013 Results: Mortality Reduction Based on Number of Guideline-Recommended Therapies at Baseline 24-Month Mortality Adjusted Odds Ratios (95% CI Displayed) Number of Therapies (vs. 0 or 1 therapy) Odds Ratio (95% confidence interval) 2 therapies 0.63 (0.47-0.85) 3 therapies 0.38 (0.29-0.51) (p = 0.0026) (p < 0.0001) 4 therapies 0.30 (0.23-0.41) 5, 6, or 7 therapies 0.31 (0.23-0.42) (p < 0.0001) (p < 0.0001) 0 0.5 1 1.5 2 Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26. Incremental Benefits with HF Therapies (Cumulative % Reduction in Odds of Death at 24 Months) -28% to -49% P<0.0001 -54% to -71% P<0.0001 -68% to -81% P<0.0001 -75% to -86% P<0.0001 -77% to -88% P<0.0001 -72% to -87% P<0.0001 Fonarow GC, et al. J Am Heart Assoc. 2012;1:16-26. HFpEF 12 2/7/2013 Table 9. Differential Diagnosis in a Patient With Heart Failure and Normal Left Ventricular Ejection Fraction Heart Failure with Preserved EF There are no guideline based treatment indications for the Rx of HFpEF ◦ No clinical/survival benefit for ACE/ARB ◦ No clinical/survival benefit for Beta Blockers ◦ No clinical/survival benefit for Aldosterone antagonists ◦ No clinical/survival benefit for CCB’s The principal goal of Rx for HFpEF is to manage co-morbidities and to control volume status Coming Up…or not Soluble beta-galactoside-binding lectin: Direct mediator of pro-fibrotic pathway; Marker of myocardial remodeling and fibrogenesis Expressed by activated macrophages (and other cell types); Induces cardiac fibroblast proliferation and deposition of type I collagen Galectin-3 expression is substantially upregulated in animal models of heart failure (HF); Precedes development of overt clinical HF Henderson NC, PNAS, 2006 Nishi Y, Allergol Int, 2007 Sharma UC, Circulation, 2004 Liu YU, Am J Physiol Heart Circ Physiol, 2009 39 Grandin EW, Clin Chem, 2011 13 2/7/2013 Galectin-3: Prognosis in Acute and Chronic HF COACH HF-ACTION PRIDE DEAL-HF 40 Percutaneous renal denervation procedure. Krum H et al. Circulation 2011;123:209-215 Copyright © American Heart Association 14 2/7/2013 Exercise & Heart Failure N=2933 pts > 65 y/o Free of HF at outset; 2-3yrs follow up NT-proBNP NT-proBNP cTnT cTnT Final Diagnosis 15 2/7/2013 Disclosure Information Robin Harris, PhD, ANP-BC I have no financial relationships to disclose. Why so much emphasis on heart failure? Evidence-based therapies improve patient outcomes 25% of patients admitted for heart failure are readmitted within 30 days; 50% of patients are readmitted within 6 months CMS changes in reimbursement/penalties for hospitals effective October 1, 2012 An estimated 40% of readmissions are avoidable Discharge teaching/patient education has been shown to reduce readmission rates 16 2/7/2013 Heart Failure: Symptom Progression Asymptomatic NYHA FC I Dyspnea with Exertion NYHA FC II Dyspnea with minimal exertion NYHA FC III End-stage HF NYHA FC IV 49 Heart Failure Management: Continuum of Care Inpatient Care ◦ Management of Acute Illness Fluid Volume Reduction Diuretics Symptom Management Hemodynamic Support Evaluation and Treatment of HF Etiology Outpatient Care ◦ Pharmacologic Management Evidence-Based Guidelines ◦ Nonpharmacologic Management 17 2/7/2013 Heart Failure Management: Continuum of Care - Barriers Decentralized health care delivery Cost, complexity, and standards for HF care Management of complex drug regimens Identification of treatment side effects Mostly elderly population Patients with multiple comorbidities HeartSUCCESS® Program can address many of these barriers WHS HeartSUCCESS® Program System-wide approach to heart failure management to prevent avoidable admissions and reduce readmissions for heart failure Integration of inpatient and outpatient heart failure care Physician supervised-NP Managed Heart Failure Clinics Multiple Heart Failure Clinic locations to increase access to heart failure care by dedicated team of heart failure experts Heart Failure Clinic Model: Benefit to Patient Improve quality of life Improve functional status Improve patient satisfaction with care Reduce frequency of hospitalizations Hauptman, P.J. et al. (2008). The Heart Failure Clinic: A consensus statement of the Heart Failure Society of America. Journal of Cardiac Failure, 14, 801-815. McAlister, F.A. et al. (2004). Multidisciplinary strategies for the management of heart failure patients at high risk for readmission: A systematic review of randomized trials. JACC, 44, 810-819. 18 2/7/2013 High-risk for heart failure readmission Patients recently hospitalized for heart failure High-risk for readmission ◦ Renal insufficiency ◦ Diabetes ◦ COPD Chronic NYHA FC III or IV symptoms Frequent hospitalizations of any cause Elderly patients or other patients with multiple comorbidities History of nonadherence to medical therapy Inadequate social support system Heart Failure Management: Continuum of Care - Outpatient ◦ Pharmacologic Medication titration and optimization Referral for Device Therapy Referral for LVAD, Cardiac Transplant Evaluation ◦ Nonpharmacologic Communication of care among Health Care Providers Management of Co-existing medical conditions Screening for Sleep Disordered Breathing Patient Education Self-care Management Behaviors Psychosocial Aspects of Chronic Illness Depression Anxiety Advance Care Planning Advanced Care Directive Power of Attorney Heart Failure Management: Nonpharmacologic Patient and Caregiver Education: ◦ Health Literacy vs. Literacy Health Literacy is the degree to which individuals obtain, process, and understand basic health information and make appropriate health decisions ◦ Heart Failure diagnosis Condition Prognosis Classification of Heart Failure Treatment Goals and Plan of Care ◦ Medications Indications Proper dosing of medications Plan and rationale for uptitration of medications Side effects of medications 2/7/2013 Heart Failure 57 19 2/7/2013 Heart Failure Management: Nonpharmacologic ◦ Self-care management Weigh daily and record Report weight gain of > 3 lbs. overnight or > 5 lbs. in a week Dietary Sodium Restriction < 2000mg sodium daily Fluid Restriction 48-64 ounces daily (1.5 to 2 quarts daily) Physical Activity Encourage daily exercise Improves endurance Improves symptoms Exercise is safe in HF patients Symptom recognition/when to notify provider ◦ Frequent follow-up Medication optimization Assessment of response to treatment Heart Failure Management: Continuum of Care Provide seamless transition of care from inpatient to outpatient setting ◦ Communication and coordination of care among providers ◦ Use of evidence-based HF management guidelines ◦ Outpatient follow-up with provider Within 7 days post-discharge Frequent follow-up to monitor treatment response and progress ◦ Referral for advanced heart failure care Patient/Caregiver Education ◦ Improve patient and caregiver understanding of heart failure condition and management ◦ Teach skills of self-care management ◦ Individualize patient education to promote health literacy and self-care management skills 20 2/7/2013 BNP levels provide no diagnostic information in patients with normal LV systolic function? True 2. False 1. False 21 2/7/2013 An appropriate initial dose of beta blocker for a patient presenting with heart failure and reduced Ejection Fraction without coronary artery disease include all but the following: Metoprolol succinate 25 mg PO daily 2. Carvedilol 3.125 mg PO BID 3. Atenolol 50 mg PO daily 4. Bisoprolol 5 mg PO daily 1. C. Atenolol 50mg PO daily 22 2/7/2013 23 2/7/2013 Within 30 days of HF Admission: • 1 in 10 dead • 1 in 4 readmitted • Recurrent HF • Co-morbid illness • 75% avoidable • Cost: $17 Billion Challenges facing Hospital LOS • Selection of patients for early D/C • Availability of early out-pt F/U • Alternatives to readmission from ED HFpEF-is it really HF at all? Table 9. Differential Diagnosis in a Patient With Heart Failure and Normal Left Ventricular Ejection Fraction Heart Failure with Preserved EF Incorrect Dx of HF Inaccurate measurement of EF Primary valvular disease Restrictive (infiltatrative) CM Hemochromatosis Pericardial constriction Myocardial ischemia High output states COPD wiwth Right HF 24 2/7/2013 Borlaug BA, Redfield MM. Circulation 2011;123:20062014 25 2/7/2013 Galectin-3: General Population: Framingham Heart Study Q1: < 11.6 ng/mL Q2: 11.7-13.7 ng/mL Q3: 13.8-16.4 ng/mL Q4: >16.4 ng/mL N=3,353; 166 first HF events Ho JE, et al., J Am Coll Cardiol 2012 76 Galectin-3: Fibrosis, Scarring & Adverse Remodeling Myocardial injury (e.g., MI) triggers inflammatory & wound healing response Macrophages release galectin-3 Collagen deposition results in scar formation Macrophages carrying galectin-3 infiltrate necrotic tissue Remodeling & dilatation) Galectin-3 binds and activates the myofibroblast leading to collagen synthesis Galectin-3 and Natriuretic Peptides Galectin-3 BNP/NT-proBNP Biology Indicator of cardiac fibrosis Indicator of cardiac stress Short Term Variability - Relatively stable - Marked variability - Not affected by acute decompensation - Elevation with acute decompensation Population 30-50% of HF patients All HF patients Response to HF Treatments Not immediately affected by HF treatment Reduced by effective therapy In HF Management Prognosis; Segmentation of HF population & response to treatment Diagnosis, Prognosis (NTproBNP), Monitoring of Rx Galectin-3 and natriuretic peptides are independent and complementary 78 26 2/7/2013 Galectin-3 and Natriuretic Peptides: DEAL-HF Study N = 232; NYHA III-IV 6+ year follow-up Both high: ~1.5 - 2-fold higher mortality risk; p=0.036 for trend Galectin-3 added value: 21% 10% • Identified ~21% more patients at the highest risk of mortality • Identified ~10% more patients at increased risk not identified by low NT-proBNP NT-proBNP: (253pmol/L = 2,144pg/mL) Galectin-3 and natriuretic peptides are independent and complementary 79 Lok, DJA, et al. Clin Res Cardiol 2010;99:323-8. Galectin-3: Readmission Meta-analysis: Acute & Chronic PRIDE COACH UMD de Boer, RA, et al., J Card Fail. 2011;17:S93. (Presented at HFSA Annual 8 Scientific Meeting, 2011, Boston, MA). 0 Galectin-3: Readmission Meta-analysis: Acute & Chronic Meta-analysis of 892 patients across 3 studies Patients with galectin-3 >17.8ng/mL are >2x as likely to be re-hospitalized (HR = 2.35) Galectin-3 testing may be of benefit in programs aiming to reduce rates of hospital readmission P=0.0012 Odds Ratio =2.61(95% CI:1.46-4.65) p=0.0012 “Galectin-3 mediated” HF: driving near-term readmission in acute and chronic HF de Boer81 RA, et al. J Cardiac Fail 2011;17:S93 27 2/7/2013 Galectin-3: General Population: Framingham Heart Study N=3,353; 166 first HF events Ho JE, et al., J Am Coll Cardiol 2012 Q1: < 11.6 ng/mL Q2: 11.7-13.7 ng/mL Q3: 13.8-16.4 ng/mL Q4: >16.4 ng/mL 82 28