lICENSE To Treat Failure: An updated approach
description
Transcript of lICENSE To Treat Failure: An updated approach
LICENSE TO TREAT FAILURE: AN UPDATED APPROACH
CDR Timothy MurrayCHF Clinic Manager
Internal Medicine TeamInpatient Pharmacy Clinical Coordinator
Claremore Indian HospitalClinical Assistant Professor
University of Oklahoma
Primary Care Cardiology UpdateApril 9, 2011
Case #1 PT is a 37 yo white male whom is being consulted to the Internal
Medicine service today secondary to an CHF exacerbation. JS presented to the ER with a 5 day history of increased shortness of breath and 10 lb weight increase.
Symptoms started after a recent trip where a “poor” diet was consumed.
Family Hx: DM, CAD Social Hx: negative PMH: HTN, CAD Medication prior to admission:
Atenolol 25mg BID, aspirin 81mg daily, fish oil 1000mg daily, tamsulosin 0.4mg daily, KCL 8meq daily, furosemide 20mg daily
Case #1
Vitals: BP- 152/77, HR-101, WT- 177lbs
Case #1 Physical Exam: CHEST/LUNGS: Chest: Nontender Lungs: RALES Bilateral mostly at right base, no wheezing
CARDOVASCULAR: Cardiac: regular rate, regular rhythm, No murmur Pulses: Equal, DIMINISHED Very diminished at feet. Carotid: No bruit JVD: + distended Abd aorta: No Bruit
Lower ext: BILATERAL Edema of both legs mostly right side 3/4 and 2/4 at left.
Case #1 PT is treated in the hospital for 3 days. Weight has decreased 15
lbs and he feels much better. PT is to be seen in the CHF clinic in 2weeks for medication adjustment, dietary education, and monitoring. Completed echocardiogram reveals an ejection fraction of 25%
PT returns to CHF clinic in 2wks with the following labs:
PNBP: 3200
Case #1 Based upon the above case what type of interventions would you
have expected to have been performed? (during admission or in clinic)
A. Continue all medications prior to admissionB. Increase Atenolol, start an ace-inhibitor, & start an aldosterone
antagonistC. DC atenolol, start metoprolol succinate, & start an ace-inhibitorD. DC atenolol, start carvedilol, & start an ace-inhibitorE. Just give up and discharge patient from clinic!!!
Heart Failure Background
Heart failure (HF) is a major public health problem resulting in substantial morbidity and mortality
Major cost-driver of HF is high incidence of hospitalizations1,2
JCAHO has initiated HF quality care indicators for hospitalized HF patients
1American Heart Association. 2003 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2002.
Population Group
Prevalence
Incidence
Mortality
Hospital Discharge
s CostTotal population 4,900,000 550,000 51,546 999,000 $24.3
billion
1
Estimated Direct and Indirect Costs of Heart Failure in US
8%8% 10%
7%
14%
53%
Hospitalization$13.6
Lost Productivity/Mortality*
$2.1Home Healthcare
$2.1
Drugs/Other Medical Durables
$2.7
Physicians/Other Professionals
$1.8
Nursing Home$3.5
*Lost future earnings of persons who will die in 2004, discounted by 3%AHA. Heart Disease and Stroke Statistics—2004 Update
Total Cost$25.8 billion
Causes of Hospital Readmission for Congestive Heart Failure
17%Other
19%Failure to Seek
Care
16%Inappropriate Rx
Rx Noncompliance 24%
Diet Noncompliance24%
Annals of Internal Medicine 122:415-21, 1995
Over 2/3 of HF Hospitalizations Preventable
Why a Hospital-based System for HF Management?
Patients Patient capture point Have patient’s/family’s attention:
“teachable moment” Predictor of care in community
Hospital structure Standardized processes / protocols / teams Accrediting bodies for standards of care Centers for Medicare and Medicaid
Services—peer review organization
• Improved use of evidence- based therapy
• Improved symptom status and functional capacity
• Improved QOL• Reduction in
hospitalization• Decrease in total
medical costs
Benefits & Drawbacks of HF Disease Management Programs
Benefits Drawbacks
96%
4%
Usual Care
HF Disease Management
Program
Moser DK, Mann DL. Circulation. 2002;105:2810–2812.
How did we get into this CHF mess??
Where did our process break down and why no reduction in hospitalizations or re-hospitalizations? Sub-optimal utilization of guidelines No standardization of care (standing orders) No team approach to treating CHF No increase in intensity of HF care after hospital
discharge
How to get out of this CHF mess?? National registry Develop a treatment plan (protocol) Utilize a team approach to treating CHF Provide a comprehensive service to monitor & make
clinical alterations with patient’s treatment plan Provide patient education & training to involve patients
in their treatment plan Follow-up on patients discharged after a CHF
admission to avoid re-admission: CHF Clinic!!!!!! Implement & utilize national standards of care for CHF GET UP TO DATE WITH THE CHF GUIDELINES! Document – Document - Document!
CMS Center of Medicaid & Medicare Services
Compliance rates for discharging CHF pts
Joint Commission/ACC/AHA CHF Performance Measures
CMS CHF Core Measures
1. Documentation of discharge instructions
2. Left ventricular function assessment
3. Use of ACE-I or ARB in pts with left ventricular systolic failure
4. Documentation of smoking cessation
CMS Hospitals should strongly consider
implementing a process of care to ensure these measures are obtained and proper documentation occurs.
The principal outcome measure of the ADHERE Registry was to assess overall hospital adherence to each of these measures for participating hospitals.
CMS CMS 2009 Documentation privileges for
pharmacists!
Electronic Health Record advantages
GIPRA Measures/Performance Improvements
2010 CMS 30 day readmission policy changes
Beta Blockers?
Medications Ace-Inhibitors Beta-Blockers Aldosterone Antagonists ARBs ISDN/Hydralazine Diuretics Digitalis Antiplatelets Statins Fish Oils Calcium Channel Blockers
Guidelines Never Die CHF care driven by two sets of national
guidelines
American College of Cardiology/American Heart Association
Heart Failure Society of America
Guidelines Never Die Both organizations provide a set of detailed
treatment guidelines for practitioners in an effort to optimize the management of chronic CHF.
Treatment guidelines provide an approach to
practice evidence based medicine.
CHF National Guidelines Heart Failure Society of America
www.hfsa.org Last update: June 2010
American College of Cardiology/American Heart Association http://circ.ahajournals.org Last update: April 2009
Guidelines 2009 ACC/AHA recommendation for: “implementation of practice based guidelines utilizing multidisciplinary disease-management programs in efforts to assist in the treatment of patients with CHF”.
Guidelines 2010 HFSA recommendation for:“patients recently hospitalized for HF & other patients at high risk for HF decompensation should be considered for comprehensive HF disease management.”
HFSA 2010 Practice Guideline (3.2)
HF Risk Factor Treatment GoalsRisk Factor GoalHypertension Generally < 130/80Diabetes See ADA guidelines1
Hyperlipidemia See NCEP guidelines2
Inactivity 20-30 min. aerobic 3-5 x wk.Obesity Weight reduction < 30 BMIAlcohol Men ≤ 2 drinks/day, women ≤ 1Smoking CessationDietary Sodium Maximum 2-3 g/day
Journal of Cardiac Failure Vol. 16 No. 6 2010
HFSA 2010 Practice Guideline (3.3-3.4)Prevention—ACEI and Beta Blockers
ACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with: Coronary artery disease Peripheral vascular disease Stroke Diabetes and another major risk factor
Strength of
Evidence = A
ACE inhibitors and beta blockers are recommended for all patients with prior MI.
Strength of Evidence = A
Journal of Cardiac Failure Vol. 16 No. 6 2010
Management of Patients with Known Atherosclerotic Disease But No HF
Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest.
NEJM 2000;342:145-53 (HOPE)Lancet 2003;362:782-8 (EUROPA)
0
5
10
15
20
0 1 2 3 4
Years
% MI,Stroke,
CV Death
0
3
6
9
12
15
0 1 2 3 4 5
Years
% MI, CV Death,
Cardiac Arrest
Placebo
Ramipril
Placebo
Perindopril
20% rel. risk red. p = .0003
22% rel. risk red. p < .001
HOPE
EUROPA
Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF ≤ 40%)
SAVE Study
All-cause mortality ↓19%
CV mortality ↓21% HF development ↓37% Recurrent MI ↓25%
0
0.1
0.2
0.3
0 0.5 1 1.5 2 2.5 3 3.5 4
Placebo
Captopril
Years
MortalityRate
19% rel. risk reduction p = 0.019
Pfeffer et al. NEJM 1992;327:669-77
HFSA 2010 Practice Guideline (7.1, 7.7)Pharmacologic Therapy: ACE Inhibitors
ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%.
Strength of Evidence = A
ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C
ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%. Post MI Strength of Evidence = B Non Post-MI Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HF
SOLVD Prevention (Asymptomatic LVD) 20% death or HF hosp. 29% death or new HF
CONSENSUS (Severe Heart Failure) 40% mortality at 6
mos. 31% mortality at 1 year 27% mortality at end of
study
SOLVD Investigators. N Engl J Med 1992;327:685-91SOLVD Investigators. N Engl J Med 1991;325:293-302CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35
(Chronic Heart Failure)SOLVD Treatment
16% mortality
ACE Inhibitors Used in Clinical Trials
Generic Name Trade Name Initial Daily Dose
Target Dose Mean Dose in Clinical Trials
Captopril Capoten 6.25 mg tid 50 mg tid 122.7 mg/day
Enalapril Vasotec 2.5 mg bid 10 mg bid 16.6 mg/day
Fosinopril Monopril 5-10 mg qd 80 mg qd N/A
Lisinopril Zestril, Prinivil
2.5-5 mg qd 20 mg qd 4.5 mg/day, 33.2 mg/day*
Quinapril Accupril 5 mg bid 80 mg qd N/A
Ramipril Altace 1.25-2.5 mg qd 10 mg qd N/A
Trandolapril Mavik 1 mg qd 4 mg qd N/A
*No mortality difference between high and low dose groups, but 12% lower risk of death or hospitalization in high dose group vs. low dose group.
HFSA 2010 Practice Guideline (7.2)Pharmacologic Therapy: Substitutes for ACEI
It is recommended that other therapy be substituted for ACE inhibitors in the following circumstances: In patients who cannot tolerate ACE inhibitors due to cough,
ARBs are recommended. Strength of Evidence = A
The combination of hydralazine and an oral nitrate may be considered in such patients not tolerating ARBs. Strength of Evidence = C
Patients intolerant to ACE inhibitors from hyperkalemia or renal insufficiency are likely to experience the same side effects with ARBs. In these cases, the combination of hydralazine and an oral nitrate should be considered.
Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
HFSA 2010 Practice Guideline (7.6, 7.7)Pharmacologic Therapy: Beta Blockers
Beta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%.
Strength of Evidence = A
Beta blockers are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%. Post MI Strength of Evidence = B Non Post-MI Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD
Study Drug
HF Severity
Target Dose (mg)
Outcome
US Carvedilol1 carvedilol mild/ moderate
6.25- 25 BID
↓48% disease progression (p= .007)
CIBIS-II2 bisoprolol moderate/ severe
10 QD ↓34% mortality (p <.0001)
MERIT-HF3 metoprolol succinate
mild/ moderate
200 QD ↓34% mortality (p = .0062)
COPERNICUS4 carvedilol severe 25 BID ↓35% mortality (p = .0014)
CAPRICORN5 carvedilol post-MI LVD
25 BID ↓23% mortality (p =.031)
1Colucci WS et al. Circulation 1196;94:2800-6. 2CIBIS II Investigators. Lancet 1999;353:9-13.3MERIT-HF Study Group. Lancet 1999;353:2001-7. 4Packer M et al. N Engl J Med 2001;3441651-8. 5The CAPRICORN Investigators. Lancet 2001;357:1385-90.
HFSA 2010 Practice Guideline (7.8) Pharmacologic Therapy: Beta Blockers
Beta blocker therapy is recommended for patients with a recent decompensation of HF after optimization of volume status and successful discontinuation of IV diuretics and vasoactive agents.
Whenever possible, beta blocker therapy
should be initiated in the hospital at a low dose prior to discharge of stable patients.
Strength of Evidence = B
Journal of Cardiac Failure Vol. 16 No. 6 2010
HFSA 2010 Practice Guideline (7.11)
Pharmacologic Therapy: Beta Blockers
Continuation of beta blocker therapy is recommended in most patients experiencing a symptomatic exacerbation of HF during chronic maintenance treatment, unless they develop cardiogenic shock, refractory volume overload, or symptomatic bradycardia. Strength of Evidence = C
Temporary dose reduction may be considered Avoid abrupt discontinuation Reinstate or gradually increase prior to discharge Titrate dose to previously tolerated dose as soon as
possible
Journal of Cardiac Failure Vol. 16 No. 6 2010
IMPACT-HF Primary End Point:Patients Receiving Beta Blocker at 60 Days
91%
73%
0%
25%
50%
75%
100%
Patie
nts
P <.0001
CarvedilolPredischarge Initiation
(n=185)
Physician DiscretionPostdischarge
Initiation*(n=178)
18%Improvement
Gattis WA et al. JACC 2004;43:1534-41
HFSA 2010 Practice Guideline (7.9)
Pharmacologic Therapy: Beta Blockers
CONCOMITANT DISEASE
Beta blocker therapy is recommended in the great majority of patients with HF and reduced LVEF—even if there is concomitant diabetes, chronic obstructive lung disease or peripheral vascular disease. Use with caution in patients with:
Diabetes with recurrent hypoglycemia Asthma or resting limb ischemia.
Use with considerable caution in patients with marked bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).
Not recommended in patients with asthma with active bronchospasm. Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
Diabetes and the Use of Beta Blockers for HF: Relative Risk for Mortality and Hospitalization for Heart Failure
0 0.5 1.0 1.5 2.0
COPERNICUS (carvedilol)1
With diabetes Without diabetesMERIT-HF (ER metoprolol succinate)2
With diabetes Without diabetes
Mohacsi. Circulation. 2001;104(17):abstr 3551.Hjalmarson. JAMA. 2000;283(10):1295.
HFSA 2010 Practice Guideline (11.8, 15.2)
Pharmacologic Therapy: Beta BlockersPRESERVED LVEF Beta blocker treatment is recommended in patients with HF and
preserved LVEF who have: Prior MI Strength of Evidence = A Hypertension Strength of Evidence = B Atrial fib. requiring control of ventricular rate
Strength of Evidence = B
THE ELDERLY Beta-blocker and ACE inhibitor therapy is recommended as
standard therapy in all elderly patients with HF due to LV systolic dysfunction. Strength of Evidence = B
In the absence of contraindications, these therapies are also recommended in the very elderly (age > 80 years).
Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
HFSA 2010 Practice Guideline
Pharmacologic Therapy: Beta Blocker Overview*
General considerations
Initiate at low doses
Up-titrate gradually, generally no sooner than at 2 week intervals
Use target doses shown to be effective in clinical trials
Aim to achieve target dose in 8-12 weeks
Maintain at maximum tolerated doseIf symptoms worsen or other side effects appear
Adjust dose of diuretic or concomitant vasoactive med.
Continue titration to target after symptoms return to baseline
If up-titration continues to be difficult
Prolong titration interval
Reduce target dose
Consider referral to a HF specialist
Journal of Cardiac Failure Vol. 16 No. 6 2010
Beta Blockers Used in Clinical Trials
Generic Name Trade Name Initial Daily Dose
Target Dose Mean Dose in Clinical Trials
Bisoprolol Zebeta 1.25 mg qd 10 mg qd 8.6 mg/day
Carvedilol Coreg 3.125 mg bid 25 mg bid 37 mg/day
Carvedilol Coreg CR 10 mg qd 80 mg qd
Metoprolol succinate CR/XL
Toprol XL 12.5-25 mg qd 200 mg qd 159 mg/day
HFSA 2010 Practice Guideline (7.3)
Pharmacologic Therapy: Angiotensin Receptor Blockers
ARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF ≤ 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency.
Strength of Evidence = A
Journal of Cardiac Failure Vol. 16 No. 6 2010
ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative
50
60
70
80
90
100
0 3 6 9 12 15 18 21 24 270
10
20
30
40
50
0 9 18 27 36
Val-HeFT
Valsartan
Placebo
p = 0.017
Months
Surv
ival
%
CV D
eath
or
HF
Hos
p %
Placebo
Candesartan
CHARM-Alternative
HR 0.77, p = 0.0004
Months
Maggioni AP et al. JACC 2002;40:1422-4Granger CB et al. Lancet 2003;362:772-6
Angiotensin Receptor Blockers Used in Clinical Trials
Generic Name Trade Name Initial Daily Dose
Target Dose Mean Dose in Clinical Trials
Candesartan Atacand 4-8 mg qd 32 mg qd 24 mg/day
Losartan Cozaar 12.5-25 mg qd 150 mg qd 129 mg/day
Valsartan Diovan 40 mg bid 160 mg bid 254 mg/day
HFSA 2010 Practice Guideline (7.14-7.15) Pharmacologic Therapy: Aldosterone Antagonists
An aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have:
NYHA class IV HF (or class III, previously class IV) HF from reduced LVEF (≤ 35%)
One should be considered in patients post-MI with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor (or ARB) and a beta blocker.
Strength of Evidence = A
Journal of Cardiac Failure Vol. 16 No. 6 2010
Aldosterone Antagonists in HF
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 3 6 9 12 15 18 21 24 27 30 33 360.40
0.50
0.60
0.70
0.80
0.90
1.00
0 3 6 9 12 15 18 21 24 27 30 33 36
RALES (Advanced HF) EPHESUS (Post-MI)
Spironolactone
Placebo
Months
RR = 0.70P < 0.001
Eplerenone
Placebo
RR = 0.85P < 0.008
Pitt B. N Engl J Med 1999;341:709-17Pitt B. N Engl J Med 2003;348:1309-21
Prob
abili
ty o
f Sur
viva
l
HFSA 2010 Practice Guideline (7.16-7.18) Aldosterone Antagonists and Renal Function
Aldosterone antagonists are not recommended when: Creatinine > 2.5mg/dL (or clearance < 30 mL/min) Serum potassium> 5.0 mmol/L Therapy includes other potassium-sparing diuretics
Strength of Evidence = A It is recommended that potassium be measured at
baseline, then 1 week, 1 month, and every 3 months Strength of Evidence = A
Supplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength of Evidence = A
Journal of Cardiac Failure Vol. 16 No. 6 2010
EMPHASIS-HF Trial of 2737 patients with NYHA class 2 heart failure and an
ejection fraction of no more than 35%.
Patients were randomized to eplerenone (up to 50mg daily) or placebo in addition to recommended therapy.
Measured outcomes included: cardiovascular death/heart-failure hospitalization, cardiovascular death, heart-failure hospitalization, and hospitalization for hyperkalemia.
Trial was stopped early at 21months.
EMPHASIS-HF EMPHASIS-HF Major results
Results in a 37% reduction in the primary end point of the composite of death from cardiovascular causes or hospitalization for heart failure!!
Hyperkalemia occurring in 11.8% of eplerenone patients vs 7.2% of those in placebo group!!!
Outcome Eplerenone (%)
Placebo (%) Adjusted hazard ratio
(95% CI)
P
Cardiovascular death/heart-failure hospitalization
18.3 25.9 0.63 (0.54-0.74)
< 0.001
Cardiovascular death
10.8 13.5 0.76 (0.61-0.94)
0.01
Heart-failure hospitalization
12.0 18.4 0.58 (0.47-0.70)
< 0.001
Hospitalization for hyperkalemia
0.3 0.2 1.15 (0.25-5.31)
0.85
HFSA 2010 Practice Guideline (7.19)
Pharmacologic Therapy:Hydralazine and Oral Nitrates
A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with HF and reduced LVEF: NYHA III or IV HF Strength of Evidence = A NYHA II HF Strength of Evidence = B
Journal of Cardiac Failure Vol. 16 No. 6 2010
A-HeFT Outcomes
End point
ISDN-HDZN (n=518)
Placebo (n=532)
p
Primary end point composite score
-0.1 -0.5 0.01
All-cause mortality (%) 6.2 10.2 0.02
1st HF hospitalization (%) 16.4 24.4 0.001
Change in quality-of-life score at 6 months**
-5.5 -2.7 0.02
Taylor AL et al. N Engl J Med 2004; 351;2049-57
A-HeFT All-Cause Mortality
85
90
95
100
0 100 200 300 400 500 600
Survival %
Days Since Baseline Visit
43% Decrease in Mortality
Fixed Dose ISDN/HDZN
Placebo
P = 0.01
Taylor AL et al. N Engl J Med 2004;351:2049-57
HFSA 2010 Practice Guideline (7.23)
Pharmacologic Therapy: Diuretics
Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by: Congestive symptoms Signs of elevated filling pressures
Strength of Evidence = A
Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF.
Strength of Evidence = B
Journal of Cardiac Failure Vol. 16 No. 6 2010
HFSA 2010 Practice Guideline (7.24) Pharmacologic Therapy: Diuretics
Restoration of normal volume status may require multiple adjustments.
Once a diuretic effect is achieved with short-acting loop diuretics, increase frequency to 2-3 times a day if necessary, rather than increasing a single dose.
Strength of Evidence = B Oral torsemide may be considered in patients exhibiting
poor absorption of oral medication or erratic diuretic effect. Strength of Evidence = C
IV administration of diuretics may be necessary. Strength of Evidence = A
Diuretic refractoriness may represent patient nonadherence, a direct effect of diuretic use on the kidney, or progression of underlying dysfunction.
Journal of Cardiac Failure Vol. 16 No. 6 2010
HFSA 2010 Practice Guideline (9.1, 9.4)
Device Therapy:Prophylactic ICD Placement
Prophylactic ICD placement should be considered in patients with an LVEF ≤35% and mild to moderate HF symptoms:
Ischemic etiology Strength of Evidence = A Non-ischemic etiology Strength of Evidence = B
In patients who are undergoing implantation of a biventricular pacing device, use of a device that provides defibrillation should be considered.
Strength of Evidence = B
Decisions should be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions, ideally after 3-6 mos. of optimal medical therapy. Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
HFSA 2010 Practice Guideline (12.5-12.20) Overview of Treatment Options for Patients with Acute
Decompensated HF
Fluid and sodium restriction Diuretics, especially loop diuretics Ultrafiltration/renal replacement therapy
(in selected patients only) Parenteral vasodilators *
(nitroglycerin, nitroprusside, nesiritide) Inotropes * (milrinone or dobutamine)
Journal of Cardiac Failure Vol. 16 No. 6 2010
HFSA 2010 Practice Guideline (12.25, Table 12.7)Discharge Criteria for Hospitalized ADHF Patients
Recommended prior to discharge for all patients with HF: Exacerbating factors addressed Near optimum fluid status and pharmacologic therapy achieved Transition from IV to oral diuretic completed Patient education completed with clear discharge instructions Follow-up clinic visit scheduled, usually 7-10 days
Should be considered prior to discharge for patients with advanced HF or a history of recurrent admissions: Oral regimen stable for 24 hours No IV inotrope or vasodilator for 24 hours Ambulation before discharge to assess functional capacity Plans for post-discharge management Referral for disease management, if available
Strength of Evidence =C
Journal of Cardiac Failure Vol. 16 No. 6 2010
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 > 43 mg/dLSystolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dL
Fonarow GC et al. JAMA 2005;293:572-80
HFSA 2010 Practice Guideline (8.1)Heart Failure Patient Education
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.
Teaching should include skill building and target behaviors.
Strength of Evidence = B
Journal of Cardiac Failure Vol. 16 No. 6 2010
Evidence-Based Treatment Across the Continuum of Systolic LVD and HF
Control Volume Improve Clinical Outcomes
DiureticsRenal ReplacementTherapy*
Digoxin
-BlockerACEIor ARB
AldosteroneAntagonist
or ARB
Treat Residual Symptoms
CRT an ICD*
HDZN/ISDN**In selected patients
Antiplatelets For years the discussion has been which
antiplatelet regimen is ideal for CHF pts? ASA Warfarin Plavix
WASH Trial WATCH Trial
Risk Stratification
CHADS2
Congestive Heart Failure
Hypertension
Age > 75
Diabetes
Stroke or TIA (2 points)
Risk Stratification CHA2DS2-VAS ScoreCongestive heart failure/LV 1 dysfunctionHypertension1Age > 75 years 2Diabetes mellitus 1Stroke/TIA 2Vascular disease (prior MI, peripheral 1 vascular disease)Age 65-75 years 1Female sex 1
Selecting an Antiplatelet “Gadget”
Patient Factors
ASA Plavix Warfarin
Myocardial Infarction <12months ago
X X
Stent <12months ago
X X
Atrial Fibrillation (CHADS2 score 0-1)
X
Atrial Fibrillation (CHADS2 score >2)
X or Dabigatran
Diabetes XBYPASS Hx X
Selecting an Antiplatelet “Gadget”
Patient Factors
ASA Plavix Warfarin
EF% < 30% X Systolic Failure w/ EF% >30%
X
Diastolic Failure XSevere CAD (no surgery option)
X X
LVAD X X X
HFSA 2010 Practice Guidelines New RecommendationVTE prophylaxsis with low dose unfractionated heparin, LMWH, or fondaparinux to prevent proximal deep venous thrombosis and pulmonary embolism is recommended for patients who are admitted to the hospital with ADHF and who are not already anticoagulated & have no contraindication.
(Strength of Evidence=B)
A View To A Trial IMPROVE-HF
Yancy CW, Fonarow GC, Albert NM, et al. Influence of patient age and sex on delivery of guideline-recommended heart failure care in the outpatient cardiology practice setting: Findings from IMPROVE HF. American Heart Journal. 2009;157:754-762.
Omega-3 (PUFAs) Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of n-3 polyunsaturated fatty acids in patients with
chronic heart failure (the GISSI-HF trial): a randomized, double-blind, placebo-controlled trial. Lancet 2008;372:1231-1239.
SELECT Trial Zebrack J, Munger M, MacGregor J, et al. B-Receptor Selectivity of Carvedilol and Metoprolol Succinate
in Patients with Heart Failure (SELECT Trial): A randomized Dose-Ranging Trial. Pharmacotherapy. 2009;29(8):883-890.
Irbesartan Massie b, Carson P, et al. Irbesartan in Patients with Heart Failure & Preserved Ejection Fraction (I-
Preserve Trial). NEJM. 2008;359(23):2456-2467 HFSA “The Heart Failure Clinic A Consensus Statement”
J Card Fail. 2008;14:801-815. Centers for Medicare and Medicaid Services 30 day congestive heart failure readmission
rates. http://www.hospitalcompare.hhs.gov
No significant differences in the patients’ global assessment of symptoms or in changes from baselinerenal function with either bolus as compared with continuous infusion of intravenous furosemide orwith a low-dose strategy as compared with a highdose strategy.
Hospital Quality Compare
Hospital Quality Compare
From Seattle With Love
Teaching tool to utilize with CHF patients Provides 5yr survival rate for patients based
upon clinical history and no intervention as compared to rate after intervention.
User friendly Internet based http://depts.washington.edu/shfm/
From Seattle With Love
From Seattle With Love
Case #1 Based upon the above case what type of interventions would you
have expected to have been performed? (during admission or in clinic)
A. Continue all medications prior to admissionB. Increase Atenolol, start an ace-inhibitor, & start an aldosterone
antagonistC. DC atenolol, start metoprolol succinate, & start an ace-inhibitorD. DC atenolol, start carvedilol, & start an ace-inhibitorE. Just give up and discharge patient from clinic!!!