Transcript Post-discharge Heart Failure Management

Post-discharge
Heart Failure Management
Ceyhun Ceyhan MD, FESC
The 80% of hospitalisations for HF
occur in individuals aged more
than 65 years.
Circulation. 2008;117(4):e25-e146
Five-year survival following a first admission
for heart failure
Readmission after hospital discharge
within 6 months
45%
55%
Am Heart J. 2000 Jan;139(1 Pt 1):72-7.
The readmission rates rise with time
J Am Geriatr Soc. 1990;38(12):1290-5
Each hospitalisation effect myocardial
and/or renal damage
Am J Cardiol. 2005;96:86G-89G.
Discharge planning…
General topics
Explanation of HF
Expected symptoms and symptoms of worsening HF
Psychological responses
Dietary recommendations
Activity and exercise
Medications
Discharge planning…
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Should be initiated within 24-48 hours after
hospital admission.
Criteria for clinical stability with
chronic heart failure
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Freedom from evidence of congestion
Angina absent or present in stable exertional pattern
Stable vital signs
No syncope or other recurrent symptomatic arrhythmias
Stability of non-cardiovascular disease
Stable renal functions
Compliance with medical regimen
Social support
Absence of serious depression or dementia
Education
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Education of pts with HF is essential aspect of pts
care that promote clinical stability.
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The education modules should be self-contained and
written in easy to understand language. Each module
should be provided practical information on a
specific topic that is useful to both patients and their
families.
Education
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Physicians, advanced practice nurses, home health
nurses and dietitians all play important roles in this
process.
Education
Approximately 40% of the
patients did not recognize the
importance of weighing
themselves daily.
Although 80% of the patients
knew they should limit the
amount of salt in their diet,
only one-third regularly
avoided salty foods.
Arch Intern Med. 1999;159(14):1613–1619
Self-management
 As up to 50% of hospital admissions may be
preventable with an effective strategy to reduce
admissions is to improve self management.
JAMA 2000; 19:2469–75
Self-management
 Optimal self management of chronic illness involves
the patient engaging in activities that promote their
health, control the impact of their illness on their
daily life, adherence to medication regimens and
medical appointments is closest to optimal.
JAMA 2000; 19:2469–75
The ineffective management programs
were less likely to follow the guidelines.
Eur Heart J. 2006;27(5):596-612
It is common practice to withdraw a β-blocker
when patients are admitted to hospital
because of worsening CHF
B-CONVINCED: Beta-blocker CONtinuation Vs.
INterruption in patients with Congestive heart
failure hospitalizED for a decompensation episode
Keep BB
Stop BB
11.5±8.3
10.4 ± 9.7
1 (HF)
2 (HF)
9
8
40
47
22
32
3
4
During hospitalization
Durations (days)
Deaths (n)
After 3 months
Deaths, %
Re-hospit, (%)
For HF
(%)
For arrhythmia
(%)
Eur Heart J. 2009;30(18):2186-92
The Recommendations of ESC Guideline
Keep BB
When Worsening symptoms/signs occur:
If increasing congestion – increase dose of
diuretic and/or halve dose of beta-blocker
If marked fatigue (and/or bradycardia—see
below) – halve dose of beta-blocker
ESC Heart Failure Guideline 2008
The Recommendations of ESC Guideline
Keep BB
 In severe situations, temporary discontinuation
can be considered. Low-dose therapy should be
re-instituted and up-titrated as soon as the
patient's clinical condition permits, preferably
prior to discharge.
ESC Heart Failure Guideline 2008
The Recommendations of ESC Guideline
Keep BB
 In patients admitted to hospital due to
worsening HF, a reduction in the β-blocker dose
may be necessary.
ESC Heart Failure Guideline 2008
Activity and Exercise
Pts should be
encouraged to
stay as active as
possible, including
sexual activity and
a moderate
exercise (aerobic
training) program.
BMJ 2004;328:189
Medications
The one of the major cause of re-
hospitalisation and heart failure
exacerbation is lack of compliance with
prescribed medications.
Am J Crit Care. 1998;7(3):168-74
Arch Intern Med. 1988;148(9):2013-6
Adherence to guidelines is a predictor of outcome in
chronic heart failure: the MAHLER survey
Eur Heart J 2005;26:1653-1659
The cost of hospital readmissions is lower in the
intervention group by $460 ($153 per pt/month)
Vaccinations
A further case series showed that 12% of hospitalizations
in HF pts were due to pulmonary infection.
Pulmonary
infection
Others
Vaccinations
Patients with chronic
HF should receive
one pneumococcal vaccination
and
an annual influenza vaccination.
Reasons for non-compliance
with therapeutic regimen
 Lack of knowledge
 Poor motivation
 Lower self-efficacy
 Comorbidities
 Forgetfulness
 Decreased support from family or caregivers
J Cardiovasc Nurs. 1997;11(4):75-84
Medications
 Pts should be taught the name of each drug and its
purpose, dosage, frequency and significant side
effects.
 A medication schedule may also minimize to
potential for drug interactions.
 Alternative medications should not be taken
without consulting the healthcare team.
Discharge Education Improves Clinical Outcomes in
Patients With Chronic Heart Failure
P=0.012.
Circulation. 2005;111:179-185
Heart Failure Clinics
Patients who received
regular cardiovascular
follow-up visits with a
physician had fewer
visits to emergency
department, fewer
admitted to hospital and
1-year mortality is
lower.
both specialist and
family physician
family physician only
no physician visits
Written materials and videotapes
are not replacement
for one-to-one education.
Impact of heart failure management unit
on heart failure-related readmission rate
and mortality
Archives of cardiovascular disease, 2010;103(2):90-6
Meta-analysis showed a significant
reduction in all cause admission
(relative risk 0.87, 95% confidence interval (CI)
0.79 to 0.95, p<0.002)
However, significant heterogenity
(p<0.002) was found
J Am Coll Cardiol, 1999; 33:1560-1566
PacifiCare and Alere Medical to Provide
Congestive Heart Failure Patients Innovative
AlereNet CHF Management System.
Patients initiate the monitoring process
each morning by simply standing on the
DayLink(R) monitor, located in their home.
A phone line to the Alere Network
automatically transmits the information to a
central call station monitored by cardiactrained nurses who analyze trends that may
reveal a change in the patient's health
status. If indicated, the patient's doctor is
Daily electronic home
notified, and the need for clinical
monitoring system intervention is assessed before an expensive
hospital admission or emergency room visit
is required.
AlereNet CHF Management System is
representing a 56.2% difference in mortality
The number of
patients needed to
treat in order to
save one life was 9.7
the Weight Monitoring in Heart Failure (WHARF) trial
Am Heart J 2003;146(4):705-12.
The cost per patient for the Home Health Monitor is $408/month
Effect of Home-Based Telemonitoring
Using Mobile Phone Technology on the
Outcome of Heart Failure Patients After
an Episode of Acute Decompensation:
Randomized Controlled Trial
the MOBIle TELemonitoring in
Heart Failure Patients Study
(MOBITEL)
The telemonitoring equipment consisted of three
commercially available components:
(1) a mobile phone (Nokia 3510, Finland),
(2) a weight scale with 0.1 kg accuracy and electronic
display (Soehnle creta, Germany), and
(3) a sphygmomanometer for fully automated
measurement of blood pressure and heart rate
(BosoMedicus, Bosch&Sohn, Germany).
J Med Internet Res 2009;11(3):e34
Tele group patients were asked to measure vital
parameters (blood pressure, heart rate, body weight)
on a daily basis at the same time, preferably in the
morning after emptying the bladder and before
dressing and taking medication.
J Med Internet Res 2009;11(3):e34
Study physicians had access to a secure website
providing both numerical and graphical depiction of
data for each patient.
Whenever necessary, study physicians could contact
patients using the mobile phone
J Med Internet Res 2009;11(3):e34
Trend chart of vital parameters of a typical patient
Providing elderly patients with an adequate user interface for daily data
acquisition remains a challenging component of such a concept.
J Med Internet Res 2009;11(3):e34
Factors predicting
early post-discharge mortality include
Age,
Serum creatinine,
Reactive airway disease,
Liver disease,
Lower systolic blood pressure,
Lower serum sodium,
lower admission weight, and depression
Am Heart J. 2008 Oct;156(4):662-73.
Multidisciplinary interventions
to patients with heart failure
not only reduces hospital admission
but also is an effective method for
reducing mortality.
Intervention costs were higher with more
complex programs ($8383 per patient per year)
versus less complex programs ($1695 per
patient per year).
Journal of Cardiac Failure 2007;13(1):56-62
Hit-P inT
Post-discharge Heart Failure
Monitorization Program in Turkey
The patients are randomized (2:1) blinded to
control and investigation group.
Intensive education about HF
before discharging, by
experienced cardiologist and
nurse
Using a teaching booklet
End-points
Primary end-point:
Cardiovascular death or hospitalisasiton
Secondary end-point;
All cause of hospitalisations
hospitalisation related to worsening HF
Admission to emergency unite
Any cause of death
Thank You
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