Transcript SPH CHF Quality Initiative 2008 Update

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
Systolic blood
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