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- 1. Heart Failure Admissionand Readmission Syndromes Dual Epidemic of Two different heart failure Worlds. Costly & deadly Syndromes “ Science or Art ? ” P D H F C R A H F C Rapid Access Heart Failure Clinic Post Discharge Heart Failure Clinic Dr AsadullahKhan Soomro KAMC Holy Makkah ( hssbasadsoomro@gmail.com
- 3. Introduction 64 million 64 million patientsworldwide are living with HF, ( 1-2% of the global population ). By 2025 30% of the global population will have heart failure. Frequent 9 of 10 Progressive Mostly its incurable syndrome,can be reversible Patients have symptoms despite treatment. HF is associatedwith reduced quality of life . Mortality Exceeds Most Cancers Deadly ,Complex syndromes 77% 5 year mortalityof HF exceeds prostatic cancer. >10% die duringDe-Novo hospitalization,decline in survival with recurrenthospitalization Economic burden of HF is 108 Million dollars worldwide ( 2017) 92,990 high income and 15,130 in low income countries. About 387 million dollars /year in KSA Costly ,especially admission and readmissions
- 4. Shocking Cost onAdmission & Readmission HF Syndromes An estimated 1.5 million patients are suffering from heart failure in three countries. ( UAE, KSA and Egypt ,highest number, 998 900 in Egypt only Annual Per patient cost was highest in UAE ( USD ,14121 ) Followed by KSA ( USD 8404 ) Lowest ,yet ( USD 1105 ) in Egypt. Total Estimated Cost for the MENA region is USD 4.88 billion. Highest in KSA USD 2.63 billion UAE USD 1.25 Billion Egypt USD 994.96 Million Major Cost associatedon Inpatient care , on admission, readmission, & invasive procedures Estimated Cost of 4 key HF medications per year = 3622 SR, ( Cost of sacubitril per year per patient 7665 SR ) 9162 SR 4 HF Drugs Per /Pt Per/Yr ARNI, MRA B Blockers & Diuretics
- 5. Heart Failure Admissionand Readmission Syndromes 70- 80%of acute HF are admitted through ER to CCU /cardiac ward. 20-30% ( low risk) are discharged to visit RAHFC ? Which patient & when/or stay for 12-24 hours in HF observation unit. ( Depend on ER admission & dispose criteria & clinical pathway ) RAHFC ( Rapid Access Heart Failure Clinic ) Referral From ER & Community Heart Failure Services PDHFC ( Early Post Discharge Heart Failure Clinic ) Transition From Hospital HF clinic DE-Novo Heart Failure First Admission ADCHF Heart Failure Readmissions Vulnerable Heart Failure Patients And Vulnerable Phase Target Right Patient at Right Time Right Place Save Money , Save Time Time is Myocardium Myocardiumis life “ Science or Art “ PREVENTABLE TREATABLE
- 6. Paradox Of Readmission Syndromes SeveralExplanations can be put forward in order to explain this apparent paradox. First , thanks to modern pharma & device therapy ,that severely affected HF patients now survive ,but at expense of rehospitalization ( costly because of prolong and recurrent hospitalization ) with a particularly critical phase in first 30 days following index hospitalization.
- 7. Paradox Of Readmission Syndromes Uptitrationof lifesaving medications remain suboptimal .Infact rate of prescription of GDMT has improved, whereas titration of these drugs is not performed in practice. In ESC countries only 25-30% reach target dose ,Multiple co morbidities in HF can result in contraindications or poor tolerance of some recommended drugs .
- 8. Paradox Of Readmission Syndromes Patientsadmitted with acute heart failure ( first time or recurrent hospitalization ) are inappropriately managed ( like, HF etiology and precipitating factors) and are prematurely discharged . There is often a gap in follow up after discharge at vulnerable phase ( first 30 days) ,when risk of being rehospitalized for decompensation is extremely high.
- 9. Paradox Of Readmission Syndromes Poorcoordination amongst inpatient physicians ( general cardiologist/internal medicine and heart failure physicians).Disorganized Post discharge out patient /community HF care, is one of the major reason why titrationof life saving medications initiated in hospital during ADcHF in not continued afterwards.
- 10. Heart Failure Admission Syndromes DrAsadullahKhan Soomro Adult Cardiologist King AbdullahMedical City Holy Makkah Email, hssbasadsoomro@gmail.com RAHFC Rapid Access Heart Failure Clinic
- 11. RAHFC Rapid Access Heart FailureClinic Case No 1 62 yr male, diabetic smoker presented to community physician clinic with exertional breathlessness FC 11,no PND, for 2 weeks, considered flu and allergy given treatment but no symptom relief. Him self went to local private hospital did echo and found to had LV systolic dysfunction. Referred to KAMC seen on 4.10.20 diagnosed to have moderate De-novoHF ,ischemic following silent MI. started full guide line directed treatment and ,did echo and labs on same day. Reviewed after a week EF 25% BNP 145,Trop 0.072,no major organ dysfunction. CAG on 8.11.20 LM+ severe 3 VD CAD, Inserted IABP shifted to CCU. Underwent CABG on 10.11.20 . Discharged on 17.11.20. Look forward to see him back for HF medications up titration. Case No 4 62 yr male DM,HTN SmokerDrug abuser( Cocktail 30 yrs) Cured follicularLymphoma. Referredby phone from oncologyclinic for ESM evaluation. Seenat screeningclinic on same morning 15.10.20 had exertional breathlessness FC11 with PND for 4 weeks. On examination,JVPnot raised ,parasternal heave palpablePSM 3/6 at apex. ChestClear, edemaabsent. EKG sinusincomplete LBBB. X ray Large heart with mild pulm congestion. Labs on same day BNP 1083,trop 0.099,no major organ dysfunction. Diagnosedto have De – Novo heart failure with severe MR ? Cause Ischemic/late chemotoxicity/ Captagon ,hashish. Started GDM therapy with entresto. Echo on same day nondilatedLV moderate to severe eccentricMR EF 40-45%. CAG on 11.20 showed3 VD CAD Discussed in MDT left DAMA. Case No 3 60 yr female DM, HTN, mother of 6 childrenlast 19 yrs. Evaluatedonscreening clinic on 11.10.20.complaining of exertional breathlessness FC 11 for 3 months increasedtoFC 111 withPND for a week. On Examination, JVP raised, Parasternal heavepalpable ,PSM 2/6 at apex. Chest clear ,noedema. Did Labs on same day ,BNP 359,nomajor organ dysfunction. Diagnosedtohave de-novoheart failure withmoderate tosevere MR. StartedGDM therapy. Done Echo on 15.10.20 showed moderately dilatedLVmoderate tosevere Global LVdysfunction EF 40-45%.RSVP 50-55%.. Normal Coronaries on18.11.20. Case No 2 69 yr male DM,HTN Smoker & old CVA recovered. Admitted at Hira hospital with biliary pancreatitis. Had new onset breathlessness so did echo and was found to have LV systolic dysfunction, so deferred surgical interventionand referred to KAMC for further evaluation. Seen at screening clinic on 21.10.20. Exertional breathlessness FC 11 no PND for 2 months. Considered De novo Heart Failure ,ischemic type 1V ( without angina & no MI) .Started GDM Therapy and did lab work on same day and reviewed after a week with Echo. Normal LV size EF 30% suspected LV thrombus. BNP 504, no major organ dysfunction. Started anticoagulants and booked for MRI to confirm LV thrombus . MRI showed laminated clot, Scarred distal LAD and Viable LCX /RCA.CAG on 19.11 .20 showed diffuse 3 VD CAD. Discussed in MDT for medical treatment De-novo Heart Failure Syndromes
- 12. RAHFC Rapid Access Heart FailureClinic Summary of 4 cases These are 4 typical examples ( 3 male 1 female)of de novo heart failure with moderate symptoms,referred to our screening clinic ,evaluated as rapid access heart failure clinic review , beforevisit to ER ist HF admission indeed. All were seen in month of October 2020, started guide line directed medical therapy (GDMT ) on clinical judgement to control symptomsand prevent visit to ER and admission. All were admitted for CAG , 3 out of 4 ( 75%) turn out to have ischemic heart failureType 1V ( without documented MI and Angina ) Severe multi vessel CAD with LV systolic dysfunction EF around 25% to 40% .One of them had suitable revascularizationtargets ( Left main 3VD) underwent CABG during index hospitalization, In 2nd patient targets were not suitable for revascularization,3rd patient for CABG and MVR but left DAMA, he was started sacubitril before ACE/ARB. Currentlywe are utilizing screeningclinic as RAHFC , not only for diagnostic but we see old diagnosed HF cases on same day ( HFSDC ) . This novel service unique in Makkah can be utilized for cluster hospitalsof the region to avert severe acute HF, recurrentER visits and ist HF hospitalization,which is more costly and deadly indeed as compare to RAHFC. After building confidence of model 11 secondary care hospitals,they can take over this novel service to pave space for advance heart failure centre ( LVAD & transplant ) at KAMC .
- 13. RAHFC Rapid Access Heart FailureClinic RAHFC Diagnostic New onset Heart failure Patients with mild to moderate symptoms usually go to community physician clinics or private hospitals ,who do not have facilities to confirm diagnosis and establishHF etiologyand precipitant ,we can see them at RAHFC ,to preventist HF admission and ER visit. RAHFC Prognostic Known Heart failure Patients with established etiologywho are following in general cardiology or internal medicine ,if need to consult HF specialistcan be seen on same day,( SDHFC) especially those patients coming fromout side makkah .In this way we can save time ,cost and thousands of Kil.m distance. RAHFC Therapeutic Ambulatory HF Patients with stage C and D, who are frequently visiting ER ( shuttle fromER to CCU ) for I/V diuretics ,or ionotrops , can be seen on this clinic to reduce burden of ER, observationunit and CCU readmissions ,this service is less costly ,but only during OPD hours. Three different RAHFC/ SDHFC Services
- 14. RAHFC What is RapidAccess Heart Failure Clinic RAHFCis based in outpatient department . every day ( 8 to 4 PM) .Mainly for new onset suspected HF. De-novo HF (with mild to moderate symptoms ) Patient will be seen without appointment on same , or next working day . For clinical assessment and basic investigationson same day. Slogan & target is One stop fast track heart referral from Community /ER to “Best care” whenever and wherever require.
- 15. RAHFC Rapid Access Heart FailureClinic RAHFC Background: The diagnosis of heart failure ( especially diverse etiologies and precipitants )is an important clinical problem at model 1 and model 11 HF services. Reported clinical diagnostic accuracy especially in primary care clinics is less than 90%. The aims of the RAHFC is to provide rapid diagnosis of heart failure in patients presenting for the first time in the community/ER, who do not require hospital admission ,and to facilitate the early introduction of evidence based life prolonging therapies.
- 16. RAHFC Rapid Access Heart FailureClinic Why RAHFC, In primary care services, an accurate clinical diagnosis of heart failure syndromes is complex and indeed difficultin the absence of heart failure physician and specialized investigations. A study from Finland showed ,the diagnosis of heart failure in the community is correct in less than 50% of cases, as compared to a gold standard of specialistclinical assessment based clinical scenario.
- 17. RAHFC Rapid Access Heart FailureClinic Who should be seen at RAHFC; All Patients with suspected new onset heart failure with mild to moderate symptoms are usually seen by primary care physicians or at the emergency department with the same diagnosis, but who do not require hospital admission ,are eligible for referral to this first novel prestigious service. Patients with known heart failure are not eligible for this clinic.
- 18. RAHFC Rapid Access Heart FailureClinic Who should run RAHFC, Every patient with new onset heart failure should be assessed by heart failure physician / dedicated experienced cardiac /internal medicine physician under supervision of chairman of the Heart Failure program.
- 19. RAHFC Rapid Access Heart FailureClinic What is to be assessed& expected at the end, Clinical assessment based on rigorous history ,meticulous physical examination,and clinical diagnosis must be clearly documented. CBC, full chemistry, electrocardiogram ( EKG ), X-ray chestPA/Lat, BNP/Pro BNP, followed by echocardiogram. At the end of the RAHFC assessment cases will categorize as definite , possible heart failure or No heart failure . After the RAHFC provided rapid assessment ,prompt diagnosis with possible etiology and triggering factors ,will start evidence based life prolonging therapy.
- 20. RAHFC Rapid Access Heart FailureClinic RAHFC documentation requirements, Those with clear clinical HF diagnosis , document type of heart failure based on ejection fraction (HFrEF, HFmrEF, HFpEF) , NYHA, Functional Class,( FC 1-1V ) Heart Failure Stage, ( stage C/stage D), establish HF etiology , and identify precipitants indeed. After all requirements transfer them to regular heart failure clinic or if admitted then follow them at post discharge HF clinic until compensated . If progressed to advance Heart failure refer them to advanced heart failure clinic for timely advanced therapies.
- 21. RAHFC Rapid Access Heart FailureClinic RAHFC final outcome , After phase 1 thorough evaluation ,if no evidence of heart failure ,write a feed back & disposition letter to referring community physician for continuation of care, & primary prevention, if stage A or stage B HF. After Phase 11, evaluation and stabilization including revascularization and surgical intervention, if fullfil dispose criteria ,write a dispose summary , treatment plan & transfer them back to referring hospital/community HF Centres for follow up. If not possible can follow at regular heart failure clinics every 6 months to one year.
- 22. RAHFC Rapid Access Heart FailureClinic Post RAHFC assessment Post RAHFC still suspected HF patients , who require specialized diagnostic tests ( Cardiac CT/MRI /CAG ) can be seen in regular heart failure clinic until results are available . Those without evidence of heart failure will be discharge from the RAHFC to primary referring physician. With a detailed feedback report including results of investigations and proposed management, shall reach primary physician within 7 days after completion of work up.
- 23. Conclusion First HF admissionand recurrent readmissions are two different worlds. New onset ( de-Novo) heart failure, acute decompensation of chronic heart failure ( ADCHF) and chronic advanced heart failure are three different syndromes with heterogeneous aetiologies , precipitants and prognosis indeed.
- 24. Conclusion Regular Heart failureclinic is old & tiny part of the multidisciplinary clinical care heart failure program and network , which is not plenteous. Which patient to be seen on which clinic and when ???. To prevent ist admission and readmission, referral and evaluation of Right patient at right time in a right clinic for better outcome is a science or art ,time will teach us. Heart failure referral , admission ,discharge and disposition criteria and clinical pathways are corner stones in diagnosis and management of heart failure syndromes.
- 25. Conclusion Our Patients are10-15 years younger than the west, they have great trust on us; let,s not be passive or anxious, and give them the best , and state of art heart failure treatment without delay regardless of color ,class and creed indeed.
- 26.