The Team Approach

to

Heart Failure

Mariell Jessup MD FACC, FAHA

Professor of Medicine

University of Pennsylvania

Philadelphia, Pennsylvania

Disclosure: No relevant relationships.

Frank Netter Montage of Heart Failure

Heart Failure in the United States:

Estimated Total Costs

American Heart Association. Heart Disease and Stroke Statistics—2004 Update.

Lowery et al. Lippincott’s Case Management. 2004;9:S1-S15.

Physicians/Other Professionals

$1.8 Billion

Total cost = $28.8 billion

Drugs/

Medical Durables

$2.7 Billion

Home

Healthcare

$2.1 Billion

Lost Productivity/

Mortality

$2.1 Billion

Hospital/

Nursing Home

$17 Billion

Normal

Systolic

Heart

Failure

Diastolic

Heart Failure

Aurigemma, Zile, Gaasch

Circulation 2005

What else needs to happen?

What else needs to happen?

• Medication reconciliation

• Continue evidenced-based therapy

• Start evidenced-based therapy

• Written discharge instructions

• Post-discharge systems of care

What else needs to happen?

ADHERE® CART: Predictors of Mortality

SYS BP 115 n=24,933

SYS BP 115 n=7,150

6.41%

n=5,102

15.28%

N=2,048

21.94%

n=620 12.42%

n=1,425

5.49%

n=4,099

2.14%

n=20,834

BUN 43 N=33,324

Greater than Less than

2.68%

n=25,122

8.98%

n=7,202

Cr 2.75 2,045

Highest to Lowest Risk Cohort

OR 12.9 (95% CI 10.4-15.9)

Fonarow GC, et al. Risk stratification for in-hospital mortality in heart failure using classification and regression tree

(CART) methodology. JAMA. 2005;293:572-580.

33,324 patients!

Revised August 2005 from Jessup M, Brozena S. NEJM 2003;348:2003

Risk factor reduction, patient and family education

Treat HTN, DM, CAD, dyslipidemia. ACEI or ARB

ACEI, BB in all. Is patient candidate for surgery?

Sodium restriction, diuretics

Aldosterone antagonists

Digoxin

Inotrope, nesiritide

VAD, TX

Stage A

High risk

with no

symptoms

CRT, ICD if applicable

Stage B

Structural

heart

disease,

no

symptoms

Stage C

Structural

disease,

prior or

current

symptoms

Stage D

Refractory

symptoms

requiring

special

intervention

Stages & steps:

treatment of systolic

HF

Hospice

Brief inotrope or nesiritide

ACEI, ARB’s if intolerant of ACEI, BB if MI or low LVEF

Annals of Internal Medicine 2008; volume 148.

2010

Who Manages CHF?

IM43%

FP/GP 29%

CARD

17%Other

11%

Who and how we will take care

of the heart failure patients?

• 2007 HF hospital discharges: 990,000

• 2007 HF office visits: 3,434,000 – 83% hospitalized once

– 43% hospitalized at least 4 times

• 2010 internists, and generalists: 50,070

• 2010 Physicians and surgeons: 293,740

• 2010 cardiologists: 20,000

Clark et al. BMJ 2007; 337:942

All cause hospitalization

Clark et al. BMJ 2007; 337:942 All cause mortality

World Health Organization

Heart failure as a model of

chronic care.