The 80% of hospitalisations for HF occur in individuals aged more than 65 years. Circulation. 2008;117(4):e25-e146
Five-year survival following a first admission for heart failure
Readmission after hospital discharge Am Heart J. 2000 Jan;139(1 Pt 1):72-7. within 6 months
The readmission rates rise with time J Am Geriatr Soc. 1990;38(12):1290-5
Am J Cardiol. 2005;96:86G-89G. Each hospitalisation effect myocardial and/or renal damage
Discharge planning… General topics Explanation of HF Expected symptoms and symptoms of worsening HF Psychological responses Dietary recommendations Activity and exercise Medications
Discharge planning… n Should be initiated within 24-48 hours after hospital admission.
Criteria for clinical stability with chronic heart failure Freedom from evidence of congestion Angina absent or present in stable exertional pattern Stable vital signs No syncope or other recurrent symptomatic arrhythmias Stability of non-cardiovascular disease Stable renal functions Compliance with medical regimen Social support Absence of serious depression or dementia
Education n Education of pts with HF is essential aspect of pts care that promote clinical stability. n The education modules should be self-contained and written in easy to understand language. Each module should be provided practical information on a specific topic that is useful to both patients and their families.
Education n Physicians, advanced practice nurses, home health nurses and dietitians all play important roles in this process.
Education Although 80% of the patients knew they should limit the amount of salt in their diet, only one-third regularly avoided salty foods. Approximately 40% of the patients did not recognize the importance of weighing themselves daily. Arch Intern Med. 1999;159(14):1613–1619
Self-management As up to 50% of hospital admissions may be preventable with an effective strategy to reduce admissions is to improve self management. JAMA 2000; 19:2469–75
Self-management Optimal self management of chronic illness involves the patient engaging in activities that promote their health, control the impact of their illness on their daily life, adherence to medication regimens and medical appointments is closest to optimal. JAMA 2000; 19:2469–75
The ineffective management programs were less likely to follow the guidelines. Eur Heart J. 2006;27(5):596-612
It is common practice to withdraw a β-blocker when patients are admitted to hospital because of worsening CHF
Keep BBStop BB During hospitalization Durations (days)11.5±8.310.4 ± 9.7 Deaths (n)1 (HF)2 (HF) After 3 months Deaths, %98 Re-hospit, (%)4047 For HF (%) 2232 For arrhythmia (%) 34 B-CONVINCED B-CONVINCED: Beta-blocker CONtinuation Vs. INterruption in patients with Congestive heart failure hospitalizED for a decompensation episode Eur Heart J. 2009;30(18):2186-92
The Recommendations of ESC Guideline When Worsening symptoms/signs occur: If increasing congestion – increase dose of diuretic and/or halve dose of beta-blocker If marked fatigue (and/or bradycardiasee below) – halve dose of beta-blocker ESC Heart Failure Guideline 2008 Keep BB
The Recommendations of ESC Guideline In severe situations, temporary discontinuation can be considered. Low-dose therapy should be re-instituted and up-titrated as soon as the patient's clinical condition permits, preferably prior to discharge. Keep BB ESC Heart Failure Guideline 2008
The Recommendations of ESC Guideline In patients admitted to hospital due to worsening HF, a reduction in the β-blocker dose may be necessary. Keep BB ESC Heart Failure Guideline 2008
Activity and Exercise Pts should be encouraged to stay as active as possible, including sexual activity and a moderate exercise (aerobic training) program. BMJ 2004;328:189
Medications The one of the major cause of re- hospitalisation and heart failure exacerbation is lack of compliance with prescribed medications. Arch Intern Med. 1988;148(9):2013-6Am J Crit Care. 1998;7(3):168-74
Adherence to guidelines is a predictor of outcome in the MAHLER survey chronic heart failure: the MAHLER survey Eur Heart J 2005;26:1653-1659
The cost of hospital readmissions is lower in the intervention group by $460 ($153 per pt/month)
Vaccinations A further case series showed that 12% of hospitalizations in HF pts were due to pulmonary infection.
Vaccinations Patients with chronic HF should receive one pneumococcal vaccination and an annual influenza vaccination.
Reasons for non-compliance with therapeutic regimen Lack of knowledge Poor motivation Lower self-efficacy Comorbidities Forgetfulness Decreased support from family or caregivers J Cardiovasc Nurs. 1997;11(4):75-84
Medications Pts should be taught the name of each drug and its purpose, dosage, frequency and significant side effects. A medication schedule may also minimize to potential for drug interactions. Alternative medications should not be taken without consulting the healthcare team.
P=0.012. Discharge Education Improves Clinical Outcomes in Patients With Chronic Heart Failure Circulation. 2005;111:179-185
Heart Failure Clinics Patients who received regular cardiovascular follow-up visits with a physician had fewer visits to emergency department, fewer admitted to hospital and 1-year mortality is lower. both specialist and family physician family physician only no physician visits
Written materials and videotapes are not replacement for one-to-one education.
Impact of heart failure management unit on heart failure-related readmission rate and mortality Archives of cardiovascular disease, 2010;103(2):90-6
Meta-analysis showed a significant reduction in all cause admission (relative risk 0.87, 95% confidence interval (CI) 0.79 to 0.95, p< 0.002) However, significant heterogenity (p< 0.002) was found
PacifiCare and Alere Medical to Provide Congestive Heart Failure Patients Innovative AlereNet CHF Management System. Daily electronic home monitoring system Patients initiate the monitoring process each morning by simply standing on the DayLink(R) monitor, located in their home. A phone line to the Alere Network automatically transmits the information to a central call station monitored by cardiac- trained nurses who analyze trends that may reveal a change in the patient's health status. If indicated, the patient's doctor is notified, and the need for clinical intervention is assessed before an expensive hospital admission or emergency room visit is required.
AlereNet CHF Management System is representing a 56.2% difference in mortality Am Heart J 2003;146(4):705-12. the Weight Monitoring in Heart Failure (WHARF) trial The number of patients needed to treat in order to save one life was 9.7
The cost per patient for the Home Health Monitor is $408/month
Effect of Home-Based Telemonitoring Using Mobile Phone Technology on the Outcome of Heart Failure Patients After an Episode of Acute Decompensation: Randomized Controlled Trial the MOBIle TELemonitoring in Heart Failure Patients Study (MOBITEL)
The telemonitoring equipment consisted of three commercially available components: (1) a mobile phone (Nokia 3510, Finland), (2) a weight scale with 0.1 kg accuracy and electronic display (Soehnle creta, Germany), and (3) a sphygmomanometer for fully automated measurement of blood pressure and heart rate (BosoMedicus, Bosch&Sohn, Germany). J Med Internet Res 2009;11(3):e34
Tele group patients were asked to measure vital parameters (blood pressure, heart rate, body weight) on a daily basis at the same time, preferably in the morning after emptying the bladder and before dressing and taking medication. J Med Internet Res 2009;11(3):e34
Study physicians had access to a secure website providing both numerical and graphical depiction of data for each patient. Whenever necessary, study physicians could contact patients using the mobile phone J Med Internet Res 2009;11(3):e34
Trend chart of vital parameters of a typical patient
Providing elderly patients with an adequate user interface for daily data acquisition remains a challenging component of such a concept. J Med Internet Res 2009;11(3):e34
Factors predicting early post-discharge mortality include Age, Serum creatinine, Reactive airway disease, Liver disease, Lower systolic blood pressure, Lower serum sodium, lower admission weight, and depression Am Heart J. 2008 Oct;156(4):662-73.
Multidisciplinary interventions to patients with heart failure not only reduces hospital admission but also is an effective method for reducing mortality.
Intervention costs were higher with more complex programs ($8383 per patient per year) versus less complex programs ($1695 per patient per year). Journal of Cardiac Failure 2007;13(1):56-62
Hit-P inT Post-discharge Heart Failure Monitorization Program in Turkey
The patients are randomized (2:1) blinded to control and investigation group. Intensive education about HF before discharging, by experienced cardiologist and nurse Using a teaching booklet
End-points Primary end-point: Cardiovascular death or hospitalisasiton Secondary end-point; All cause of hospitalisations hospitalisation related to worsening HF Admission to emergency unite Any cause of death