Transcript Incorporating Heart Failure Patients into Cardiac

Lynne Hamilton Weir, PT, CYT
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List risk factors/causes of HF and discuss treatment
List key self care skills for the heart failure
patient/family/caregiver to learn for self management of HF
Develop an exercise prescription for the heart failure patient
Identify the CMS HF eligibility criteria necessary for HF
participation and reimbursement
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Heart Failure Facts and Guidelines
CR in HF Disease Management
Staff Training
CMS HF Criteria
Core Components for CR HF ITP
Self Care Behaviors
Exercise Training and Prescription
CR Session Boarding Pass and Red Flags
Heart failure is “a complex clinical syndrome
that can result from any structural or functional
cardiac disorder that impairs the ability of the ventricle
to fill or eject blood.”
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The main manifestations of HF are dyspnea, fatigue,
limited exercise tolerance and fluid retention which may
lead to pulmonary, and/or splanchnic congestion, and/or
peripheral edema.
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HFrEF
HFpEF
Stage
Definition
A
At high risk for later HF but without current structural heart
disease
B
Structural heart disease but without signs or symptoms of
HF
C
Structural heart disease with current or prior symptoms of
HF
D
Refractory HF
HF Stage
Patients with the following:
A
• Risk Factors – smoking, HTN, HLD, DM, obesity,
Metabolic Syndrome, known CAD
• Exposure cardiotoxins – cocaine, some chemotherapies
• Hx of familial cardiomyopathy
B
• Known structural heart changes-MI, valve, CM,
LVH,<EF
• No signs or symptoms of HF
C
• Known structural heart disease – MI, CM, Valve disease
PLUS
• Signs and symptoms of Heart Failure: HFPEF or HFREF
D
• Marked HF signs and symptoms even at rest,
hospitalizations despite GDMT
HF Stage
Treatment
A
Risk factor modification
•
therapeutic lifestyle changes
•
drug therapies as indicated
B
• Drug therapy – ACEI or ARB, BB as indicated
• Revascularization or valve surgery if indicated
C
• Drug therapy - ACEI/ARB plus BB, diuretics
Aldosterone antagonists
Hydralazine/nitrates – African Americans
• ICD, CRT, revascularization, valvular surgery as indicated
D
•
Drug therapy, LVAD, transplant, palliative care, hospice
NYHA Functional Capacity Classification
I
No limitation of physical activity. Ordinary physical
activity does not cause symptoms.
II
Slight limitation of physical activity. Comfortable at
rest. Ordinary physical activity results in symptoms.
III
Marked limitation of physical activity. Comfortable at
rest. Less than ordinary activity causes symptoms.
IV
Inability to carry on any physical activity without
symptoms. Symptoms may be present even at rest.
HF Stage
Cardiac Rehabilitation
A
CR for Primary Prevention for at risk population-self pay
B
CR for MI, angina, PCI, CABG, Valve
C
CR for HF < 35% EF Medicare/Medicaid
CR for all other HF covered by private carriers
D
Cardiac Rehabilitation for LVAD, transplant
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>5.1 Million in US have HF
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Incidence of HF is increasing
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By 2050 - 1 in 5 individuals will have HF
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Primary diagnosis for Medicare hospital admissions
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High rate of hospital all cause 30 day readmissions – average 25%
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Cost of HF care in US >$30 billion/year with>50% due to
hospitalizations
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Individual
treatment
plan
creation
Provider
assessment
What’s missing?
Hospital
•Diet non adherence
•RX non adherence
•Failure to seek care
•Care not readily available
•Socioeconomic factors
•Inappropriate RX
or
ED
Patient
education
on
treatment
plan
Patient
non-adherence
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Every patient with HF should have an evidence based plan of
care that ensures GDMT goals, management of comorbid
conditions, timely FU with health care team, dietary instruction
and physical activities - updated regularly and made available
to each patient’s healthcare team.
Effective systems of care coordination should be deployed for
every patient with chronic HF to achieve GDMT and prevent
hospitalizations.
HF pts. should receive specific education to facilitate self-care
Cardiac Rehabilitation can be useful in clinically stable
patients with HF to improve functional capacity, exercise
duration, HR- QOL and mortality.
Ex. training (or regular physical activity) is recommended as safe
and effective for pts. with HF who are able to participate to
improve functional status.
CR has a unique opportunity to provide
HF disease management significantly
impacting clinical outcomes.
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Facilitate self care skills leading to self
management – Health Care 90% Self Care
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Health coaching and motivational interviewing
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Support families/caregivers
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Identify barriers – comorbidities
(cognition/depression), financial,
transportation, education
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Identify resources
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Medication reconciliation
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Track and communicate clinical variances
with physician
Facilitate obtaining office visits with fast
track intervention
Medication adjustment according to diuretic
protocol if authorized by physician
And importantly….
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Collect data and track outcomes with AACVPR
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Report tracking HF admissions/discharge
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Inpatient visits
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Automatic CR referrals at discharge
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Heart Failure Clinic and Provider Offices
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Transitions/Home Health
HF patients….
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Clinically stable, HFrEF <35%
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On optimal medical therapy for at least 6 wks
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Cannot have had a recent (<6wk) and does
not have a planned major CV hospitalization
or procedure in the next 6 mo.
6 week waiting period is
an opportunity for CR to
impact HF care at their
facility
6 Weeks of ENGAGEMENT
• Enrollment telehealth program
• Follow up patient/family calls
• Self care education/disease management skills –
telephone, internet, 1:1 or classes
• Schedule appointment to begin CR in 6 weeks
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Obtain a reliable scale, record weight daily,
monitor for excessive change in body weight –
+ 3 lb from baseline “dry” weight
Observe changes in signs/symptoms of SOB,
lightheadedness, swelling, fatigue, cough,
nocturia, pillow count
Contact health care provider promptly for
unexpected weight change or increasing
symptoms
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Develop a system for taking mediation as
prescribed-pill organizer, timely refills
Limit dietary sodium intake (<2.0-2.3g/d in
most cases)
Avoid excess fluid intake (<1.5-2 L/d in most
cases)
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Do not use dietary supplements or herbal
medicines unless approved by HCP or
pharmacist
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Avoid all tobacco products/2nd hand smoke
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Restrict alcohol intake <2/d M;<1/d F
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Avoid recreational toxins, especially cocaine
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Seek treatment for depression/anxiety
Discuss sleep disturbances w/HCP such as
heavy snoring
Achieve and maintain physical fitness by
engaging in regular exercise
Visit HCP at regular intervals as advised
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Monitor coexisting conditions, such as HBP,
DM, cholesterol levels, obesity, renal disease
Maintain current immunizations, especially
influenza and pneumococcal pneumonia
Follow prescribed nutrition plan
 Patient Assessment – Hx, Medication, Symptom Management, Physical
 Nutrition Counseling
 Weight Management
 Blood Pressure Management
 Lipid Management
 Diabetes Management
 Tobacco Cessation
 Psychosocial Management
 Physical Activity/Training
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Medical Record – hospital and provider
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Medical History from patient/caregiver
Cardiac –
ischemic or idiopathic, valve related, HTN
Paced, CRT, ICD
Comorbidities and Risk Factors
Complex Patients: pulmonary disease, CKD, anemia,
depression, sleep apnea, DM,
musculoskeletal, neurological,
cognitive
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Medication Reconciliation- dose/frequency
◦ Have patient bring in list/bottles – compare DC instructions and physician
OV list
◦ Any problems accessing medications? – financial, transportation, refills
◦ Medication compliance – taking regularly what % of the time? Morinsky
Survey
◦ Medication schedule
◦ What system do they have for taking – who manages?
Is your patient on optimal GDMT??
HFrEF Stage C
NYHA Class I – IV
Treatment:
Class I, LOE A
ACEI or ARB AND
Beta Blocker
For all volume overload,
NYHA class II-IV patients
For persistently symptomatic
African Americans,
NYHA class III-IV
For NYHA class II-IV patients.
Provided estimated creatinine
>30 mL/min and K+ <5.0 mEq/dL
Add
Add
Add
Class I, LOE C
Loop Diuretics
Class I, LOE A
Hydral-Nitrates
Class I, LOE A
Aldosterone
Antagonist
LCZ696 from Novartis
………may replace ACEI
Current and recent:
◦ Dyspnea
◦ Fatigue
◦ Angina
◦ Lightheadedness
Current and recent:
◦ Edema – LE’s and abdominal
◦ Cough
◦ Orthopnea -how many pillows
◦ Cachexia
◦ Sleep Apnea – Berlin Sleep Apnea Questionnaire
Determine the following:
◦ ACCF/AHA - Heart Failure Stage (C or D)
◦ NYHA Functional Class I-IV
◦ ACCF/AHA Risk Stratification – High based on EF
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Weight and height
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BP - symptomatic hypotension or orthostatic
hypotension
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EKG – HR, BBB, pacing, ectopy, atrial fib
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O2 Sat % - undiagnosed pulmonary component
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Waist circumference - abdominal edema?
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Edema LE 1+ to 4+
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Lung sounds – baseline rales ?
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Gait, strength and balance
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Fall risk, frailty index
Assessments
◦ Dietary habit assessment tool
◦ Daily Caloric Intake- undernourished?
◦ Daily Sodium Intake
Assessments
HR-QOL – Minnesota Living with HF Questionnaire
Kansas City Cardiomyopathy Questionnaire
Depression - Beck Depression Inventory
Patient Health Questionnaire-9
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Assessments
◦ Anxiety, anger/hostility
◦ Social isolation, marital/family distress
◦ Substance abuse
◦ Psychotropic medications and provider
Assessment
◦ Duke Activity Survey
◦ Days per week of exercise, minutes per day
◦ Occupational and recreational needs
◦ Activity of Daily Living needs
◦ Exercise Stress Test or 6 Min Walk Test
◦ MET level of 1st exercise session
Types
◦ Cardiorespiratory Endurance Training
◦ Resistance Training
◦ Flexibility
◦ Balance
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Type - Cardiorespiratory Endurance Training
◦ Frequency 2-3 (CR) progressing to 5+ days/week
◦ Intensity
 ETT (recommended)
 55% progressing to 80% HRR=THR
 Without ETT/Beta Blocker/ Afib
 Initial rest HR + 20/ RPE 10-12 …Progressing to
RPE 13-14 = THR
 Afib – use RPE only
High Intensity Interval Training- selected pts
30 sec-4 min HII followed by LII, 3-5 min
◦ Time/Duration – 16-20 min progressing to
40 min-50 min
 Deconditioned pts. may need rest
periods
◦ Mode – cardio equipment, walking +++
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Type – Resistance Training
◦ Utilize fixed weight machines, hand held weights, body
weight for 4-6 primary muscle groups
◦ Post 2-4 weeks of cardio training
◦ Intensity –
 UE - 40% 1 rep max progressing to 70%
 LE – 50% 1 rep max progressing to 70%
◦ Frequency
 1-2 days/wk,
 1-2 sets/day
Duration 12-20 min total
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Type – Flexibility Training
◦ Stretching exercises for major muscle groups
◦ End of warm up and/or during cool down at least 3 x per
week
◦ Purpose to maintain joint flexibility
Type – Balance Training
◦ Fall risk patients
◦ 1-2 days per week
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Rate SOB – Dyspnea Scale 0-4
More swelling? 0 to 4
Difficulty breathing at night/sleeping? Need
more pillows?
Take all medications? Out of any?
Daily weight – chart, morning, trending
Lightheadedness?
Pain/discomfort? (angina or other) Where and
rating
Lab work? Next physician appt?
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Weight Gain > 2-3 lb in a day or 5 lb within a week
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Worsening dyspnea (on exertion or rest)
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Excessive fatigue, lack of energy
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Increased edema legs, abdomen
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Increased urination at night, nocturia
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Productive cough
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Increased orthopnea or nocturnal dyspnea
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Lightheadedness/dizziness- hypotension
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Shock from ICD
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Disease Management
Review of 2013 ACCF/AHA Heart Failure
Guidelines
Clinical health coaching and motivational
interviewing
LVAD and Transplant Specific Training
Palliative care, hospice and EOL decisions
Heart Failure Facts and Guidelines
CR in HF Disease Management
CMS HF Criteria
Self Care Behaviors
Core Components for CR HF ITP
Exercise Training and Prescription
CR Session Boarding Pass and Red Flags
Staff Training
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Yancy, CW, et al. ACCF/AHA Guideline for the Management of Heart Failure.
JACC, 2013; 62:e147-e239.
American College of Sports Medicine. ACSM’s Guidelines for Exercise
Testing and Prescription, 9th ed. Philadelphia, PA: Lippincott Williams &
Wilkins: 2014.
American College of Sports Medicine. ACSM’s Resource Manual for
Guidelines for Exercise Testing and Prescription, 7th ed. Philadelphia, PA:
Lippincott Williams & Wilkins: 2014.
SJ Keteyian, SJ, et al. Incorporating Patients With Chronic Heart Failure Into
Outpatient Cardiac Rehabilitation. JCRP, 2014:Volume 34, Number4
Lynne Hamilton Weir, PT, CYT
[email protected]