Maximizing Treatment Options with Congestive Heart failure David Wolinsky FACC Prime Care Physicians Jan 31, 2009
CHF Magnitude in the US <ul><li>   5 million have CHF (prevalence) 1 </li></ul><ul><li>   550,000 new cases annually (in...
Classification of Heart Failure: ACC/AHA Stage vs NYHA Class
Heart Failure Treatment Algorithm
CHF Patients Survival Results 1 1  Framingham Heart Study (1948-1988) in Atlas of Heart Diseases. 2  American Heart Associ...
Hospitalization for Congestive Heart Failure is a Sentinel Event
Paradigms of CHF Management <ul><li>Patient Based management </li></ul><ul><li>ADHF </li></ul><ul><li>Chronic Heart Failur...
 
Adjusted* hazard ratios (95% CI) for one-year outcomes, beta blocker therapy vs no beta blocker therapy, by LV functional ...
Beyond CORE Measures <ul><li>Reduce readmission rate at 30 days </li></ul><ul><li>Reduce 30 day and 180 day mortality </li...
 
Neurohormonal Activation in  Heart Failure RAS, renin-angiotensin system; SNS, sympathetic nervous system. Myocardial inju...
JCAHO: Quality-of-Care Indicators for HF <ul><li>HF-1:   Discharge Instructions </li></ul><ul><li>HF-2:   Assessment of LV...
 
 
 
 
Health Grades CHF
Goals for Patients Hospitalized  With HF <ul><li>Relieve symptoms rapidly </li></ul><ul><li>Reverse hemodynamic abnormalit...
Case History <ul><li>73 yo  moved up from Fla and presented to SPH via car in acute CHF </li></ul><ul><li>Past HX  remote ...
Hospital Course <ul><li>Diuresed with bolus IV  Bumex 2mg IV BID </li></ul><ul><li>Seen by cardiology for CHF  x3 days </l...
Readmitted 8  days later with sob <ul><li>“ I told them I didn’t have enough diuretics” </li></ul><ul><li>Placed on hosp s...
Hospitalizations for Acute Decompensated  Heart Failure <ul><li>Congestion is the primary reason for heart failure admissi...
Can we Risk Stratify Patients <ul><li>Early determination of level of care needed </li></ul><ul><li>Determination of  shor...
Therapeutic Challenges <ul><li>Decongest organs  </li></ul><ul><li>Diurese </li></ul><ul><li>Win the Battle with the Kidne...
Cardiorenal Syndrome <ul><li>Worsening renal function in CHF patient who remains congested despite increasing doses of diu...
Prognostic /Therapeutic Targets <ul><li>Blood Pressure </li></ul><ul><li>Body Weight </li></ul><ul><li>Serum Na </li></ul>...
Fonarow GC et al. Circulation 1994; 90: I-488 High PCWP at Hospital Discharge is Associated with Higher Long-Term Mortalit...
 
 
ADHERE ®  CART: Predictors of Mortality Highest to Lowest Risk Cohort OR 12.9 (95% CI 10.4-15.9) Reference: Fonarow GC, et...
 
 
 
 
 
 
Primary Prevention of  Sudden Cardiac Arrest in  Heart Failure Patients  with LV Dysfunction
SCD in Heart Failure <ul><li>Despite improvements in medical therapy, symptomatic HF still confers a 20-25%  risk of prema...
Severity of Heart Failure Modes of Death 1  MERIT-HF Study Group.  LANCET.  1999;353:2001-2007.   12% 24% 64% CHF Other Su...
(n = 300) (n = 283) (n = 284) (n = 292) Hazard Ratio .98 (p = 0.92) 0.52 (p = 0.07) 0.50 (p = 0.02) 0.62 (p = 0.09) Wilber...
 
Disease Management Program for Congestive Heart Failure
 
 
 
 
Transitional Care for Heart Failure <ul><li>May  assist in device guided monitoring of volume status </li></ul><ul><li>May...
CHF Education and Rehab <ul><li>Cardiac Rehab not approved by CMS for CHF </li></ul><ul><li>Recovery from AHDF  is slower ...
Post Discharge Vulnerable Period  <ul><li>Two period of neurohormonal modification which are crucial to prognosis and surv...
 
MONITORING OUTPATIENT THERAPY TIME-CHF <ul><li>To compare  intensified BNP-guided  therapy to  standard symptom-guided   t...
TIME-CHF <ul><li>Intensified, BNP-guided therapy did not improve the primary endpoint of all-cause hospitalisation free su...
Sleep Related Breathing Disorder <ul><li>Affects 40-50% of pts with systolic HF </li></ul><ul><li>Central  sleep apnea Che...
Central Sleep Apnea and CHF <ul><li>Withdrawal of central respiratory drive to respiratory muscles  during sleep </li></ul...
Relationship of Sleep Apnea to CHF <ul><li>Epiphenomenon vs Risk predictor </li></ul><ul><li>Lanfranchi  Apnea index of no...
Impedance Pulmonary Congestion Impedance Monitoring Bi-V devices As fluid accumulates in the lungs, intrathoracic  impedan...
OptiVol Fluid Trends OptiVol Threshold OptiVol Fluid Index: Accumulation of the difference between the Daily and Reference...
 
Types of Chronic Heart Failure   <ul><li>The use of the term “Diastolic Heart Failure” is controversial </li></ul><ul><li>...
Treatment Options for Diastolic Heart Failure <ul><li>Diuretics  </li></ul>
Hazard ratios (95% CI) for outcomes in I-PRESERVE, irbesartan vs placebo, over a mean of 50 months Massie BM,  Carson PE. ...
Advanced Glycation End-products (AGEs) in Heart Failure   Hartog et al.  European Journal of Heart Failure  9 (2007) 1146–...
Alagebrium: Effects in Reversing Cardiac Pathology    arterial stiffness    left ventricular stiffness    end diastolic...
 
The Clinician Perspective What the palliative care team can do for clinicians : Save time  by helping to handle repeated, ...
The Hospital Perspective <ul><li>For hospitals, a palliative  </li></ul><ul><li>care team can help - </li></ul><ul><ul><li...
30 Day Mortality Tracking
 
 
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  • Slide ID: 7753 The American College of Cardiology/American Heart Association (ACC/AHA) writing committee decided to take a new approach to the classification of heart failure – one that emphasized the evolution and progression of the disease. Only Stages C and D qualify for the traditional clinical diagnosis of heart failure. This classification is intended to complement, but not replace, the New York Heart Association (NYHA) Functional Classification. ACC/AHA Heart Failure Stage Stage A: patients who are at high risk for developing heart failure but have no structural disorder of the heart. Stage B: patients with structural disorders of the heart who have never had symptoms of heart failure. Stage C: patients with past or current symptoms of heart failure associated with underlying structural heart disease. Stage D: patients with end-stage disease who require specialized treatment strategies such as mechanical circulatory support, continuous IV inotrope infusions, cardiac transplantation, or hospice care. NYHA Functional Classification Assigns patients to 1 of 4 functional classes depending on the degree of effort needed to elicit symptoms. Patients with very low LV ejection fractions may be asymptomatic, whereas patients with preserved LV systolic function may have many symptoms. The apparent discordance between severity of systolic dysfunction and the degree of functional impairment is not well understood. Class I: symptoms of heart failure only at levels that would limit normal individuals (asymptomatic). Class II: symptoms of heart failure on ordinary exertion. Class III: symptoms of heart failure on less-than-ordinary exertion. Class IV: symptoms of heart failure at rest. References Hunt SA et al. J Am Coll Cardiol . 2001;38:2101-2113. Farrell MH et al. JAMA . 2002;287:290-297.
  • Goals for Patient Hospitalized With HF There are several methods of improving outcomes of patients with ADHF. Rapidly reversing decompensation and congestion is the first step. Starting patient education and survival medications before hospital discharge is also important. Physicians must optimize survival-enhancing oral medications, such as ACE inhibitors, beta blockers, and spironolactone, as well as optimize patient education and HF disease management.
  • In summary, almost all hospitalizations for heart failure are related to congestion, while low cardiac output signs and symptoms are uncommon. During hospitalization, more than 50% of patients have minimal or no weight loss. Although most patients experience a significant symptomatic improvement, there is a dissociation between their apparent improved clinical status and the continued hemodynamic congestion. The inability to identify persistent congestion despite some apparent clinical improvement is the main cause of readmission in heart failure patients.
  • Reduction of PCWP below 16 mmHg before hospital discharge has been associated with improved two-year survival in an observational study of patients with advanced heart failure who were hospitalized for worsening heart failure. In contrast, no difference in survival was observed after improvement in the cardiac index in this group. These results show again that congestion at discharge is a poor prognostic predictor.
  • These results come from the MADIT-II study. Mortality risk in contemporary post- MI pts with EF &lt; 30% tends to increase as a function of time from last MI. Correspondingly, survival benefit from the ICD increases significantly with time, up to 15 years following MI. Mortality risk in contemporary post- MI pts with EF &lt; 30% tends to increase as a function of time from last MI. These results show the mortality results for each time period studied. They are not cumulative mortality rates. MADIT-II showed that a patient’s risk for SCA increased with time.
  • Before placement, LV function should be re-assessed, ideally after 3-6 months of optimal medical therapy.
  • High risk patients include those with renal insufficiency, low output state, diabetes, COPD, persistent NYHA class III or IV symptoms, frequent hospitalization for any cause, multiple active co-morbidities, or a history of depression, cognitive impairment, or persistent non-adherence to therapeutic regimens. The evidence that led to the A rating was a collection of single-center randomized controlled trials. Examples include the following: Stewart S, MarleyJE, Horowitz JD. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with congestive heart failure: a randomised controlled study. Lancet 1999;354:1077-83. Intervention: Home visit be a nurse 7-14 days after discharge Results: During 6 month follow up there were 129 primary endpoint events (unplanned readmission for HF) in usual-care group, 77 in the treatment group (p = .02). More intervention group that usual-care patients remained event-free ( 38 vs. 51, p = .04). Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995;333:1190-5. Intervention: Nurse-directed multidisciplinary intervention on high risk hospitalized patients 70 or older. Results: Risk ratio for readmission at 90 days .56 (p = .02). Quality of life improved at 90 days (p = .0001) Cline CM, Israelsson BY, Willenheimer RB, Broms K, Erhardt LR. Cost effective management programme for heart failure reduces hospitalisation. Heart 1998;80:442-6. Intervention: Education on HF and self-management with follow-up at nurse-directed HF clinic for 1 year after discharge. Results: No difference in survival rate at 1 year. Mean time to readmission 141 days in treatment vs. 106 in control (p &lt; .05). Days in hospital fewer for treatment, but at p = .07 level. Doughty RN, Wright SP, Pearl A, Walsh HJ, Muncaster S, Whalley GA, et al. Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study. Eur Heart J 2002;23:139-46. Intervention: Clinical review at hospital-based HF clinic early after discharge, education sessions, personal diary, information booklets, and regular follow up at HF clinic and PC practitioner. Results: No significant difference in groups for combined endpoint of death or readmission. Quality of life improved in treatment group at 12 months (p = .015). Readmissions were 56 in the treatment group vs 95 in the control group (p = .015). Stromberg A, Martennson J, Fridlund B, Leven LA, Karlsson JE, Dahlstrom U. Nurse-led heart failure clinics improve survival and self-care behaviour in patients with heart failure: results from a prospective, randomized trial. Intervention: Follow-up at a nurse-led HF clinic. Results: Fewer patients with events (death or admission) in treatment group at 12 months (29 vs 40, p = .03). Fewer deaths after 12 months (7 vs 20, p = .005. Treatment group had higher self-care scores at 3 and 12 months (p = .02 and p = .01).
  • Sample studies below. All are single-site studies or studies done at associated hospitals (see Naylor). Interventions range from a single home visit by a nurse (Stewart) to more complex and long-term strategies using a HF clinic. Cline CM, Israelsson BY, Willenheimer RB, Broms K, Erhardt LR. Cost effective management programme for heart failure reduces hospitalisation. Heart 1998;80:442-6. Intervention: Education on HF and self-management with follow-up at nurse-directed HF clinic for 1 year after discharge. Results: No difference in survival rate at 1 year. Mean time to readmission 141 days in treatment vs. 106 in control (p &lt; .05). Days in hospital fewer for treatment, but at p = .07 level. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995;333:1190-5. Intervention: Nurse-directed multidisciplinary intervention on high risk hospitalized patients 70 or older. Results: Risk ratio for readmission at 90 days .56 (p = .02). Quality of life improved at 90 days (p = .0001) Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc 2004;52:675-84 Intervention: 3-month advanced practice nurse-directed discharge planning and home follow-up in six hospitals. Mean age of patients 76. Results: Time to first readmission or death longer in study group (p = .026). At 1 year, study group had fewer readmissions (104 vs 162, p = .047). Improvements in QOL were only short-term. Stewart S, MarleyJE, Horowitz JD. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with congestive heart failure: a randomised controlled study. Lancet 1999;354:1077-83. Intervention: Home visit be a nurse 7-14 days after discharge Results: During 6 month follow up there were 129 primary endpoint events (unplanned readmission for HF) in usual-care group, 77 in the treatment group (p = .02). More intervention group that usual-care patients remained event-free ( 38 vs. 51, p = .04).
  • : AHT
  • Animal and human studies have shown that intrathoracic impedance decreases with fluid accumulation in the lung. Medtronic data on file Wang L et al. J Cardiac Failure. 1999;5(suppl.):S55{abstract}. Wang L et al. PACE. 2000;23(4):612{abstract}.
  • The OptiVol Fluid Trends track intrathoracic fluid and Thoracic impedance changes over time. Fluid status can be monitored for 14 months of rolling trend information, allowing the clinician to better understand how the patient’s fluid status compares with changes in medications, clinical events and outcomes, and overall patient status.
  • Although diastolic dysfunction has many definititions, perhaps a unifying definition is that it represents an abnormality of diastolic distensibility, filling, or relaxation of the LV, regardless of whether the ejection fraction is normal or abnormal, and whether the patient is symptomatic or asymptomatic. Diastolic dysfunction is thought to play a central role in the etiology of heart failure with preserved ejection fraction , which accounts for a substantial proportion of patients with HF
  • Highlights from our clinical experience
  • Maximizing Treatment Options with Congestive Heart Failure ...

    1. 1. Maximizing Treatment Options with Congestive Heart failure David Wolinsky FACC Prime Care Physicians Jan 31, 2009
    2. 2. CHF Magnitude in the US <ul><li> 5 million have CHF (prevalence) 1 </li></ul><ul><li> 550,000 new cases annually (incidence) 1 </li></ul><ul><li>HF most common cardiovascular discharge in elderly patients 2 </li></ul><ul><li>25% probability of dying over 2.5 years 3 </li></ul><ul><ul><li>50% of these deaths occur suddenly </li></ul></ul>1 American Heart Association. Heart Disease and Stroke Statistics – 2005 Update. 2 NHLBI, CHF Data Fact Sheet, September 1996. 3 Sweeney MO. PACE. 2001;24:871-888.
    3. 3. Classification of Heart Failure: ACC/AHA Stage vs NYHA Class
    4. 4. Heart Failure Treatment Algorithm
    5. 5. CHF Patients Survival Results 1 1 Framingham Heart Study (1948-1988) in Atlas of Heart Diseases. 2 American Heart Association. Heart Disease and Stroke Statistics—2005 Update. <ul><ul><ul><li>100 </li></ul></ul></ul><ul><ul><ul><li>90 </li></ul></ul></ul><ul><ul><ul><li>80 </li></ul></ul></ul><ul><ul><ul><li>70 </li></ul></ul></ul><ul><ul><ul><li>60 </li></ul></ul></ul><ul><ul><ul><li>50 </li></ul></ul></ul><ul><ul><ul><li>40 </li></ul></ul></ul><ul><ul><ul><li>30 </li></ul></ul></ul><ul><ul><ul><li>20 </li></ul></ul></ul><ul><ul><ul><li>10 </li></ul></ul></ul><ul><ul><ul><li>0 </li></ul></ul></ul><ul><ul><ul><li>Probability of Survival (%) </li></ul></ul></ul><ul><ul><ul><li>Men ( N = 237) </li></ul></ul></ul><ul><ul><ul><li>Time After CHF Diagnosis (Years) </li></ul></ul></ul><ul><ul><ul><li>0 </li></ul></ul></ul><ul><ul><ul><li>2 </li></ul></ul></ul><ul><ul><ul><li>4 </li></ul></ul></ul><ul><ul><ul><li>6 </li></ul></ul></ul><ul><ul><ul><li>8 </li></ul></ul></ul><ul><ul><ul><li>10 </li></ul></ul></ul>80% of men and 70% of women who have CHF will die within 8 years. 2 <ul><ul><ul><li>Women ( N = 230) </li></ul></ul></ul>
    6. 6. Hospitalization for Congestive Heart Failure is a Sentinel Event
    7. 7. Paradigms of CHF Management <ul><li>Patient Based management </li></ul><ul><li>ADHF </li></ul><ul><li>Chronic Heart Failure </li></ul><ul><li>Patient Based approach </li></ul><ul><li>CORE Measures </li></ul><ul><li>ACC/AHA/HFSA Guidelines </li></ul><ul><li>Systems Based Approach </li></ul><ul><li>Inpatient Therapy </li></ul><ul><li>Outpatient Therapy </li></ul><ul><li>Transitional Care </li></ul><ul><li>Measured by Readmission and Mortality Rates </li></ul><ul><li>Benchmarks? </li></ul>
    8. 9. Adjusted* hazard ratios (95% CI) for one-year outcomes, beta blocker therapy vs no beta blocker therapy, by LV functional status *Adjusted for baseline age, sex, race, HF etiology, LVEF, systolic blood pressure, smoking, signs of congestion, laboratory values, discharge medications, in-hospital invasive procedures, and history of diabetes and cardiovascular, neurological, pulmonary, and renal diseases Hernandez AF et al. J Am Coll Cardiol 2009; 53:184-192. End point LV systolic dysfunction, n=3001 Preserved LV systolic function, n=4153 Mortality 0.77 (0.68–0.87) 0.94 (0.84–1.07) Readmission 0.89 (0.80–0.99) 0.98 (0.90–1.06) Mortality or readmission 0.87 (0.79–0.96) 0.98 (0.91–1.06)
    9. 10. Beyond CORE Measures <ul><li>Reduce readmission rate at 30 days </li></ul><ul><li>Reduce 30 day and 180 day mortality </li></ul><ul><li>Improve documentation </li></ul><ul><li>Incorporation of transitional care i.e. redefine ‘home care” </li></ul><ul><li>Identlify endstage patients early on and enroll into appropriate care algorithms </li></ul><ul><li>Implications of outcomes to patients, physicians, and hospitals </li></ul>
    10. 12. Neurohormonal Activation in Heart Failure RAS, renin-angiotensin system; SNS, sympathetic nervous system. Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease) Morbidity and mortality Arrhythmias Pump failure Peripheral vasoconstriction Hemodynamic alterations Heart failure symptoms Remodeling and progressive worsening of LV function Initial fall in LV performance,  wall stress Activation of RAAS and SNS Fibrosis, apoptosis, hypertrophy, cellular/ molecular alterations, myotoxicity Fatigue Activity altered Chest congestion Edema Shortness of breath
    11. 13. JCAHO: Quality-of-Care Indicators for HF <ul><li>HF-1: Discharge Instructions </li></ul><ul><li>HF-2: Assessment of LV Function </li></ul><ul><li>HF-3: ACEI or ARB at Discharge in Appropriate Patients </li></ul><ul><li>HF-4: Smoking Cessation Advice/Counseling </li></ul>www.jcaho.org <ul><li>Daily weights 4. What to do if Sx worsen </li></ul><ul><li>2 gram sodium diet 5. Follow-up appointment </li></ul><ul><li>Activity Rx 6. List of medications </li></ul>
    12. 18. Health Grades CHF
    13. 19. Goals for Patients Hospitalized With HF <ul><li>Relieve symptoms rapidly </li></ul><ul><li>Reverse hemodynamic abnormalities </li></ul><ul><li>Prevent end-organ dysfunction </li></ul><ul><li>Initiate patient education and survival-enhancing medications before discharge </li></ul><ul><li>Optimize survival-enhancing oral medications (ACE inhibitor, beta blocker, aldosterone receptor antagonist) </li></ul><ul><li>Optimize patient education and HF disease management </li></ul>
    14. 20. Case History <ul><li>73 yo moved up from Fla and presented to SPH via car in acute CHF </li></ul><ul><li>Past HX remote MI, remote CABG,Hx ICD, Hx chronic CHF, AFib EF less than 30 </li></ul><ul><li>COPD, OSA, DM, Hx carotid stent </li></ul><ul><li>Non compliance felt to be component </li></ul><ul><li>Initial BP 130/70 BUN 58 CR1.9 </li></ul><ul><li>ECG : Afib LBBB </li></ul>
    15. 21. Hospital Course <ul><li>Diuresed with bolus IV Bumex 2mg IV BID </li></ul><ul><li>Seen by cardiology for CHF x3 days </li></ul><ul><li>Seen by EP for evaluation of rhythm- active GI bleed precludes TEE cardioversion. Later consider upgrade to Bivent device. Maintain rate control </li></ul><ul><li>Discharged with BUN 34 and Cr 1.7 </li></ul><ul><li>Meds Bumex 2 PO BID , Imdur 30QD, Coreg 25 BID, Hydralazine 25 TID </li></ul>
    16. 22. Readmitted 8 days later with sob <ul><li>“ I told them I didn’t have enough diuretics” </li></ul><ul><li>Placed on hosp service boarded in PCU </li></ul><ul><li>Seen by cardiology 3 days later </li></ul><ul><li>Moved to CCU started on Nesiritide and Lasix gtts </li></ul><ul><li>Diuresed 30 #, BUN 24 CR 1.4 </li></ul><ul><li>Repeat EP evaluation BiV IVD already in place </li></ul><ul><li>MEDS: Lasix 80 BID, Coreg 25 BID, Coumadin, Accupril 20, </li></ul>
    17. 23. Hospitalizations for Acute Decompensated Heart Failure <ul><li>Congestion is the primary reason for heart failure admissions </li></ul><ul><li>This may be associated with systolic or diastolic dysfunction </li></ul><ul><li>Low cardiac output and associated signs/ symptoms are uncommon. </li></ul><ul><li>Sub-optimal weight reduction during hospitalization. </li></ul><ul><li>Although appear improved clinically, many patients are discharged with persistent fluid overload (related to pulmonary congestion that is not being identified clinically). </li></ul>
    18. 24. Can we Risk Stratify Patients <ul><li>Early determination of level of care needed </li></ul><ul><li>Determination of short term risk and needs </li></ul><ul><li>Predict long term risk to guide adjunct therapy- ICD, CRT, Transplant , Hospice </li></ul>
    19. 25. Therapeutic Challenges <ul><li>Decongest organs </li></ul><ul><li>Diurese </li></ul><ul><li>Win the Battle with the Kidneys </li></ul><ul><li>Cardiac Decompensation urges the kidneys to play unfairly </li></ul>
    20. 26. Cardiorenal Syndrome <ul><li>Worsening renal function in CHF patient who remains congested despite increasing doses of diuretics </li></ul><ul><li>Increased venous pressure with ”choked kidneys” and decreased cardiac output </li></ul><ul><li>Neurohormonal activation </li></ul><ul><li>Decreased renal perfusion </li></ul><ul><li>Fluid retention </li></ul><ul><li>Worsening cardiac performance </li></ul><ul><li>POOR PROGNOSIS </li></ul>
    21. 27. Prognostic /Therapeutic Targets <ul><li>Blood Pressure </li></ul><ul><li>Body Weight </li></ul><ul><li>Serum Na </li></ul><ul><li>Renal Function </li></ul><ul><li>QRS Duration </li></ul><ul><li>CAD </li></ul>
    22. 28. Fonarow GC et al. Circulation 1994; 90: I-488 High PCWP at Hospital Discharge is Associated with Higher Long-Term Mortality Time (months) N=199 N=257 PCWP > 16 mmHg PCWP < 16 mmHg Mortality (%) 0 6 12 18 24 0 10 20 30 40 50 60 P = 0.001 CI > 2.6 L/min /m 2 CI < 2.6 L/min /m 2 Mortality (%) 0 6 12 18 24 0 10 20 30 40 50 60 P = NS N=236 N=220 Time (months)
    23. 31. ADHERE ® CART: Predictors of Mortality Highest to Lowest Risk Cohort OR 12.9 (95% CI 10.4-15.9) Reference: 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. 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
    24. 38. Primary Prevention of Sudden Cardiac Arrest in Heart Failure Patients with LV Dysfunction
    25. 39. SCD in Heart Failure <ul><li>Despite improvements in medical therapy, symptomatic HF still confers a 20-25% risk of premature death in the first 2.5 years after diagnosis 1-4 </li></ul><ul><li> 50% of these premature deaths are SCD (VT/VF) 1-4 </li></ul>1 SOLVD Investigators. N Engl J Med 1992;327:685-691. 2 SOLVD Investigators. N Engl J Med 1991;325:293-302. 3 Goldman S. Circulation 1993;87:V124-V131. 4 Sweeney MO. PACE. 2001;24:871-888.
    26. 40. Severity of Heart Failure Modes of Death 1 MERIT-HF Study Group. LANCET. 1999;353:2001-2007. 12% 24% 64% CHF Other Sudden Death (N = 103) NYHA II 26% 15% 59% CHF Other Sudden Death (N = 103) NYHA III 56% 11% 33% CHF Other Sudden Death (N = 27) NYHA IV
    27. 41. (n = 300) (n = 283) (n = 284) (n = 292) Hazard Ratio .98 (p = 0.92) 0.52 (p = 0.07) 0.50 (p = 0.02) 0.62 (p = 0.09) Wilber, D. Circulation . 2004;109:1082-1084. Relation of Time from MI to ICD Benefit in the MADIT-II Trial Time from MI % Mortality for Each Time Period
    28. 43. Disease Management Program for Congestive Heart Failure
    29. 48. Transitional Care for Heart Failure <ul><li>May assist in device guided monitoring of volume status </li></ul><ul><li>May determine needs for supplemental oxygen therapy Involve Palliative care/ Hospice </li></ul><ul><li>Effective reporting to all appropriate physicians </li></ul><ul><li>Goal is to reduce rehospitalization and mortality </li></ul><ul><li>If patient is readmitted maintain transparency of care allocation </li></ul>
    30. 49. CHF Education and Rehab <ul><li>Cardiac Rehab not approved by CMS for CHF </li></ul><ul><li>Recovery from AHDF is slower than from acute coronary event </li></ul><ul><li>More likely to have repeat setbacks over first 180 days than from CAD </li></ul><ul><li>Heart Failure Monitoring can be accomplished how? </li></ul>
    31. 50. Post Discharge Vulnerable Period <ul><li>Two period of neurohormonal modification which are crucial to prognosis and survival </li></ul><ul><li>Changes in renal and hepatic function worsening signs and symptoms were predicitive of early events </li></ul><ul><li>BEST PREDICTORS : </li></ul><ul><li>rising BUN and rising body weight </li></ul><ul><li>cTHESE PEOPLE NEED CLOSE COMPETENT FOLLOWUP </li></ul>
    32. 52. MONITORING OUTPATIENT THERAPY TIME-CHF <ul><li>To compare intensified BNP-guided therapy to standard symptom-guided therapy on 18-month outcome. </li></ul><ul><li>To assess if there is a difference in response to such therapy in patients ≥75years of age compared to those <75years of age , previously included in large heart failure trials. </li></ul><ul><li>Can monitoring of BNP reduce hospitalization in high risk patients? </li></ul>
    33. 53. TIME-CHF <ul><li>Intensified, BNP-guided therapy did not improve the primary endpoint of all-cause hospitalisation free survival overall </li></ul><ul><li>However, it improved the more disease-specific endpoint of heart failure hospitalisation free survival </li></ul><ul><li>Response to therapy differed significantly between age groups </li></ul><ul><li>Patients age 60-74 years </li></ul><ul><ul><li>Reduced mortality </li></ul></ul><ul><ul><li>Improved HF hospitalisation free survival </li></ul></ul><ul><li>Patients aged ≥75 years </li></ul><ul><ul><li>No benefit on outcome </li></ul></ul><ul><ul><li>Less improvement in quality of life </li></ul></ul>
    34. 54. Sleep Related Breathing Disorder <ul><li>Affects 40-50% of pts with systolic HF </li></ul><ul><li>Central sleep apnea Cheyne Stokes respiration </li></ul><ul><li>Does not correlate with ejection fraction </li></ul><ul><li>Overnight oximetry- easy diagnostic test </li></ul><ul><li>Treatment with supplemental oxygen </li></ul><ul><li>May also need mild sleeping pills, acetazolamide </li></ul><ul><li>May need Full sleep study -BiPap </li></ul><ul><li>Nocturnal 02 lowers BNP and catecholamine levels </li></ul>
    35. 55. Central Sleep Apnea and CHF <ul><li>Withdrawal of central respiratory drive to respiratory muscles during sleep </li></ul><ul><li>Usually more than five events per hour of more than 10 seconds of apnea </li></ul><ul><li>Disrupted sleep </li></ul><ul><li>Hypersomnia during the day </li></ul><ul><li>CHF- often associated with hyperventilatory events- hypocapnia </li></ul>
    36. 56. Relationship of Sleep Apnea to CHF <ul><li>Epiphenomenon vs Risk predictor </li></ul><ul><li>Lanfranchi Apnea index of nonsurvivors twice that of survivors </li></ul><ul><li>AHI> 30 worst prognosis </li></ul><ul><li>Treatment includes </li></ul><ul><li>-treat underling decompensated HF </li></ul><ul><li>-Positive airway pressure </li></ul><ul><li>-nocturnal oxygen </li></ul>
    37. 57. Impedance Pulmonary Congestion Impedance Monitoring Bi-V devices As fluid accumulates in the lungs, intrathoracic impedance decreases
    38. 58. OptiVol Fluid Trends OptiVol Threshold OptiVol Fluid Index: Accumulation of the difference between the Daily and Reference Impedance Reference Impedance adapts slowly to daily impedance changes Daily impedance is the average of each day’s multiple impedance measurements
    39. 60. Types of Chronic Heart Failure <ul><li>The use of the term “Diastolic Heart Failure” is controversial </li></ul><ul><li>Some experts prefer the terms “Heart Failure with Preserved Ejection Fraction” or “Heart Failure with Preserved Systolic Function” </li></ul><ul><li>The term diastolic heart failure is used to describe patients with the signs and symptoms of heart failure, a normal EF, and LV diastolic dysfunction </li></ul><ul><li>It is not simply LVH </li></ul>Aurigemma N Engl J Med 355 (2006) 308-310
    40. 61. Treatment Options for Diastolic Heart Failure <ul><li>Diuretics </li></ul>
    41. 62. Hazard ratios (95% CI) for outcomes in I-PRESERVE, irbesartan vs placebo, over a mean of 50 months Massie BM, Carson PE. American Heart Association 2008 Scientific Sessions; November 11, 2008; New Orleans, LA. *Composite of death from any cause or hospitalization for heart failure, MI, unstable angina, arrhythmia, or stroke End point HR (95% CI) p Primary end point* 0.95 (0.86–1.05) 0.35 CV mortality 1.02 (0.87–1.19) 0.85 HF death or hospitalization 1.01 (0.88–1.16) 0.89
    42. 63. Advanced Glycation End-products (AGEs) in Heart Failure Hartog et al. European Journal of Heart Failure 9 (2007) 1146–1155 Advanced Glycation End-products (AGEs) have been proposed as a novel factor involved in the development and progression of chronic heart failure Pathways involved include cross-linking of extra cellular matrix as well as enhanced stimulation of AGE receptors leading to (prolonged) cellular activation and release of inflammatory cytokines The clinical and prognostic value of AGEs in patients with CHF remains largely unproven.
    43. 64. Alagebrium: Effects in Reversing Cardiac Pathology  arterial stiffness  left ventricular stiffness  end diastolic volume  diastolic compliance  stroke volume  fractional shortening  pulse wave velocity Prevents increase in cardiac A.G.E.s, BNP, CTGF, collagen III Restoration of collagen solubility Optimized ventriculo-vascular coupling
    44. 66. The Clinician Perspective What the palliative care team can do for clinicians : Save time by helping to handle repeated, intensive patient-family communications, coordination of care across settings, comprehensive discharge planning. Bedside management of pain and distress of highly symptomatic and complex cases, 24/7, thus supporting the treatment plan of the primary physician. Promote patient and family satisfaction with the clinician’s quality of care.
    45. 67. The Hospital Perspective <ul><li>For hospitals, a palliative </li></ul><ul><li>care team can help - </li></ul><ul><ul><li>Effectively treat the growing number of people with complex advanced illness. </li></ul></ul><ul><ul><li>Provide service excellence, patient-centered care. </li></ul></ul><ul><ul><li>Increase patient and family satisfaction . </li></ul></ul><ul><ul><li>Improve staff satisfaction and retention. </li></ul></ul><ul><ul><li>Meet JCAHO quality standards. </li></ul></ul><ul><ul><li>Rationalize the use of hospital resources . </li></ul></ul><ul><ul><li>Increase capacity, reduce costs . </li></ul></ul>
    46. 68. 30 Day Mortality Tracking
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