Heart_Failure_Presentation

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					Multi-Disciplinary Heart Failure
         Management

       Connie Keibler, MSN, ARNP
     Western Washington Medical Group,
                Cardiology

                                     1
2
          Heart Failure Outlook
•   5 million Americans have Heart Failure
•   1/2 million new diagnosis of HF annually
•   $27 Billion annual health care burden
•   250,000 deaths from HF annually
•   Leading cause of hospitalization for those
    over 65 years old

                                                 3
   Heart Failure Hospitalization
• $14 Billion spent annually for those
  admitted to the hospital in Acute
  Decompensated Heart Failure
• 3.5 million hospitalizations annually
• 1/3 of those admitted for ADHF are re-
  admitted within 90 days
• A hospital visit for ADHF results in 60 day
  mortality rates between 8 and 20%
• Increased mortality risk persists for 6 mos.   4
Heart Failure Future




                       5
       Heart Failure Mortality
• 250, 000 deaths annually
• 1/2 of those diagnosed with Heart Failure
  die within 5 years




                                              6
7
             Heart Failure Risk
Common Causes                  Less Common Causes
  –   Ischemic heart Disease      –   Familial Hypertrophic CM
  –   Diabetes                    –   Postpartum CM
  –   Hypertension                –   Thyroid Abnormality
  –   Valvular Heart Disease      –   Connective Tissue
  –   ETOH Abuse                      Disorders
  –   Obesity                     –   Toxin Exposure
  –   Cigarette Smoking           –   Myocarditis
  –   Hyperlipidemia              –   Sarcoidosis
  –   Physical Inactivity         –   Hemochromatosis
  –   Sleep Apnea                 –   Medication Exposure

                                                                 8
       Heart Failure-A Syndrome
Heart failure is a constellation of symptoms and
 signs produced by a complex circulatory and
 neuro-hormonal response to cardiac dysfunction

Heart failure is a complex clinical syndrome that
 can results from any structural or functional
 cardiac disorder that impairs the ability of the
 ventricle to fill with or eject blood.
                                                    9
       Clinical Classifications
• Backward
  – Inability of the ventricle to eject its contents,
    resulting in elevated filling pressures
• Forward
  – decreased cardiac output and inadequate tissue
    perfusion



                                                        10
        Clinical Classifications
• Left-Sided
   – Left Ventricle is weakened or overloaded
      • Results in pulmonary congestion
• Right-Sided
   – Right Ventricle is impaired
      • Results in systemic venous overload
      • May occur independently from conditions affecting
        the right ventricle only
• Left-Sided failure usually is the cause of right-
  sided failure                                         11
          Clinical Classifications
• Systolic:
  –   Impaired ability of the heart to contract
  –   Weakened muscle, enlarged heart size
  –   Inability of heart to empty
  –   Left ventricular ejection fraction (LVEF) < 40–45%
• Diastolic:
  –   inability of the heart to relax is impaired
  –   Stiff, thickened myocardial wall but normal size
  –   Inability of heart to fill
  –   LVEF  45%

                                                           12
       Clinical Classifications
• Acute
  – sudden onset with associated signs and
    symptoms
• Chronic
  – secondary to slow structural changes occurring
    in the stressed myocardium
• Acute Decompensated
  – sudden exacerbation or onset of symptoms in
    chronic heart failure
                                                  13
       Clinical Classifications
Heart Failure is a Symptomatic Disorder
  New York Heart Association-Functional
                 Classification
  Class I: No abnormal symptoms with activity
  Class II: Symptoms with normal activity
  Class III: Marked limitation due to symptoms
    with less than ordinary activity
  Class IV: Symptoms at rest and severe limitations
    in functional activity
                                                  14
         Clinical Classifications
Heart Failure is a Progressive Disorder
             ACC/AHA Stages of HF
  Stage A--Presence of risk factors for heart failure
  Stage B--Presence of structural heart disease but no
    Symptoms
  Stage C--Presence of structural heart disease along with
    signs and symptoms
  Stage D--Presence of structural heart diseases and
    advanced signs and symptoms
                                                     15
ACC/AHA 2005 Guidelines




                          16
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          HF Hospitalization
• 1/3 of those admitted for ADHF are re-
  admitted within 90 days
• 1/2 of all HF Hospital Re-Admissions are
  Avoidable

• A hospital visit for ADHF results in 60 day
  mortality rates between 8 and 20%

                                                18
            Clinical Predictors
• A Multivariate Analysis using the
  ADHERE Data Identified the Following
  Most Significant Predictors of Mortality:
  –   Bun
  –   Systolic BP
  –   HR
  –   Age

                                              19
        Seattle Heart Failure Model
Multivariate risk model using the following Predictors of
      Survival at Baseline and after Interventions
•   Age                    •   % Lymphocyte Count
•   Gender                 •   Uric Acid
•   Ischemic Etiology      •   Sodium
•   NYHA                   •   Use of
•   Ejection Fraction           – K-Sparing Diuretic
•   Systolic BP                 – Statin
•   Cholesterol                 – Allupurinol
•   Hemoglobin                  – Diuretic
                                                       20
    Reasons for Re-Admission
• Compliance with Medication
• Compliance with Diet, Specifically Sodium
• Delays in Seeking Medical Attention




                                          21
    JACHO Quality of Care Indicators


•   DC Instructions
•   Assessment of LV Function
•   ACEI or ARB at Discharge
•   Smoking Cessation Advice/Counseling


                                          22
 JACHO Quality of Care Indicators
• Education better absorbed when the patient is
  stable and adapted to living with HF
• OPTIMIZE-HF found that DC Instructions did
  not have an effect on Mortality or Re-
  hospitalization @ 60-90 days.
• Missing continuity of Care in the Community
     • Home Care
     • Heart Failure Clinics
     • Primary Care                        23
    Barrier to HF Management
• Cognitive Impairment       • Multiple Co-Morbidities
• Complex Self Care          • Psychosocial/Financial
  Management                   Concerns
• Lack of Motivation         • Physical Limitations
  – Poor Physical Capacity   • Multiple Heath Care
  – Depression                 Providers and Lack of
  – Anxiety                    Shared Communication


                                                   24
25
    Heart Failure Management
                Goals
• Improve Access to Appropriate Cost-
  Effective Health Care
• Prevent Hospitalization
• Improve QOL
• Improved Survival
• Control Health Care Costs
                                        26
 Multi-Disciplinary HF MGMT
               Characteristics
              • Fluid Management
                  • Education
               • Intensity of Care
                    • Access
Strategy must outline and follow clinical rationale
based on practice guidelines that define target care
patterns for patients.
                                                       27
                  Systematic Review
• Literature Review
• 74 Trials and 30 Meta-
  Analysis
• Shared Key Elements
   – One to One Patient
     Education
   – Symptom Monitoring
     and Strategies for Self-
     Management

                                      28
       Self-Management of HF
•   Compliance with evidence based medications
•   Adopt a low-sodium diet
•   Reduce fat and cholesterol in diet
•   Restrict fluid intake if indicated
•   Stop smoking
•   Eliminate alcohol consumption
•   Increase activity/exercise
•   Monitor daily weight

                                                 29
          Self-Management of HF
AND Notify health care provider of signs and
 symptoms of worsening heart failure
   –   pain in jaw, neck, or chest
   –   increased SOB
   –   increased fatigue
   –   dizziness of syncope
   –   swelling in feet, ankles, legs, or abdomen
   –   palpitations
   –   tachycardia
   –   weight gain
   –   decreased exercise capacity                  30
      Deventer-Alkmaar HF Study
• Physician and Nurse Directed HF Clinic vs. Usual Care
   – 1 year intervention
   – 9 scheduled visits
      • 3 telephone
      • 6 office
      • 1 week after discharge
      • Verbal and written education
      • Optimized Rx
      • Easy Access
      • Advice for self-care
                                                   31
   Deventer-Alkmaar HF Study
• 51% risk reduction in Primary End-Point
   – Hospitalization for worsened HF and/or
     All Cause Mortality
   – NNT - 5
• Improved EF at 1 Year
• Improved NYHA Class
• Significant Improvement in QOL Scores
                                              32
    Multi-Disciplinary Management
       Comprehensive inpatient education, discharge planning,
              and outpatient support vs. usual care*

                               •Multi-Disciplinary Team
                                  Physician Champion
• Quick and sustained             Advanced Practice Nurse or PA
  improvements                    Nurse Educator
• 6 wk intervention               Home Health Nurse
                                  Dietician
• Cost savings of $67,804
                                  Physical Therapy
                                  Social Services
                                  Pharmacist

                                                            33
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                            Nursing
Nursing is a profession focused on assisting individuals, families,
and communities in attaining, maintaining, and recovering
optimal health and functioning. Modern definitions of nursing
define it as a science and an art that focuses on promoting quality
of life as defined by persons and families, throughout their life
experiences from birth to care at the end of life.




                                                                    35
             Collaborative Practice
   Shared responsibility and outcomes
Collaborative practice is intended to combine the knowledge and skills
of several health professionals to maximize the efficiency of both the clinicians
and the health care system.


Collaborative practice brings together health care professionals with different
and complimentary knowledge and skills to increase the scope of and
access to patient services.



                                                                                    36
        Collaborative Practice
          Expected Outcomes
• Correct and accurate transfer of vital patient
  information
• Effective team collaboration that produces
  positive patient care outcomes
• Behaviors that aid and encourage respect, trust and
  credibility among team members


                                                   37
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                                     Just One Day
EL                                         DS
89 y/o female
                                           76 y/o Male
CAD, S/P MI
                                           CAD w/ recent MI/Stent
Ischemic CM/EF 20/NYHA Class III
DM Type II                                 Ischemic CM/EF 45/NYHA Class II

Chronic Renal Insufficiency/GFR 38         Diabetes/Poorly controlled/HgA1C 10
Parox Afib on Amiodarone
                                           HTN
Dyslipidemia
                                           Dyslipidemia
ICD/DDD
                                           Chronic renal insufficiency

SB
                                           LO
70 y/o Male
                                           87 y/o Male
SSS                                        CM/EF 24/NYHA Class III
Chronic Afib                               HTN

Idiopathic CM/EF 30/NYHA Class I           Dyslipidemia
                                           Chronic Alcoholism
HTN
                                           Chronic Afib
                                                                                 39
                                           Chronic renal insufficiency/GFR 37
                   Just One Day
MG                       RK
59 y/o Male              59 y/o Male
CAD                      CAD
Ischemic CMEF 36         Ischemic CM/EF 15/NYHA Class III
CAD                      COPD
Ischemic CMEF 36         On-going smoking
PVD/BKA                  HTN
Anemia                   Dyslipidemia
Legally Blind            ICD/BIV Pacing
Hypothyroidism           Hypothyroidism
HTN                      Hx ETOH abuse/Depression
ICD




                                                            40
Cardiac Rhythm Management


           •Small improvements in
           hemodynamics =significant
           improvements in HF symptoms
           symptoms.
           •Optimizing hemodynamics has
           long been a target of
           therapy in HF.




                                    41
   Cardiac Rhythm Management

•Risk Reduction
•CRT
•Diagnostics
  •HR Trends
  •HR Variability
  •Patient Activity
  •Intrathoracic Impedance
•Arrhythmias
•Remote Monitoring             42
       Cardiac Rhythm Management
    Goals for Heart Failure Management
• Identify and recognize cardiac device patients who
  are eligible for monitoring
• Download device data
• Analyze/interpret the data
• Use the data to guide therapy
• Establish a collaborative model and cooperative
  environment between the EP team and HF
                                                   43
      Quality of Life Issues


And

       End of Life Issues

                               44
Challenges are what make life interesting;
overcoming them is what makes life meaningful.
-Joshua J. Marine
             I am only one,
             But still I am one.
             I cannot do everything,
             But still I can do something;
             And because I cannot do everything
             I will not refuse to do the something that I can do.
             - Edward Everett Hale                             45
References




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References




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References




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posted:11/29/2011
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