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1 - CHF management in LTC 2011-10

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									Heart Failure management
    in long term care
   PMDA 19th Annual Symposium
       October 21, 2011

              Leon S. Kraybill, MD, CMD
   Geriatric Specialists, Lancaster General Hospital

    PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
   Dr. Kraybill has no conflicts of interest or financial
    benefit from this presentation
   Digital copy of powerpoint slides and handouts
    available at: www.pamda.org/2011-handouts/
   Email contact: leonkraybill@gmail.com




            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Who gets heart failure?
     Primarily older people; female > male
     Over age 65 = 10/100
     80% of patients hospitalized for HF are > 65 yo
     Multiple comorbidities (ie diabetes increases the
      risk of HF by 80%)




           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Why discuss heart failure?
     HF is the most common Medicare DRG
      diagnosis, and consumes more Medicare dollars
      than any other diagnosis
     Common cause of death in LTC population
     2005: 37% of all Medicare spending, and ~ 50%
      of inpatient costs.
     2008: Estimated US direct and indirect cost of
      heart failure = $34.8 billion.

           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
So……Heart failure is….
    Common
    Expensive
    Can we alter the course, management, outcome,
     and cost?




          PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
LTC disease management
    Interventions to reduce hospitalizations from
     nursing homes: Interact II, JAGS April 2011
        17-24% reduction in hospital admissions
    Interact II website: a variety of tools and care
     pathways to help reduce acute care transfers;
     including dehydration, fever, mental status
     changes, heart failure, lower respiratory infection,
     and UTI --- http://interact2.net/tools.html
    See attached Early Warning tool, and SBAR
           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Lecture goals
   Efficient, compassionate, and cost effective
    management of heart failure in LTC –
    honoring the wishes of the people who entrust
    their health decisions to us
   …..And not push ourselves over the edge in the process




                PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Heart failure definition (HF)
     A complex clinical syndrome that results from
      any structural or functional disorder that impairs
      the ability of the ventricles to fill with or eject
      blood at a rate commensurate with the body's
      needs
     Congestive heart failure (CHF) = HF + clinical
      signs and symptoms of volume overload



           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
HF etiology
    The simple explanation - a failing heart
    The more complex explanation - a consequence
     of cardiac muscle remodeling, mediated by
     neurohormonal responses (rennin-angiotensin-
     aldosterone system)




          PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
HF is a clinical diagnosis
     A clinical constellation of symptoms and signs
     Labs can only confirm clinical suspicions, or
      demonstrate consequences
     Older patients may not present typically




           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Start and end with treatment goals
     Prolongation of life
     Improvement of quality of life
     Prevention of exacerbations
     Prevention of hospital readmissions (and
      associated cost)
     Timely provision of palliative care




           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Identify
     History of heart failure
         Look at the records! EKG, ECHO, chest x-ray,
          consults.
     Suspect if: hypertension, diabetes, CAD,
      ischemic heart disease, cardiomyopathy, valvular
      heart disease.
     Do not be surprised by a diagnosis that is already
      documented on the record.


            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Symptomatic heart failure: Signs
      Ascites
      Hypoalbuminemia
      Increased jugular venous pressure
      Positive hepatojugular reflux
      Laterally displaced apical impulse
      Peripheral edema not due to venous insufficiency
      Rales on lung exam
      Tachycardia
      Third heart sound (S3)
      Weight gain
         PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Symptomatic heart failure: Symptoms
       Abdominal symptoms (nausea, abdominal pain or distention)
       Acute confusional state, delirium
       Anorexia
       Decline in functional status
       Decreased exercise tolerance
       Decreased food intake
       Dyspnea at rest
       Dyspnea on exertion
       Fatigue
       Orthopnea
       Paroxysmal nocturnal dyspnea
       Unexplained cough, especially at night
       Weakness
           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
What your staff may actually report to you:
     New or increasing lower extremity swelling
     Clothing (shoes, pants) appears tight compared
      previous week
     Resident appears lethargic or mentally inert
     Resident is less active
     Resident has more difficulty breathing with or
      without exertion
     Unexplained cough
     Unexplained weight gain
           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Accurate weights are key!
     Same time of day
     Same state of dress
     Same scale (and staff members that know how to
      use the scale)
     How often?
     What is your facility P&P?




           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Identify and manage risk factors
     Anemia
     Dysrhythmia (atrial fibrillation)
     Hypertension
     Chronic lung disease
     CAD
     Diabetes
     Excessive alcohol
     Noncardiac fluid volume overload
     Sleep disordered breathing
     Thyroid disease
     Valvular heart disease
     Medications – NSAIDs, metformin, glitazones (Actos), calcium channel
      blockers

             PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
New York Heart Association HF classification
Class I (mild)             No limitation of physical activity. Ordinary physical
                           activity does not cause undue fatigue, palpitation, or
                           dyspnea (shortness of breath)
Class II (mild)            Slight limitation of physical activity. Comfortable at rest,
                           but ordinary physical activity results in fatigue,
                           palpitation, or dyspnea
Class III (moderate) Marked limitation of physical activity. Comfortable at
                     rest, but less than ordinary activity causes fatigue,
                     palpitation, or dyspnea
Class IV (severe)          Unable to carry out any physical activity without
                           discomfort. Symptoms of cardiac insufficiency at rest. If
                           any physical activity is undertaken, discomfort is
                           increased
                    PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Differentiating types of HF
     HF with reduced left ventricular ejection fraction (systolic heart failure)
          Reduced myocardial contractility (CAD, cardiomyopathy)
          Generally worse prognosis
          EF cutoff – usually 35-45%
          More dyspnea, cough, wheezing, fatigue, hypotension, confusion, delirium
     HF with preserved left ventricular ejection fraction (diastolic heart failure)
          Decreased left ventricular filling pressures (decreased rate of relaxation, rapid
           heart rate, ventricular stiffness)
          Primary cause = hypertension
          More than 50% of HF patients > 70 yo
     Right-sided heart failure
          Right ventricle changes
          Cause: pulmonary disease, left sided heart failure (most residents with advanced
           HF have both L and R-sided HF
          More leg edema, nausea, vomiting, abd ominal sx, dependent edema

               PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Decide regarding evaluation
     Is there another terminal/end-stage condition?
     Will the evaluation change the management?
      (would the patient decline treatment?)
     Will the burden of evaluation be greater than the
      benefit of treatment?
     Are there likely to be reasonable treatments?
     Document, document, document


           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Evaluation tools
     CXR
     ECHO
     Pulse oximetry
     Labs: CBC, CMP (lytes, calcium, renal, liver),
      magnesium, TSH, ?lipids
     To BNP or not to BNP?
     EKG – angina, dysrhythmia, hx of ischemia


           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Reassess the individual’s goals and realistic options

      What does the resident want? QOL/comfort vs
       prolongation of life?
      Do the resident/family understand the availability
       of palliative care in LTC?




            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Possible reasons for transfer to hospital
     Acutely symptomatic and decompensating
     Unstable cardiac ischemia
     Limited reasonable treatment options in LTC
     Resident wants full and aggressive intervention




           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Dietary restrictions
     Restrictions should be consistent with the resident’s
      prognosis and quality of life
     Salt restriction (< 2 grams/day rarely feasible) - may be
      helpful in moderate to severe heart failure
     Fluid restriction - hyponatremia, unstable fluid balance
      despite diuretics
       Maybe 1.5-2 L daily fluid restriction in advanced
          heart failure (grades III & IV) – evidence grade B1
     Nutritional supplements – generally not indicated
       CoQ10 - not recommended as a therapy for heart
          failure by the ACC/AHA
            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Heart failure medications
   Goal is euvolemia
   Most patients will need diuretics




            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Low EF HF: Diuretics
    Thiazide diuretics usually ineffective once CrCl < 30 (? stop @ 50)
    Loop diuretics improve symptoms and quality of life but do not
     prolong life
        Few meaningful clinical differences between different meds
        Furosemide 20 – 40 mg daily, double until desired diuresis
        Bumetanide and torsemide may be more bioavailable with an
         edematous bowel
    Metolazone 2.5-5 mg prior to furosemide may improve diuresis (but
     cause more ↓K and ↓Mg
    When volume has stabilized, seek lowest possible diuretic dose
    Follow renal function and electrolytes


            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Diuretics: Hypomagnesemia
    Thiazides and loop diuretics increase Mg loss
    ↓Mg is often present with ↓K and ↓Na
    Serum Mg levels are unreliable measures of total
     body Mg
    Magnesium gluconate is more soluble, and causes
     less diarrhea




          PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Low EF HF : Angiotensin-converting enzyme inhibitors (ACEIs)

      Improve quality of life, ↓mortality by 23%, and
       ↓ risk of hospitalization by 35%
      First-line agent in HF with EF < 35%
      Caution: hypotension (?tolerate SBP of 80-90),
       hyperkalemia, worsening renal function
      Accept 20-30% rise in creatinine
      Angiotensin receptor blocker (ARB) if intolerant
       to ACEI

            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Low EF HF: Beta blockers
    Good evidence for ↓symptoms and ↑sense of well-being,
     ↓risk of death (↓30-65%), and ↓hospitalization
    Indicated for all patients with stable HF due to ↓EF, if no
     contraindication
    Should be used in combination with diuretics if fluid
     retention is present
    Proven benefit: carvedilol, metoprolol succinate,
     bisoprolol (metoprolol has less hypotension than
     carvedilol)
    Titrate slowly to target dose (see chart) by doubling dose
     every 2-4 weeks
           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Low EF HF: Beta blockers
                                   Initial Dose                         Target Dose
Bisoprolol                         12.5 mg daily                        10 mg daily
Carvedilol immed release           3.125 mg BID                         25 mg BID
Carvedilol ext. release            10 mg daily                          40-80 mg daily
Metoprolol ext. release            12.5 mg daily                        200 mg daily




                  PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Low EF HF: Digoxin
    Less widely used
    No mortality benefit but some improvement in
     symptoms and hospitalization
    Dosage – rarely > 0.125 mg daily
    Serum levels – usually < 1.0




          PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Low EF HF: Aldosterone antagonists (spironolactone)

      May help to counter adverse effects of
       aldosterone in NYHA Class III & IV
      High risk for ↑K and ↑creatinine (esp if CKD, or
       on ACEI)
      Not good clinical data on age > 75-80 yo




            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Low EF HF: Isosorbide dinitrate + hydralazine

     For African-American residents with HF –
      ↓ mortality, ↓hospitalizations, ↑ QOL
     Adjunctive therapy if symptomatic despite
      standard therapies




           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Low EF HF: Other treatments
    Calcium channel blockers
        Nifedipine, diltiazem, verapamil-- ↑HF and mortality
        Amlodipine & felodipine okay for BP control - no HF benefit
    Implantable cardioverter defibrillators
        Risk of sudden death if EF < 35
        Do not treat symptoms, only prolong life
    Cardiac resynchronization therapy
        Consider if symptomatic HF despite optimal medical
         management, EF< 35, QRS > 120 ms, Class III or IV, AND
         prognosis for good functional status > 1 year



            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Low EF HF treatment summary
    ACEIs - most patients
    Beta blockers – most patients
    Diuretics – most patients
    Aldosterone antagonists – selected patients
    Digoxin – selected patients
    Isosorbide dinitrate/hydralazine - selected
     African-American patients


          PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
HF with preserved EF (diastolic HF)
     Evidence based therapy is less clear
     Goals – decrease fluid overload, and treat elevated filling
      pressures
     Control hypertension – perhaps most important
     Diuretics – if fluid overload
     ACEI/ARB – less clear benefit (unless concomitant
      diabetes) – studies lean towards benefit
     Beta Blockers – sparse data
     Digoxin – if symptomatic despite other meds


            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
HF with preserved EF: Summary
   Control of systolic and diastolic hypertension
   Control of ventricular rate in patients with AF
   Control of pulmonary congestion and
    peripheral edema with diuretics
   If ischemia – consider coronary
    revascularization (if consistent with goals)


           PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Peripheral edema management
    Elevation of extremities
    Support hose
    Elastic tubular bandages




          PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
End of life care in HF
    Sudden death – up to 60% of HF patients, but can’t predict
    Gradual deterioration with increasingly frequent acute episodes
    Explain and offer palliative measures sooner rather than later
    Discuss the goals of care, code status, intubation, hospitalization
    Listen and give opportunity for questions
    Deactivate the defibrillator
    Dyspnea – diuretics, oxygen, thoracentesis, opiods
    Hallucinations, delirium – atypical antipsychotics
    Myoclonus, seizures - lorazepam




              PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
HF monitoring & assessment protocol & tools
     Early Warning Tool (general)
     SBAR – a general preparation tool for the assessing nurse
      to report any clinical change to provider
     “BELLS WARN” – HF screening tool for direct
      caregivers
     Heart failure in long-term care monitoring protocol
     Heart failure graphic flow sheet
     LTC Heart Failure assessment tool

      Digital versions at www.pamda.org/2011-handouts/
            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Developing clinical assessment tools and treatment protocols

      PMDA has interest in developing further
      If interested, contact
          Leon Kraybill – leonkraybill@gmail.com
          Tom Lawrence - tomlawrence@comcast.net




             PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
Heart failure in LTC
     Common
     Expensive in time and money
     Proactive identification and management will help to
      prevent subsequent complications and resident distress
     The resident and the family must be engaged early and
      throughout the process to identify their goals and wishes
     This is a collaborative effort – none can do it alone, all
      must be involved



            PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org
References
   Heart Failure in the Long-Term Care Setting, AMDA Clinical practice guideline, 2010,
    www.amda.com/tools/guidelines.cfm
   Interact2 - from Florida Atlantic University – dedicated to reducing acute care transfers, website contains
    a variety of tools and resources: http://interact2.net/tools.html
          Interventions to reduce hospitalizations from nursing homes: Interact II, JAGS April 2011;
           http://onlinelibrary.wiley.com/doi/10.1111/jgs.2011.59.issue-4/issuetoc
          Care path: symptoms of congestive heart failure: http://interact2.net/tools.html
          SBAR: Situation, Background, Assessment, Request- a conceptual tool for supervising nursing
           staff to assess and report a LTC clinical change: http://interact2.net/tools.html
   Assessing Heart Failure in Long Term Care Facilities; Harrington, C. University of Iowa Gerontological
    Nursing Interventions Research Center, Research Translation and Dissemination Core; 2006 Oct 2006 –
    an EBM practice guideline, 38 page PDF with a variety of tools: http://www.public-
    health.uiowa.edu/icmha/outreach/documents/GerontologicalNursingInterventionsResearchCenter.pdf
   DEFEAT heart failure: assessment and management of heart failure in nursing homes made easy. Ahmed
    A, Jones L, Hays CI, J Am Med Dir Assoc. 2008 Jul;9(6):383-9. Epub 2008 Jun 3,
    http://www.ncbi.nlm.nih.gov/pubmed/18585640
   Clinical manifestations, diagnostic assessment, and etiology of heart failure in older adults, Ahmed A,
    Clin Geriatr Med. 2007 Feb;23(1):11-30, http://www.ncbi.nlm.nih.gov/pubmed/17126753

                     PMDA: Pennsylvania's Association for Long Term Care Medicine   www.pamda.org

								
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