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10/5/15 Healthy Kingsport Conference Heart Failure Management: Con6nuum of Care Robin Harris PhD, ANP-­‐BC, ACNS-­‐BC Clinical Assistant Professor University of Tennessee College of Nursing Important Info •  I, Robin Harris, do not have any financial disclosures. •  I, Robin Harris, will not discuss any off-­‐label or inves6ga6onal devices in my presenta6on. Objec6ves •  Discuss guidelines for care of the pa6ent with heart failure. •  Discuss strategies to prevent acute CHF illness exacerba6on. •  Iden6fy treatments for management of advanced heart failure. 1 10/5/15 Heart Failure -­‐ Defini/on •  “A condi6on in which the heart fails to discharge its contents adequately” (Thomas Lewis, 1933) •  A pathophysiological state in which an abnormality of cardiac func6on is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolising 6ssues” (E Braunwald, 1980) •  “A clinical syndrome caused by an abnormality of the heart and recognised by a characteris6c pa_ern of haemodynamic, renal, neural and hormonal responses” (Philip Poole-­‐Wilson, 1985) •  A syndrome in which cardiac dysfunc6on is associated with reduced exercise tolerance, a high incidence of ventricular arrhythmias and shortened life expectancy” (Jay Cohn, 1988) •  A brief history of heart failure care • 
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1628 -­‐William Harvey describes the circula6on 1785 -­‐William Withering publishes an account of medical use of digitalis 1819 -­‐René Laennec invents the stethoscope 1895 -­‐Wilhelm Röntgen discovers x rays 1920 -­‐Organomercurial diure6cs are first used 1954 -­‐Inge Edler and Hellmuth Hertz use ultrasound to image cardiac structures 1958 -­‐Thiazide diure6cs are introduced 1967 -­‐Chris6aan Barnard performs first human heart transplant 1987 -­‐CONSENSUS-­‐I study shows unequivocal survival benefit of angiotensin conver6ng enzyme inhibitors in severe heart failure 1995 -­‐European Society of Cardiology publishes guidelines for diagnosing heart failure 1997 – COMET – Carvedilol first beta blocker with FDA approval for mild—moderate heart failure 2015 – PARADIGM HF – Entresto approved; 2015 – Corlanor approved Famous People with Heart Failure • 
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Elizabeth Taylor Ginger Rogers Helen Hayes Barbara Stanwyck Donald O’Connor Danny Thomas Randy Travis Karen Carpenter Dick Cheney James Monroe Harry Truman 2 10/5/15 Where we are today… •  5 million people diagnosed with heart failure •  Most common diagnosis for hospital admission for pa6ents > 65 •  Only cardiovascular diagnosis on the increase •  555,000 new cases diagnosed each year •  Incidence – 10 out of every 1000 people over age 65 Figure 6. Changing management of heart failure over the past 40 years.
Katz A M Circ Heart Fail. 2008;1:63-71
Copyright © American Heart Association, Inc. All rights reserved.
3 10/5/15 Prognos/c Significance of Heart Failure Stages Circulation. 2007;115:1563-1570
ACC Stages of Heart Failure At risk for development of heart failure Stage A – High risk for developing heart failure Stage B – Asymptoma6c LV dysfunc6on Heart Failure Stage C – History of heart failure/current sx. Stage D – End stage heart failure Stage A Heart Failure Management • 
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Treat known risk factors Evalua6on for S/S heart failure Rhythm control Echocardiogram to assess LV control Treat Lipid disorders Control diabetes Lifestyle modifica6ons Medica6ons: ACE Inhibitors, ARBs 4 10/5/15 Mortality Findings in Large Placebo-Controlled ACEI Trials
J Am Coll Cardiol 2001;37:1456-1460
Patients With Reduced Left Ventricular
Ejection Fraction
I IIa IIb III
I IIa IIb III
Angiotensin ll Receptor Blockers
Angiotensin II receptor blockers are recommended inpatient with current or prior symptoms of HF and
reduced LVEF who are ACE- inhibitor intolerant (see
full text guidelines).
Drugs known to adversely affect the clinical status of
patients with current or prior symptoms of HF and
reduced LVEF should be avoided or withdrawn
whenever possible (e.g., nonsteroidal antiinflammatory drugs, most antiarrhythmic drugs, and
most calcium channel blocking drugs).
NO CHANGE
J Am Coll Cardiol 2009, 53: 1343-­‐82 24
Val-­‐HeFT: Valsartan in Heart Failure N Engl J Med 2001;345:1667-75
5 10/5/15 CHARM-­‐Alterna/ve: Candesartan in Place of ACEI Lancet 2003; 362: 772-­‐76 Patients With Reduced Left Ventricular
Ejection Fraction
I IIa IIb III
ARB and Conventional Therapy
The addition of an ARB may be considered in persistently
symptomatic patients with reduced LVEF who are already
being treated with conventional therapy.
I IIa IIb III
Routine combined use of an ACE inhibitor, ARB, and
aldosterone antagonist is not recommended for
patients with current or prior symptoms of HF and
reduced LVEF.
I IIa IIb III
Calcium Channel Blocking Drugs
Calcium channel blocking drugs are not indicated as
routine treatment for HF in patients with current or prior
symptoms of HF and reduced LVEF.
J Am Coll Cardiol 2009, 53: 1343-­‐82 35
Stage B Heart Failure Management •  Same general measures as Stage A •  Medica6ons: ACE Inhibitors, ARBs, Beta blockers •  Implantable Cardioverter Defibrillator – EF < 35% on op6mal medical therapy •  Treat structural disorder: CABG, PTCA/PCI, valve repair/replacement •  Avoid use of calcium channel blockers with nega6ve inotropic effects 6 10/5/15 Lancet 1999;353:9-13. JAMA 2000;283:1295-302. N Engl J Med 2001;344:1651-8. N Engl J Med
2001;344:1659-67.
Stage C Heart Failure Management •  Same general measures as Stage A and B •  Medica6ons: ACE Inhibitors, ARBS, Beta blockers, Diure6cs •  Other Medica6on that may be indicated: Aldosterone Antagonists, Digitalis, Hydralazine/nitrates •  Implantatable Cardioverter Defibrillator •  Cardiac Resynchroniza6on (biventricular PM) Patients With Reduced Left Ventricular
Ejection Fraction
I IIa IIb III
The Risks of Aldosterone Antagonists
Addition of an aldosterone antagonist is recommended
in selected patients with moderately severe to severe
symptoms of HF and reduced LVEF who can be carefully
monitored for preserved renal function and normal
potassium concentration. Creatinine 2.5 mg/dL or less
in men or 2.0 mg/dL or less in women and potassium
should be less than 5.0 mEq/L. Under circumstances
where monitoring for hyperkalemia or renal dysfunction
is not anticipated to be feasible, the risks may outweigh
the benefits of aldosterone antagonists.
J Am Coll Cardiol 2009, 53: 1343-­‐82 28
7 10/5/15 RALES: Spironolactone Plus Usual Therapy N Engl J Med 1999; 341:709-17
Patients With Reduced Left Ventricular
Ejection Fraction
Recommendations for Hydralazine and Nitrates
I IIa IIb III
I IIa IIb III
The combination of hydralazine and nitrates is
recommended to improve outcomes for patients selfdescribed as African-Americans, with moderate-severe
symptoms on optimal therapy with ACE inhibitors, beta
blockers, and diuretics.
The addition of a combination of hydralazine and a
nitrate is reasonable for patients with reduced LVEF
who are already taking an ACE inhibitor and beta
blocker for symptomatic HF and who have persistent
symptoms.
J Am Coll Cardiol 2009, 53: 1343-­‐82 29
Patients With Reduced Left Ventricular
Ejection Fraction
Hydralazine and Nitrate Combination
I IIa IIb III
A combination of hydralazine and a nitrate
might be reasonable in patients with current
or prior symptoms of HF and reduced LVEF
who cannot be given an ACE inhibitor or ARB
because of drug intolerance, hypotension, or
renal insufficiency.
J Am Coll Cardiol 2009, 53: 1343-­‐82 34
8 10/5/15 A-­‐HeFT: Isosorbide Dinitrate Plus Hydralazine in Black Pa/ents N Engl J Med 2004;351:2049-57
Patients With Reduced Left Ventricular
Ejection Fraction
Recommendations for Atrial Fibrillation and Heart Failure
I IIa IIb III
It is reasonable to treat patients with atrial
fibrillation and HF with a strategy to maintain
sinus rhythm or with a strategy to control
ventricular rate alone.
J Am Coll Cardiol 2009, 53: 1343-­‐82 30
Patients With Reduced Left Ventricular
Ejection Fraction
The Benefits of Digitalis
I IIa IIb III
Digitalis can be beneficial in patients with
current or prior symptoms of HF and
reduced LVEF to decrease hospitalizations
for HF.
J Am Coll Cardiol 2009, 53: 1343-­‐82 32
9 10/5/15 DIG Trial: Digoxin in Heart Failure N Engl J Med 1997; 336: 525-33
Stage D Heart Failure Management • 
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Control/Prevent fluid reten6on Heart Failure Clinic Program/Specialist Discuss end-­‐of-­‐life care Discuss deac6va6on of defibrillator Cardiac transplant/LVAD Evalua6on Drug Therapy – con6nuous inotrope infusion Heart Failure Management: Goals •  Increase access to heart failure care •  Improve outcomes –  Reduce mortality –  Reduce rehospitaliza6on rates • 
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Improve quality of life Provide quality, evidence-­‐based pa6ent care Individualized pa6ent care Improve pa6ent adherence to treatment regimen Minimize acute heart failure exacerba6ons and reduce hospitaliza6ons 10 10/5/15 Heart Failure Management: Con/nuum of Care — Inpa/ent Care ◦  Management of Acute Illness –  Fluid Volume Reduc6on –  Diure6cs –  Symptom Management –  Hemodynamic Support –  Evalua6on and Treatment of HF E6ology — Outpa/ent Care ◦  Pharmacologic Management –  Evidence-­‐Based Guidelines ◦  Nonpharmacologic Management Heart Failure Management: Con/nuum of Care -­‐ Barriers — Decentralized health care delivery — Cost, complexity, and standards for HF care — Management of complex drug regimens — Iden6fica6on of treatment side effects — Mostly elderly popula6on — Pa6ents with mul6ple comorbidi6es Disease Management Models •  Telephone Nurse Follow-­‐up –  Nurse calls pa6ent at designated intervals –  Review of treatment plan, goals •  Telemonitoring System –  Daily weights, vital signs transmi_ed to remote site –  Informa6on shared with providers •  Home Health Nurse follow-­‐up –  CHF programs –  IV Lasix protocols, home infusion therapy •  Outpa6ent Follow-­‐up – 
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Team approach to heart failure care Op6mize medical therapy Regular/frequent follow-­‐up Pa6ent/caregiver educa6on Rapid response to clinical change Coordina6on of care 33 11 10/5/15 HF Treatment Protocols • 
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Evidence-­‐based Protocols Heart Failure Management –  Pharmacologic •  Medica6on up6tra6on –  Beta blockers –  ACE I/ARB –  Aldosterone agonists •  Diure6cs –  Nonpharmacologic •  Diet •  Fluid restric6on •  Daily weights •  Lifestyle changes –  E6ology of Heart Failure •  Laboratory and diagnos6c tes6ng as indicated
–  Advanced Heart Failure Care •  EP referral –  CRT, ICD –  Fluid volume monitoring –  Referral for LVAD, cardiac transplant evalua6on •  Advanced Direc6ves, Pallia6ve Care 34 Advanced Heart Failure Management •  Fluid Management –  Decompensated heart failure –  Fluid management strategies •  New Therapies – –  valsartan-­‐sacubitril (LCZ696, Entresto; Novar6s) •  an angiotensin-­‐receptor/neprilysin inhibitor (ARNI), showed as sharp an edge against the ACE-­‐inhibitor comparator for the CV death/heart-­‐failure hospitaliza6on primary end point regardless of baseline LV ejec6on frac6on or whether the target dosage was achieved. –  Corlanor® (ivabradine) •  indicated to reduce the risk of hospitaliza6on for worsening heart failure in pa6ents with stable, symptoma6c chronic heart failure with lev ventricular ejec6on frac6on ≤ 35%, who are in sinus rhythm with res6ng heart rate ≥ 70 beats per minute and either are on maximally tolerated doses of beta-­‐blockers or have a contraindica6on to beta-­‐blocker use. •  Referral for LVAD evalua6on/Cardiac transplant evalua6on Referral for Advanced Heart Failure Care •  LVAD •  Cardiac Transplant 12 10/5/15 Lev Ventricular Assist Device Lev Ventricular Assist Device HeartMate Devices HeartWare Lev Ventricular Assist Device 13 10/5/15 LVAD Shared Care Center The LVAD Shared Care program includes: • Pa6ent management protocols with partnering LVAD implan6ng center • Extensive in-­‐person and online training/cer6fica6on on HeartMate II pa6ent management • Equipment to interrogate the HeartMate II LVAD for local follow-­‐up in coordina6on with LVAD center 40 LVAD Shared Care Center •  Work in collabora6on with implant centers •  Coordinate pa6ent visits for follow-­‐up and device interroga6on with implant centers Heart Failure: Quality of Life 14 10/5/15 When to refer to Pallia6ve Care… •  Discussion of pa6ent wishes should occur early in treatment •  Discussion between pa6ent and primary physicians Heart Failure: Cost of care Heart Failure: Readmissions 15 10/5/15 High-­‐risk for heart failure readmission —  Pa6ents recently hospitalized for heart failure —  High-­‐risk for readmission ◦  Renal insufficiency ◦  Diabetes ◦  COPD —  Chronic NYHA FC III or IV symptoms —  Frequent hospitaliza/ons of any cause —  Elderly pa/ents or other pa6ents with mul/ple comorbidi/es —  History of nonadherence to medical therapy —  Inadequate social support system Why all the focus on heart failure? •  The Pa6ent Protec6on and Affordable Care Act (PPACA) established the Hospital Readmissions and Reduc/on Program. • 
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October 1, 2012: hospitals penal6es in effect Ini6al penal6es for AMI, CHF, and Pneumonia Focus is on all-­‐cause readmissions within 30 days In 2015, at least four more condi6ons will be added (likely COPD, coronary artery bypass grav, percutaneous coronary interven6ons, vascular procedures, and orthopedic procedures.) Timeline for Readmissions Reduc/on Program We are
HERE
FY08
FY09
FY10
FY11
FY12
FY13
Data Available on Hospital Compare
Year 1: 1% Penalty Maximum
Data Available on Hospital Compare
Penalties: AMI, CHF, Pneumonia
Year 2: 2% Penalty Maximum
Data presently being updated on Hospital Compare
Penalties: AMI, CHF, Pneumonia
Year 3: 3% Penalty Maximum
Data available September 2014
FY14
FY15
Penalties: AMI, CHF, Pneumonia, possibly COPD, THA/TKA Year 4: At least 3% Penalty Maximum
Data available September 2015
Penalties: TBD
Year 5: At least 3% Penalty Maximum
Data available September 2016
Penalties: TBD
48 16 10/5/15 Heart Failure Readmissions —  Evidence-­‐based therapies improve pa6ent outcomes —  25% of pa6ents admi_ed for heart failure are readmi_ed within 30 days; 50% of pa6ents are readmi_ed within 6 months —  CMS changes in reimbursement/penal6es for hospitals effec6ve October 1, 2012 —  An es6mated 40% of readmissions are avoidable —  Discharge teaching/pa6ent educa6on has been shown to reduce readmission rates Heart Failure Management: Reducing Readmissions •  Early post-­‐discharge follow-­‐up within 7 days •  Pa6ent and Caregiver Educa6on: –  Disease Process and Progression –  Pharmacologic Management: •  Indica6ons, Dosage, side effects –  Nonpharmacologic management •  Monitor weight daily •  Dietary Sodium Restric6on •  Fluid Restric6on •  Exercise •  Symptom recogni6on 10/5/15 Heart Failure 50 Ques6on 1 Which of the following condi6ons increase risk of readmission for heart failure? 1. recent admission for heart failure 2. history of COPD 3. lives alone/poor social support 4. all of the above 17 10/5/15 Ques6on 2 Which beta blockers have FDA indica6on for heart failure? 1. Carvedilol, Atenolol, Metoprolol tartrate 2. Carvedilol, Metoprolol tartrate, Bisoprolol 3. Carvedilol, Metoprolol tartrate, Metoprolol succinate 4. Carvedilol, Metoprolol succinate, Bisoprolol Ques6ons? 18