There are different stages of HF syndromes , stage B HF is grossly neglected by cardiology community ,which is a ticking bomb to prevent symptomatic HF

1. Heart Failure Admission
& Readmissions
Syndromes
Dr Asadullah Khan Soomro
Adult Cardiologist & heart failure specialist
Altamash General Hospital Block 1 Clifton Karachi
Email; hssbasadsoomro@gmail.com Mobile ; 0302 - 2308718
“ Millions Heart
Ticking
time Bomb “
Heart Failure Hospitalizations, can we predict / or Prevent it ?

2. Heart Failure Admission
& Readmissions Syndromes
Dr Asadullah Khan Soomro
Adult Cardiologist & heart failure specialist
Awwad Albishri Hospital Holy Makkah Kingdom of Saudi Arabia
Visiting Consultant Saad medical center Larkana Sindh Pakistan
“ Millions Heart
Ticking
time Bomb “
Heart Failure Hospitalizations, can we predict / or Prevent it ?

3. Introduction
Epidemic of athero-thrombosis is on rise in the form of heart attack,
especially in our in younger population.
With the technological revolution and network of primary PCI acute
MI is aborted successfully , but at the expense of new epidemic of
stage B heart failure .
Cardiology community all over the globe are woefully underprepared
for the Demographic time bomb of heart failure syndromes .
Introduction

4. Introduction
With the result millions heart are under threat of development of
uninterrupted cascade of pre-HF to heart failure and advanced heart
failure syndromes.
Stage B heart failure is sought of a Virus, behave like time bomb
hiding their presence and destructiveness until time to explode.
It has to be managed carefully in the form of Value-based
multidisciplinary heart failure programme and network, if not it will
have substantial impact on economies.
Introduction

5. Heart Failure Admission and
Readmission Syndromes
Heart Failure Hospitalization
“Can We Prevent or Predict it ? “
Why hospitalization is Important ?
1) It is associated with a very
poor quality of life
2) Costly business , it puts
considerable strain on
families and healthcare
system indeed. 77% is spent
on Hospitalization.
With the modern drugs
and Device therapies
Mortality has declined
but
Re-hospitalizations
have increased
WHY ?
Is a matter of concern
Heart Failure Admission and
Readmission Syndromes

6. Heart Failure Admission and
Readmission Syndromes
Heart Failure Mortality has reduced but at the cost of increased Hospitalizations
“ Bidirectional Trend “
Worrisome ?
Its not only affecting quality of life, but
“ lengthy & Recurrent “
Hospitalizations are very costly indeed.
77%
Spent
On
Hospitalizations
7
7
%
Heart Failure Admission and
Readmission Syndromes

7. Heart Failure Admission and
Readmission Syndromes
Explanations of this apparent Paradox
1) Severely affected HF
Patients now survive
,thanks to revolutionary
drugs and device
therapies, but at the
expense Of
re-hospitalization Syndromes
,particularly during
Vulnerable phase , first 30
days After index
hospitalization.
3) Majority of HF patients are
managed by non HF
cardiologists with no regular
HF clinic/ MDHFP.
There is a big gape in post
discharge transitional phase
,when the risk of being
rehospitalized for ADCHF is
extremely high .
Vulnerable patients in
vulnerable phase are largely
neglected because of non
availability of early post
discharge HF service.
2) Up-titration of lifesaving
medication remains suboptimal.
Recent survey of ESC shows that
,overall only 25% to 30% patients
reach the target dose .
Rate of prescription of GDMT has
improved but dose titration is not
performed in real life.
Moreover Up-titration scheme is bit
complex also , because of multiple
comorbidities ,poor dose tolerance
and contraindications indeed.
Heart Failure Admission and
Readmission Syndromes

8. Heart Failure Admission and
Readmission Syndromes
Explanations of this apparent Paradox
There is poor/ or no coordination at all amongst multiple HF
stakeholders , because of lack of HF programme ( MDHFP )
( Most patients have 3-6 months follow up appointment after discharge )
One of the major reason ?, so ,where , how and who should do up-titration of
life saving drugs initiated in hospital during decompensation phase , is not
continued afterwards .
Only open option for post discharge HF patients is Emergency department , and
for ED , easy way is to admit patient.
Heart Failure Admission and
Readmission Syndromes

9. Patients hospitalized first time, is vulnerable for re-hospitalization, with in 30-60 days ,especially with
1 or more following complex features.
1) Non adherence to therapeutic regimens .
2) Renal insufficiency
3) Low cardiac out-output states
4) Uncontrolled diabetes
5) Chronic obstructive pulmonary disease ( COPD )
6) Persistent symptoms FC III,IV . Premature discharge
7) Frequent non HF hospitalizations
8) Multiple active comorbidities
9) History of depression
10) Poor HF education
11) Inadequate social support
Identification of Vulnerable HF
Patients for Re-hospitalization

10. Heart Failure Admission and
Readmission Syndromes
Better Communication amongst heart failure stakeholders
“ To improve ( re ) hospitalization “
Department of
Cardiology
Department of
Internal
Medicine
Heart Failure
Physician
&
HF Clinic
Community
Physicians
Private
Cardiologist
Fragmented
Journey,
No
Communication &
Coordination
Ideally
This can take place in
Structured
( MDHFP )
Multidisciplinary
Heart Failure Progeamme
&
Network.
No Unique Solution
Broken chain
Heart Failure Admission and
Readmission Syndromes

11. Heart Failure Admission and
Readmission Syndromes
Better heart failure Education & self care
“ To improve ( re ) hospitalization “
Patient
Education &
Self Care
Family
Education
Community/
Emergency
Physicians
Education
Para-medical
Personnel
Education
Payers /
Policy makers
Education
Better & in group Education
Visual tools in lay language
Disease information
Warning signs of decompensation
Drugs side effects & adherence
Daily weight & edema monitoring
Diet & Fluid advise
Sex, travel and recreation
HF Zones ,( Green, yellow & Red )
When to go ER & contact physician
Focus on fundamental
issues to improve
outcomes. PDHFC follow up
( who should do uptitration )
Primary goal of treatment
should not be only symptoms
relief but to improve
outcomes ( Mortality & hospitalization )
“Transform relationship to
partnership”
No Unique Solution
HF Education
HF Education & self Care
Make them independent to avoid disability
Heart Failure Admission and
Readmission Syndromes

12. Heart Failure Admission and
Readmission Syndromes
Heart Failure Admission
First time (De-novo) acute
HF With in 3 months of
symptoms. Mild to
moderate symptoms
usually go to community
clinics.
Severe symptoms directly
go to Emergency. Goal is to
establish diagnosis
HF etiology & precipitants.
Heart Failure Readmission
After first HF admission
Readmission with in 3 months of
ist admission is still acute HF.
After 3 months become chronic
Heart Failure .
Compensated phase , variable in
every patient , if symptoms get
worse ,usually go to emergency /
OPD, if admitted called
readmission syndrome
( ADCHF ) , they usually have
precipitating factors .
RAHFC
( Rapid Access HF Clinic )
(Post discharge HF
Clinic)
PDHFC
Heart Failure Admission and
Readmission Syndromes

13. Rapid Access Heart Failure Clinic ( RAHFC )
New Onset Suspected HF Referral Pathway
New onset Breathlessness , Cough /PND Fatigue, Ankle Edema
Suspected for Heart Failure.
If sudden, Severe
Breathlessness ,
Usually go to
Emergency
If mild to moderate
Breathlessness
Usually go to Community
Physician/non HF public/private
( model 11 ) hospitals.
At community level at least record history,
especially old MI ,thorough physical
examination Labs , EKG and chest x ray
If all are normal HF unlikely .
If still doubt refer to RAHFC.
In ER to be assessd by Cardiology on call If HF
is confirmed Admit to CCU/ward according
to clinical condition.
Establish HF etiology and precipitating factors.
Stabilize heart failure according to inpatient
clinical pathway and follow up at post
discharge HF failure clinic with in 2 weeks.
If symptoms stabilized and patient
refuse for admission .
Book him on Rapid access HF
clinic with in 3 days for full workup.
RAHFC
( This is one stop, without appointment ,same
day clinic. Full workup to establish diagnosis
Functional Class , LV function ,EKG , X-ray &
blood work up . Start GDMT ,if probability of
CAD book for coronary angiogram to assess
severity of CAD and targets of
revascularization.
Cardiac MRI if need to assess viability .
After establishing HF etiology , precipitating
factors & revascularization
Follow them at HF clinic until achievement of
target dose of GDMT/ device implant .
When in compensated phase follow at regular
HF clinic for continuation of care.
Majority of these patients are misdiagnosed as
COPD/ flu ,despite multiple visits to different
clinics.
Referred to cardiology/HF clinic of model 111
hospitals but get long appointments.
With the result HF diagnosis, etiology &
precipitants are lately diagnosed and do not
receive GDMT , therefore land in ER or die
suddenly.
To avoid ist HF admission,&
adverse events , refer them to
novel rapid access HF clinics
( RAHFC ) .We need to develop
network of such clinics ,like
chest pain clinics.
Rapid Access Heart Failure Clinic ( RAHFC )
New Onset Suspected HF Referral Pathway

14. Heart Failure Admission and
Readmission Syndromes
Virtual contacts & telemonitoring to remote distance
“ To improve ( re ) hospitalization “
Improve Community&
Emergency
Physicians
Communication &
Coordination
Wight
Edema
Vitals
BNP
EKG
Echocardiogram
Implantable
Device
Monitoring
( Cardio MEM )
Re-imbursement of the time spent by
Professionals ??
Heart Failure Nurse/Coordinator Heart Failure Physician/Coordinator
Heart Failure Admission and
Readmission Syndromes

15. Conclusion
Heart failure services are fragmented, there are multiple
communication gaps amongst HF stakeholders at all stages of HF
journey .
In order to improve situation ,we need to recognize that the
management of this chronic condition is a continuum and that post-
discharge treatment and follow-up are as important as in-
hospital management.
Heart failure education and self care is corner stone not only for
patients but families indeed, and it should be started during
hospitalization.
Conclusion

16. Conclusion
Our heart Failure patients are younger than western counterparts ,therefore they will stay and we will
have to play with them.
Ischemic heart failure was, is and will remain commonest cause of acute & chronic heart failure
Syndromes.
Heart Failure stage A & B are uncountable in millions ( 55-65% HF population) . Hypertension, cigarette
smoking & metabolic syndrome , was and will remain on rise .
Asymptomatic structural heart defects with LV dysfunction ( Old MI, RHD , Corrected grownup CHD,
recreational unexplored cardio toxic agents ( Captagon, alcohol & Hashish ) are challenging .
Chemotherapy induced cardiomyopathy & Peripartum cardiomyopathies are still under & lately
diagnosed . COVID cardiomyopathy new toy on globe . ( Reversable or irreversible ? )
Cardiology Community is concerned , but is not doing enough to prevent heart failure and to delay
advanced heart failure ( root cause of hospitalization ) .
“ Its ticking time Bomb “ But ???.
Conclusion

17. Conclusion
Heart Failure readmission syndromes are
heterogeneous ,multifaceted ,and not easily
categorized as preventable or not .
Therefore policies and interventions aimed at
reducing unnecessary HF readmissions
should better integrate patient input.
Conclusion