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Multi-Disciplinary Heart Failure Management

Connie Keibler, MSN, ARNP

Western Washington Medical Group, Cardiology

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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

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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.

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Heart Failure Future

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Heart Failure Mortality

• 250, 000 deaths annually

• 1/2 of those diagnosed with Heart Failure die within 5 years

Leading Causes of Death CDC 2005

Heart Disease

Cancer

Stroke

Accidents

Chronic Lung Disease

Diabetes

Nephritis

Alzheimers

Influenza/Pneumonia

Septicemia

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Heart Failure Risk

Common Causes– Ischemic heart Disease

– Diabetes

– Hypertension

– Valvular Heart Disease

– ETOH Abuse

– Obesity

– Cigarette Smoking

– Hyperlipidemia

– Physical Inactivity

– Sleep Apnea

Less Common Causes– Familial Hypertrophic CM

– Postpartum CM

– Thyroid Abnormality

– Connective Tissue Disorders

– Toxin Exposure

– Myocarditis

– Sarcoidosis

– Hemochromatosis

– Medication Exposure

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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.

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Clinical Classifications

• Backward– Inability of the ventricle to eject its contents,

resulting in elevated filling pressures

• Forward– decreased cardiac output and inadequate tissue

perfusion

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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

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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%

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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

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Clinical ClassificationsHeart 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

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Clinical ClassificationsHeart Failure is a Progressive Disorder

ACC/AHA Stages of HFStage 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

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ACC/AHA 2005 Guidelines

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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%

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Clinical Predictors

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

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Seattle Heart Failure Model

• Age

• Gender

• Ischemic Etiology

• NYHA

• Ejection Fraction

• Systolic BP

• Cholesterol

• Hemoglobin

• % Lymphocyte Count

• Uric Acid

• Sodium

• Use of

– K-Sparing Diuretic

– Statin

– Allupurinol

– Diuretic

Multivariate risk model using the following Predictors of Survival at Baseline and after Interventions

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Reasons for Re-Admission

• Compliance with Medication

• Compliance with Diet, Specifically Sodium

• Delays in Seeking Medical Attention

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JACHO Quality of Care Indicators

• DC Instructions

• Assessment of LV Function

• ACEI or ARB at Discharge

• Smoking Cessation Advice/Counseling

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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

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Barrier to HF Management

• Cognitive Impairment• Complex Self Care

Management• Lack of Motivation

– Poor Physical Capacity

– Depression

– Anxiety

• Multiple Co-Morbidities• Psychosocial/Financial

Concerns• Physical Limitations• Multiple Heath Care

Providers and Lack of Shared Communication

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Heart Failure Management

• Improve Access to Appropriate Cost-Effective Health Care

• Prevent Hospitalization

• Improve QOL

• Improved Survival

• Control Health Care Costs

Goals

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Multi-Disciplinary HF MGMT

• Fluid Management• Education

• Intensity of Care• Access

Characteristics

Strategy must outline and follow clinical rationalebased on practice guidelines that define target care patterns for patients.

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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

0% 5% 10% 15% 20% 25% 30%

All CauseHospitalization

All CauseMortality

HFHospitalization

Multi-Disciplinary Interventions for Heart Failure

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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

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Self-Management of HFAND 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

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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

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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

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Multi-Disciplinary Management

• Quick and sustained improvements

• 6 wk intervention

• Cost savings of $67,804

Comprehensive inpatient education, discharge planning,and outpatient support vs. usual care*

•Multi-Disciplinary TeamPhysician ChampionAdvanced Practice Nurse or PANurse EducatorHome Health NurseDieticianPhysical TherapySocial ServicesPharmacist

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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.

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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.

Collaborative Practice

Shared responsibility and outcomes

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Collaborative Practice

• 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

Expected Outcomes

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Just One DayEL

89 y/o female

CAD, S/P MI

Ischemic CM/EF 20/NYHA Class III

DM Type II

Chronic Renal Insufficiency/GFR 38

Parox Afib on Amiodarone

Dyslipidemia

ICD/DDD

SB

70 y/o Male

SSS

Chronic Afib

Idiopathic CM/EF 30/NYHA Class I

HTN

DS

76 y/o Male

CAD w/ recent MI/Stent

Ischemic CM/EF 45/NYHA Class II

Diabetes/Poorly controlled/HgA1C 10

HTN

Dyslipidemia

Chronic renal insufficiency

LO

87 y/o Male

CM/EF 24/NYHA Class III

HTN

Dyslipidemia

Chronic Alcoholism

Chronic Afib

Chronic renal insufficiency/GFR 37

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Just One Day

MG

59 y/o Male

CAD

Ischemic CMEF 36

CAD

Ischemic CMEF 36

PVD/BKA

Anemia

Legally Blind

Hypothyroidism

HTN

ICD

RK

59 y/o Male

CAD

Ischemic CM/EF 15/NYHA Class III

COPD

On-going smoking

HTN

Dyslipidemia

ICD/BIV Pacing

Hypothyroidism

Hx ETOH abuse/Depression

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Cardiac Rhythm Management

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

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Cardiac Rhythm Management

•Risk Reduction•CRT•Diagnostics

•HR Trends•HR Variability•Patient Activity•Intrathoracic Impedance

•Arrhythmias•Remote Monitoring

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Cardiac Rhythm 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

Goals for Heart Failure Management

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Quality of Life Issues

End of Life Issues

And

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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 everythingI will not refuse to do the something that I can do.- Edward Everett Hale

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References

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References

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References