Heart failure programe strategy

1. KAMC ,
CLINICAL CARE ADVANCED HEART FAILURE
PROGRAME
STRATEGY
ASADULLAH KHAN SOOMRO
ADULT CARDIOLOGIST
KING ABDULLAH MEDICAL CITY HOLLY MAKKAH

2. A minority of HF patients have a rapid progression and never
achieve sustained compensation, with debilitating refractory
symptoms FC 111 ,1V, recurrent ,prolong hospitalizations, with
major organ dysfunction and ionotropic dependency, despite
optimal medical treatment called , advanced heart failure
syndrome .
KAMC, Advanced Heart Failure CCPC Strategy
Introduction

3. This unique entity is bit complex ,difficult to diagnose
especially during transitional phase ( stage c to D
),with reversible precipitating factors .
Its my pleasure and honor indeed to present the strategy
briefly for our prestigious heart centre clinical scientists for
discussion .
KAMC, Advanced Heart Failure CCPC Strategy
Introduction

4. Every institution will have some common and some unique
challenges; its how we approach them ,which determines your success .
Target is to provide
Heart Failure team professionals with resources and materials ,designed
to help advance heart failure , awareness, prevention, timely diagnosis
and treatment to right patient at right time..
KAMC, Advanced Heart Failure CCPC Strategy
2019
WAR
Against
Heart Failure

5. Strategies , which we can apply at
K A M C Holly Makkah
Hospital-wide / regional Official Launch of Heart
Failure education and awareness.
Interdepartmental ,Heart Failure Team Consultation service .
Heart Failure Education by HF Care Coordinators .
Effective use of EMR clinical pathways.
KAMC, Advanced Heart Failure CCPC Strategy

6. Strategies , which we can apply at
K A M C Holly Makkah
Discharge follow-up within 1 week with a primary care,
cardiologist or the heart failure clinic.
Eligible patients may be disposed to community-based HF
services .
Friendly pathways for regional referral to Heart Failure
Clinic Multidisciplinary Team.
Establishment of Heart Failure Inpatient Unit.
KAMC, Advanced Heart Failure CCPC Strategy

7. Achieve Gold-Star recognition for Quality Management of advanced
Heart Failure syndromes JCI accreditation.
“ Five Star Education”
Patient education & self care, Families Education. Paramedical
personnel education, physician education & managers / payers
education.
Cut down, Readmission rate
< 20% (significantly below standard average)
Reduce Length of Stay
4.5 days (significantly better than standard average)
Reduce Cost of HF admission
Reduce HF deaths and disabilities.
KAMC, Advanced Heart Failure CCPC Strategy

8. What should be the strategy to overcome this costy business ??.
1) Thoroughly evaluate HF stage, FC ,LV function, etiology
,major organ dysfunction &, precipitants of acute
decompensation especially most common but relatively
neglected complex ischemic heart failure syndromes .
2) Clinical pathways guided in hospital care , must fulfill
discharge criteria , and achieve dry weight.
3) Optimize and titrate guide line directed medical
treatment , assess the pathway for device therapy ( LVAD )
before RV dysfunction.( forgotten neighbour).
4) Post discharge early follow up with in 7 to 14 days .
KAMC, Advanced Heart Failure CCPC Strategy

9. Suggested indications for heart failure admissions:
Symptomatic arrhythmias, syncope, pre syncope, cardiac arrest, multiple discharges of ICD
Suggested indications for heart failure
Symptomatic arrhythmias, syncope, pre syncope, cardiac arrest, multiple discharges of ICD
New MI or Ischemia
Rapid onset of new symptoms of Heart Failure
Decompensation of Chronic Heart Failure
Need for Immediate Hospitalization.
Pulmonary edema or respiratory distress in sitting position
Arterial desaturation < 90% in absence of known hypoxia
Heart rate > 120 beat/ min
Systolic BP< 75 mmhg
Decreased mentation due to hypo perfusion
Need for urgent hospitalization.
New evidence of simultaneous congestion and hypo perfusion
New development of severe hepatic distension, tense ascites or anasarca
Decompensation in presence of acute worsening non-cardiac conditions such as pulmonary disease, renal
and thyroid dysfunction
Consider hospitalization.
Rapid fall in serum sodium < 130 mg/l
Rising serum creatinine at least two fold or> 2.5. mg/dl
Persistent symptoms of resting congestion despite repeated out -patient clinic visits.
KAMC, Advanced Heart Failure CCPC Strategy
ADMISSION CRITERIA

10. Suggested indications for heart failure admissions:
Symptomatic arrhythmias, syncope, pre syncope, cardiac arrest, multiple discharges of ICD
Conideration of course and exacerbating factors for heart failure
Exclusion of reversible factors .
Correction of exacerbating factors
Relief from congestion.
Dry weight
No orthopnea
No /or minimal edema /Ascites .
Dressing without cardiac limitation.
Establishment of oral regimen.
24 hour stability,on oral diuretic dose with stable weight.
24 hour stable potassium level
24 hour stable on oral vasodilators
Acceptable BP without ionotropes.
Adequate anticoagulation if indicated.
Safe and tolerable antiarrhythmic therapy.
Weight scale present at home
Visiting community HF nurse or telephonic follow up within 3 days.
HF written education.
Written medication schedule 24 hours before discharge
Follow up appointment with in 7 to 14 days with community HF or post discharge HF physician clinic.
24 hour number of caring physician in selective vulnearable patients.
Self care HF Zones awareness.
Patient with family HF education session ,cardiac rehebilitation appointment.
KAMC, Advanced Heart Failure CCPC Strategy
DISCHARGE CRITERIA

11. Who can be discharged from HF clinic
Low risk HF patient , can be discharged if established co - ordinated follow up at
community heart failure services are available at primary / secondary care units.
Minimum of at least two of the following patient characteristics should be present
to justify discharge from HF clinic.
1) Stable NYHA class 1 or 11 for 6-12 months.
2) Using optimal devices and pharmacological therapies.
3) Stable adherence to optimal HF therapy.
4) No hospitalization for > one year.
5) LVEF > 35% ( Consistently shown if > 1 recent EF measurement).
6) Reversible causes of heart failure controlled.
7) Follow up by community physician interested in management of HF.
KAMC, Advanced Heart Failure CCPC Strategy
Disposed Criteria

12. 1) Following patients should be referred for advanced HF
therapies like, durable mechanical circulatory support,/
transplant & palliative care.
2) Age < 50 years
3) NYHA FC 111 & 1V symptoms
4) Without reversible etiologies.
5) Unresponsive to guide line directed optimal medical treatment .
6) Severe LV systolic dysfunction EF < 30%.
7) Recurrent HF hospitalization > 3 in past one year ,without
obvious precipitating cause.
8) Heart failure with major organ dysfunction
KAMC, Advanced Heart Failure CCPC Strategy
Who should be referred at advanced HF clinic.

13. How soon should I see Newly Referred HF patients
Triage category/
Access target
Clinical Scenario
Emergent < 24 hours • Acute severe myocarditis /Cardiogenic Shock
• Transplant & Device evaluation of unstable patient.
• New onset acute Pulmonary Edema
• HF in setting of acute coronary syndromes
Urgent < 2 Weeks *Progressive /Decompensated heart failure.
*New onset decompensated heart failure.
*New progression to NYHA FC1V HF.
*Post Myocardial infarction HF/ Post hospitalization HF ER visit.
*Heart Failure with severe valve disease.
Semi Urgent < 4 Weeks • New Onset heart failure FC 1 & 11 compensated.
• HF with NYHA class 11 & 111 symptoms
• Worsening HF despite treatment .
• Severe valve disease with mild symptoms with renal impairment or hypotension .
Routine/Schedule
< 6 Weeks
< 12 Weeks
*Chronic heart failure FC11
*Structural heart disease with NYHA FC 1/ or asymptomatic stage B.
KAMC, Advanced Heart Failure CCPC Strategy
How soon patient should be seen

14. High Risk HF patients
Follow up every 1-4 weeks /or visits may
increase because of medication titration.
Intermediate Risk HF patients.
Every 1 to 6 months
Low Risk HF patients
Every 6 -12 months
• Recent HF hospitalization
• NYHA class 111 or 1V
symptoms
• New onset heart failure
• During titration of HF
medications
• Complications of HF therapy
,like renal and electrolyte
imbalance & hypotension.
• Need to down titrate or
discontinue beta blockers/ACE
or ARB /ARNI
• Severe concomitant and
active illness like COPD
exacerbation.
• Frequent ICD shocks
/Infections.
No Clear high /low risk
features of HF.
• No hospitalizations in past
one year.
• NYHA Class 1 or 11.
• No recent changes in
medications.
• Receiving optimal medical
/device HF therapies.
KAMC, Advanced Heart Failure CCPC Strategy
How Often should my HF Patient be seen
( Follow up frequency)

15. Clinical
Scenario
Timing of Measurement Modality of
Measurement
Comments
New onset HF Immediately or with
in 2 weeks as baseline
assessment.
Preferably Echo
when available/
MUGA/CMRI
70% request echo
30% other modalities
according to clinical
judgement
Following titration of
triple therapy. Or for
ICD & CRT
implantation.
3 months after
completion of
titration
Echo or
MUGA or
CMRI
Preferably same
modality
LVEF after GDMT
might improve
,obviating device
therapy.
Stable Heart
Failure.
After significant clinical
event/HF admission
2 to 3 years if EF >
40%
With in 30 days during
hospitalization
Echo, MUGA or CMRI.
Echo, MUGA ,CMRI
Or Cath if ACS
For prognostic
significance. If get
worse need ICD/CRT.
Helpful for EF, Valve
Suggested Timing for Measurement of LV Ejection Fraction according to scenario
KAMC, Advanced Heart Failure CCPC Strategy

19. KING ABDULLAH MEDICAL CITY
HOLLY MAKKAH
CLINICAL CARE HEART FAILURE
PROGRAME
RAHFC( RAPID ACCESS HEART FAILURE
CLINIC )
“Goal is same Day “
One stop fast track heart referral from,
PHC/ER to “Best Care “ whenever and where ever
requires.
IN PATIENT
HEART FAILURE
CARE
COMMUNITY
HEART FAILURE
CARE
OUT PATIENT
HEART FAILURE
CARE
EMERGENCY
HEART FAILURE
CARE
Regular
Heart Failure
Clinic
Post Discharge Heart
failure &
Rehabilitation
Clinic
Nurse Led
Heart Failure
Clinic
Advanced
Heart Failure
Clinic
4
21
3
KAMCClinical care Heart Failure Programe Holly Makkah
Multidisciplinary Heart Failure Care

20. Diagnostic Criteria for Advanced Heart Failure
A )Major criteria ( All required)
1) Resting LV ejection fraction < 30%
2)Presence of NYHA FC ,111,1V
3) Cardio-pulmonary exercise ,peak oxygen consumption VO2 < 14ml/kg/min.
B ) Additional Criteria that contributes to the diagnosis .
1) Trial of GDMT for at least 3 months, yet persistanace of HF symptoms .
2) Hyponatremia sodium < 130meq.
3) Severely impaired functional capacity ( inability to exercise 6min walk <300m.
4) HF hospitalization ( >1 in past 6month).
5) Episodes of volume overload /or peripheral hypoperfusion.
KAMC, Advanced Heart Failure CCPC Strategy

21. Since heart transplantation, the gold standard therapy for end- stage HF, is
not sufficiently available, other advanced therapeutic approaches are crucial.
LVADs provide a bridge for patients awaiting heart transplantation or myocardial
recovery.
Rates of successful and durable recovery are very low, but this can be stimulated
pharmacologically.
Better-sustained results could be expected from combining LVADs with regenerative
therapies such as gene therapy, biomaterials, and cell-based therapies. Especially, cell
therapy for the treatment of heart disease has been extensively studied, showing
promising results.
KAMC, Advanced Heart Failure CCPC Strategy

22. Patients potentially eligible for left ventriculat assist device
KAMC, Advanced Heart Failure Strategy
Who benefit from LVAD
Patients with > 2 months of severe symptoms despite optimal medical & device
therapy, and more than one of the following
LVEF < 25% , and ,if measured , peak VO2 < 12 ml/kg/min
> 3 hospitalizations in previous one year ,without an obvious
precipitating cause
Dependence on I/V ionotropic therapy
Progressive major organ dysfunction, ( Cardio-renal & cardio hepatic syndromes) due to
reduced perfusion, not to inadequate ventricular filling pressure ( PCWP > 20mm HG,
Systolic BP < 80- 90mmHG, and cardiac index < 2 Lit /min/m2
Deteriorating Right Ventricular systolic function
KAMC, Advanced Heart Failure CCPC Strategy

23. KAMC, Advanced Heart Failure Strategy
Differentiating Acute MI from HF in setting of positive Troponin
KAMC, Advanced Heart Failure
Troponin Mystery
Symptoms Type 1 Non STEMI Acute Heart Failure
Chest Pain Usually Occasionally
Shortness of Breath Some times Usually
Detectable Troponin Always Some times
Troponin Level > 1.0 ng/ml Usually Occasionally
Troponin Pattern Rise & Fall Persistently low level
Elevation/or gradual
decline
CK-MB elevation Usually Rarely
BNP > 100 pg/ml Some times Almost always
BNP > 400 pg/ml Rarely Usually

24. No Clinical
Improvement
Exclude reversible causes
& Optimize medical treatment
Clinical
improvement
Re-evaluate every 3-6
months or if symptoms
get worse
Reversible causes excluded
Medical & device therapy
Optimized
Reversible causes of
Heart Failure
1) Ongoing ischemia
2) Valve disease
3) Dysrrhythmias
4) Toxins
5) Endocrinopathies
No
Yes
Does this patient meet any of the following
criteria for transplant
1) Is there major organ failure
2) Is there increase burden of
dysrrhythmias or ICD shocks.
3) Is peak Vo2 < 12 or Vco2slop >43
4) Decrease in 6 min walk distance
5) Medium to high HF survival score
6) Is cardiac index < 1.8 on RH
catheterization
Yes
Patient with acute
cardiogenic shock Consider
1) LVAD
destination
therapy
2) Palliative care
& ionotropes
Yes Yes
Are absolute contraindications
to transplant
Is Pt interested in transplant
No
No
Why educate
Him about options
Refer to Transplant
center
Absolute
contraindications to
Heart Transplant
1 ) HIV/AIDS with CD4
2) Active or recent uncured
malignancy , ( with in 5
years )
3) Irreversible lung, liver or
renal disease
4) Systemic disease with
multi organ involvement.
5) Non Compliant Patient
6) Lack of social support
Yes
Management of Chronic
Ambulatory Advanced Heart Failure

25. KAMC
ADVANCED HEART FAILURE & TRANSPLANT
INSTITUTE.

26. THANK YOU

28. Heart Failure clinic started on Tuesday 2nd October 2018.
Total Patients = 23
First Out patient started on 9th Oct 2018
First Inpatient started on 15 Oct 2018
Age range, 25 Yrs to 68 years
Males, 21 ( 91%)
Females (2 9% )
Out patient 14 (61%)
In patient 9 ( 39% )
Non Ischemic HF = 18 ( 78% )
Ischemic HF = 5 ( 22% )
3 Patients ,post CRTD, 4 post ICD,1 MV clip,1 post DVR,1 post CABG,1
Peripartum.
KAMC, Advanced Heart Failure
Clinic
Sacubitril Registry
9.10.2018 to 18.10.2018

29. Following are the aims of the programe.
1) Establishment of the network of multidisciplinary Novel Heart failure Clinics.
2) Implementation and monitoring of updated guidelines on heart failure diagnosis and
management.
3) To familarize and encourage cardiology community to apply evidence based therapies and
discoveries to prevent or delay of development of overt heart failure and prevention of deaths
before onset of symptoms
4) To promote heart failure prevention by public education ,on healthy life style, HF symptom
awareness and self care to prevent recurrent decompensation and hospitalization.
5) Introduction of heart failure rehabilitation and, creat a highly supportive habitate for research
in heart failure ,especially amongst disappearing breed of physician scientists
KAMC, Advanced Heart Failure CCPC Strategy