1. Heart Failure management in long term care
PMDA 19th Annual Symposium
October 21, 2011
Leon S. Kraybill, MD, CMD
Geriatric Specialists, Lancaster General Hospital
PMDA: Pennsylvania's Association for Long Term Care Medicine

2. Email contact: leonkraybill@gmail.com
Dr. Kraybill has no conflicts of interest or financial benefit from this presentation
Digital copy of powerpoint slides and handouts available at:
contact:
PMDA: Pennsylvania's Association for Long Term Care Medicine

3. Who gets heart failure? Primarily older people; female > male
Over age 65 = 10/100
80% of patients hospitalized for HF are > 65 yo
Multiple comorbidities (ie diabetes increases the risk of HF by 80%)
PMDA: Pennsylvania's Association for Long Term Care Medicine

4. Why discuss heart failure?
HF is the most common Medicare DRG diagnosis, and consumes more Medicare dollars than any other diagnosis
Common cause of death in LTC population
2005: 37% of all Medicare spending, and ~ 50% of inpatient costs.
2008: Estimated US direct and indirect cost of heart failure = $34.8 billion.
PMDA: Pennsylvania's Association for Long Term Care Medicine

5. So……Heart failure is…. Common Expensive
Can we alter the course, management, outcome, and cost?
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6. LTC disease management
Interventions to reduce hospitalizations from nursing homes: Interact II, JAGS April 2011
17-24% reduction in hospital admissions
Interact II website: a variety of tools and care pathways to help reduce acute care transfers; including dehydration, fever, mental status changes, heart failure, lower respiratory infection, and UTI
See attached Early Warning tool, and SBAR
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7. Lecture goals
Efficient, compassionate, and cost effective management of heart failure in LTC – honoring the wishes of the people who entrust their health decisions to us
…..And not push ourselves over the edge in the process
PMDA: Pennsylvania's Association for Long Term Care Medicine

8. Heart failure definition (HF)
A complex clinical syndrome that results from any structural or functional disorder that impairs the ability of the ventricles to fill with or eject blood at a rate commensurate with the body's needs
Congestive heart failure (CHF) = HF + clinical signs and symptoms of volume overload
PMDA: Pennsylvania's Association for Long Term Care Medicine

9. HF etiology The simple explanation - a failing heart
The more complex explanation - a consequence of cardiac muscle remodeling, mediated by neurohormonal responses (rennin-angiotensin-aldosterone system)
PMDA: Pennsylvania's Association for Long Term Care Medicine

10. HF is a clinical diagnosis
A clinical constellation of symptoms and signs
Labs can only confirm clinical suspicions, or demonstrate consequences
Older patients may not present typically
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11. Start and end with treatment goals
Prolongation of life
Improvement of quality of life
Prevention of exacerbations
Prevention of hospital readmissions (and associated cost)
Timely provision of palliative care
PMDA: Pennsylvania's Association for Long Term Care Medicine

12. Identify History of heart failure
Look at the records! EKG, ECHO, chest x-ray, consults.
Suspect if: hypertension, diabetes, CAD, ischemic heart disease, cardiomyopathy, valvular heart disease.
Do not be surprised by a diagnosis that is already documented on the record.
PMDA: Pennsylvania's Association for Long Term Care Medicine

13. Symptomatic heart failure: Signs
Ascites
Hypoalbuminemia
Increased jugular venous pressure
Positive hepatojugular reflux
Laterally displaced apical impulse
Peripheral edema not due to venous insufficiency
Rales on lung exam
Tachycardia
Third heart sound (S3)
Weight gain
PMDA: Pennsylvania's Association for Long Term Care Medicine

14. Symptomatic heart failure: Symptoms
Abdominal symptoms (nausea, abdominal pain or distention)
Acute confusional state, delirium
Anorexia
Decline in functional status
Decreased exercise tolerance
Decreased food intake
Dyspnea at rest
Dyspnea on exertion
Fatigue
Orthopnea
Paroxysmal nocturnal dyspnea
Unexplained cough, especially at night
Weakness
PMDA: Pennsylvania's Association for Long Term Care Medicine

15. What your staff may actually report to you:
New or increasing lower extremity swelling
Clothing (shoes, pants) appears tight compared previous week
Resident appears lethargic or mentally inert
Resident is less active
Resident has more difficulty breathing with or without exertion
Unexplained cough
Unexplained weight gain
PMDA: Pennsylvania's Association for Long Term Care Medicine

16. Accurate weights are key!
Same time of day
Same state of dress
Same scale (and staff members that know how to use the scale)
How often?
What is your facility P&P?
PMDA: Pennsylvania's Association for Long Term Care Medicine

17. Identify and manage risk factors
Anemia
Dysrhythmia (atrial fibrillation)
Hypertension
Chronic lung disease
CAD
Diabetes
Excessive alcohol
Noncardiac fluid volume overload
Sleep disordered breathing
Thyroid disease
Valvular heart disease
Medications – NSAIDs, metformin, glitazones (Actos), calcium channel blockers
PMDA: Pennsylvania's Association for Long Term Care Medicine

18. New York Heart Association HF classification
Class I (mild)
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath)
Class II (mild)
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea
Class III (moderate)
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea
Class IV (severe)
Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased
PMDA: Pennsylvania's Association for Long Term Care Medicine

19. Differentiating types of HF
HF with reduced left ventricular ejection fraction (systolic heart failure)
Reduced myocardial contractility (CAD, cardiomyopathy)
Generally worse prognosis
EF cutoff – usually 35-45%
More dyspnea, cough, wheezing, fatigue, hypotension, confusion, delirium
HF with preserved left ventricular ejection fraction (diastolic heart failure)
Decreased left ventricular filling pressures (decreased rate of relaxation, rapid heart rate, ventricular stiffness)
Primary cause = hypertension
More than 50% of HF patients > 70 yo
Right-sided heart failure
Right ventricle changes
Cause: pulmonary disease, left sided heart failure (most residents with advanced HF have both L and R-sided HF
More leg edema, nausea, vomiting, abd ominal sx, dependent edema
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20. Decide regarding evaluation
Is there another terminal/end-stage condition?
Will the evaluation change the management? (would the patient decline treatment?)
Will the burden of evaluation be greater than the benefit of treatment?
Are there likely to be reasonable treatments?
Document, document, document
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21. Evaluation tools CXR ECHO Pulse oximetry
Labs: CBC, CMP (lytes, calcium, renal, liver), magnesium, TSH, ?lipids
To BNP or not to BNP?
EKG – angina, dysrhythmia, hx of ischemia
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22. Reassess the individual’s goals and realistic options
What does the resident want? QOL/comfort vs prolongation of life?
Do the resident/family understand the availability of palliative care in LTC?
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23. Possible reasons for transfer to hospital
Acutely symptomatic and decompensating
Unstable cardiac ischemia
Limited reasonable treatment options in LTC
Resident wants full and aggressive intervention
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24. Dietary restrictions
Restrictions should be consistent with the resident’s prognosis and quality of life
Salt restriction (< 2 grams/day rarely feasible) - may be helpful in moderate to severe heart failure
Fluid restriction - hyponatremia, unstable fluid balance despite diuretics
Maybe L daily fluid restriction in advanced heart failure (grades III & IV) – evidence grade B1
Nutritional supplements – generally not indicated
CoQ10 - not recommended as a therapy for heart failure by the ACC/AHA
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25. Heart failure medications
Goal is euvolemia
Most patients will need diuretics
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26. Low EF HF: Diuretics
Thiazide diuretics usually ineffective once CrCl < 30 (? 50)
Loop diuretics improve symptoms and quality of life but do not prolong life
Few meaningful clinical differences between different meds
Furosemide 20 – 40 mg daily, double until desired diuresis
Bumetanide and torsemide may be more bioavailable with an edematous bowel
Metolazone mg prior to furosemide may improve diuresis (but cause more ↓K and ↓Mg
When volume has stabilized, seek lowest possible diuretic dose
Follow renal function and electrolytes
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27. Diuretics: Hypomagnesemia
Thiazides and loop diuretics increase Mg loss
↓Mg is often present with ↓K and ↓Na
Serum Mg levels are unreliable measures of total body Mg
Magnesium gluconate is more soluble, and causes less diarrhea
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28. Low EF HF : Angiotensin-converting enzyme inhibitors (ACEIs)
Improve quality of life, ↓mortality by 23%, and
↓ risk of hospitalization by 35%
First-line agent in HF with EF < 35%
Caution: hypotension (?tolerate SBP of 80-90), hyperkalemia, worsening renal function
Accept 20-30% rise in creatinine
Angiotensin receptor blocker (ARB) if intolerant to ACEI
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29. Low EF HF: Beta blockers
Good evidence for ↓symptoms and ↑sense of well-being, ↓risk of death (↓30-65%), and ↓hospitalization
Indicated for all patients with stable HF due to ↓EF, if no contraindication
Should be used in combination with diuretics if fluid retention is present
Proven benefit: carvedilol, metoprolol succinate, bisoprolol (metoprolol has less hypotension than carvedilol)
Titrate slowly to target dose (see chart) by doubling dose every 2-4 weeks
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30. Low EF HF: Beta blockers
Initial Dose
Target Dose
Bisoprolol
12.5 mg daily
10 mg daily
Carvedilol immed release
3.125 mg BID
25 mg BID
Carvedilol ext. release
40-80 mg daily
Metoprolol ext. release
200 mg daily
PMDA: Pennsylvania's Association for Long Term Care Medicine

31. Low EF HF: Digoxin Less widely used
No mortality benefit but some improvement in symptoms and hospitalization
Dosage – rarely > mg daily
Serum levels – usually < 1.0
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32. Low EF HF: Aldosterone antagonists (spironolactone)
May help to counter adverse effects of aldosterone in NYHA Class III & IV
High risk for ↑K and ↑creatinine (esp if CKD, or on ACEI)
Not good clinical data on age > yo
PMDA: Pennsylvania's Association for Long Term Care Medicine

33. Low EF HF: Isosorbide dinitrate + hydralazine
For African-American residents with HF –
↓ mortality, ↓hospitalizations, ↑ QOL
Adjunctive therapy if symptomatic despite standard therapies
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34. Low EF HF: Other treatments
Calcium channel blockers
Nifedipine, diltiazem, verapamil-- ↑HF and mortality
Amlodipine & felodipine okay for BP control - no HF benefit
Implantable cardioverter defibrillators
Risk of sudden death if EF < 35
Do not treat symptoms, only prolong life
Cardiac resynchronization therapy
Consider if symptomatic HF despite optimal medical management, EF< 35, QRS > 120 ms, Class III or IV, AND prognosis for good functional status > 1 year
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35. Low EF HF treatment summary
ACEIs - most patients
Beta blockers – most patients
Diuretics – most patients
Aldosterone antagonists – selected patients
Digoxin – selected patients
Isosorbide dinitrate/hydralazine - selected African-American patients
PMDA: Pennsylvania's Association for Long Term Care Medicine

36. HF with preserved EF (diastolic HF)
Evidence based therapy is less clear
Goals – decrease fluid overload, and treat elevated filling pressures
Control hypertension – perhaps most important
Diuretics – if fluid overload
ACEI/ARB – less clear benefit (unless concomitant diabetes) – studies lean towards benefit
Beta Blockers – sparse data
Digoxin – if symptomatic despite other meds
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37. HF with preserved EF: Summary
Control of systolic and diastolic hypertension
Control of ventricular rate in patients with AF
Control of pulmonary congestion and peripheral edema with diuretics
If ischemia – consider coronary revascularization (if consistent with goals)
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38. Peripheral edema management
Elevation of extremities
Support hose
Elastic tubular bandages
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39. End of life care in HF
Sudden death – up to 60% of HF patients, but can’t predict
Gradual deterioration with increasingly frequent acute episodes
Explain and offer palliative measures sooner rather than later
Discuss the goals of care, code status, intubation, hospitalization
Listen and give opportunity for questions
Deactivate the defibrillator
Dyspnea – diuretics, oxygen, thoracentesis, opiods
Hallucinations, delirium – atypical antipsychotics
Myoclonus, seizures - lorazepam
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40. HF monitoring & assessment protocol & tools
Early Warning Tool (general)
SBAR – a general preparation tool for the assessing nurse to report any clinical change to provider
“BELLS WARN” – HF screening tool for direct caregivers
Heart failure in long-term care monitoring protocol
Heart failure graphic flow sheet
LTC Heart Failure assessment tool
Digital versions at
PMDA: Pennsylvania's Association for Long Term Care Medicine

41. Developing clinical assessment tools and treatment protocols
PMDA has interest in developing further
If interested, contact
Leon Kraybill –
Tom Lawrence -
PMDA: Pennsylvania's Association for Long Term Care Medicine

42. Heart failure in LTC Common Expensive in time and money
Proactive identification and management will help to prevent subsequent complications and resident distress
The resident and the family must be engaged early and throughout the process to identify their goals and wishes
This is a collaborative effort – none can do it alone, all must be involved
PMDA: Pennsylvania's Association for Long Term Care Medicine

43. References
Heart Failure in the Long-Term Care Setting, AMDA Clinical practice guideline, 2010,
Interact2 - from Florida Atlantic University – dedicated to reducing acute care transfers, website contains a variety of tools and resources:
Interventions to reduce hospitalizations from nursing homes: Interact II, JAGS April 2011;
Care path: symptoms of congestive heart failure:
SBAR: Situation, Background, Assessment, Request- a conceptual tool for supervising nursing staff to assess and report a LTC clinical change:
Assessing Heart Failure in Long Term Care Facilities; Harrington, C. University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core; 2006 Oct 2006 – an EBM practice guideline, 38 page PDF with a variety of tools:
DEFEAT heart failure: assessment and management of heart failure in nursing homes made easy. Ahmed A, Jones L, Hays CI, J Am Med Dir Assoc Jul;9(6): Epub 2008 Jun 3,
Clinical manifestations, diagnostic assessment, and etiology of heart failure in older adults, Ahmed A, Clin Geriatr Med Feb;23(1):11-30,
PMDA: Pennsylvania's Association for Long Term Care Medicine