FINISHING WELL: WHEN TO DISCHARGE THE ADHF PATIENT BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE

DISCLOSURES NONE

2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES Journal of Cardiac Failure 2010; 16:e1-e194

AHA STATISTICS 2010 > 1 million ADHF admissions /year HF complicates the admission diagnosis in another 2 million admissions / year In- hospital mortality for ADHF 4% 90 day readmission rate for ADHF: >50% Admission LVEF > 40%: 40- 50% Cost of HF: $37 billion/year (most of cost is hospitalization)

WHAT’S WRONG WITH READMISSION? If readmitted within 30 days: no reimbursement Readmission increases the chances of readmission Readmission increases mortality

MARKERS OF RISK OF READMISSION FROM ESCAPE, ADHERE, AND EFFECT BNP BUN AND CREATININE CARDIAC ARREST OR MECHANICAL INTUBATION SERUM Na AGE SBP RESPIRATORY RATE COMORBID CONDITIONS HEART RATE

MARKERS OF 6 MONTH READMISSION RISK: ESCAPE BNP > 500 (HIGH) AND > 1300 (HIGHER BUN > 40 (HIGH) AND >90 (HIGHER) DIURETIC DOSE > 240 mg/day FUROSEMIDE SERUM Na < 130 INABILITY TO TOLERATE BETA BLOCKERS AGE >70 6 MINUTE WALK < 300 FEET

2010 HFSA GUIDELINES: HOSPITAL DISCHARGE It is recommended that criteria in the following table be met before a patient with Heart Failure is discharged from the hospital. (Strength of Evidence = C)

DISCHARGE CRITERIA FOR ALL HEART FAILURE PATIENTS Exacerbating factors addressed Near optimal volume status observed Transition from IV to PO diuretic successfully completed Patient and family education completed, including clear discharge instructions LVEF documentation

DISCHARGE CRITERIA FOR ALL HEART FAILURE PATIENTS Smoking cessation counseling initiated Near optimal pharmacologic therapy achieved, including ACEI and beta blocker (for patients with reduced LVEF) or intolerance documented Follow up clinic visit scheduled, usually for 7-10 days

HOSPITAL DISCHARGE In patients with advanced Heart Failure or recurrent admissions for Heart Failure, additional criteria listed in the following table should be considered. (Strength of Evidence = C)

CRITERIA SHOULD BE CONSIDERED FOR PATIENTS WITH ADVANCED HF OR RECURRENT HF ADMISSIONS Oral medication regimen stable for 24 hours No IV vasodilator or inotropic agent for 24 hours Ambulation before discharge to assess functional capacity after therapy Plans for post discharge management (scale present in home, visiting RN or telephone follow up within 3 days after discharge) Referral for disease management, if available

2010 HFSA GUIDELINES: PRECIPITATING FACTORS It is recommended that patients admitted with ADHF undergo evaluation for the following precipitating factors: Atrial fibrillation or other arrhythmias Exacerbation of hypertension Myocardial ischemia/infarction Exacerbation of pulmonary congestion Anemia Thyroid disease Significant drug interaction Other less common factors

COMMON AND UNCOMMON PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION Dietary and medication related causes Progressive cardiac dysfunction Cardiac causes not primarily myocardial in origin Non-cardiac causes Adverse cardiovascular effects of medications

PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: DIETARY AND MEDICATION RELATED CAUSES Dietary indiscretion - excessive salt or water intake Nonadherence to medications Iatrogenic volume expansion

PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: PROGRESSIVE CARDIAC DYSFUNCTION Progression of underlying cardiac dysfunction Physical, emotional, and environmental stress Cardiac toxins: alcohol, cocaine, chemotherapy Right ventricular pacing

PRECIPITATING FACORS ASSOCIATED WITH ADHF HOSPITALIZATION: CARDIAC CAUSES NOT PRIMARILY MYOCARDIAL IN ORIGIN Cardiac arrhythmias Atrial fibrillation with RVR VT Marked bradycardia Conduction abnormalities Uncontrolled hypertension Myocardial ischemia or infarction Valvular disease: progressive MR

PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: NONCARDIAC CAUSES Pulmonary disease - PE, COPD Anemia - bleeding, BM suppression, relative lack of erythropoietin Systemic infection - especially pulmonary infection, UTI, viral illness Thyroid disorders

PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION- ADVERSE CV EFFECTS OF MEDICATION Cardiac depressant medications Nondihydropyridine calcium antagonists Type Ia and Ic antiarrhythmic agents Sodium retaining medications Steroids NSAID, COX-2 inhibitors, pregabalin, thiazolidinediones

PRECIPITATING FACTORS: MY HEARTS DIE MYOCARDIAL DISEASE PROGRESSION HIGH OUTPUT CAUSES/ HYPERTENSION EMBOLISM (PE) ARRHYTHMIAS REDUCTION OF THERAPY THE DEVELOPMENT OF A SYSTEMIC ILLNESS /TOXINS SECOND HEART DISEASE DRUGS, DEPRESSANTS, DOC INFECTION, INFLAMMATION, ISCHEMIA, INFARCT EXCESS IN ENVIRONMENTAL, EMOTIONAL, OR PHYSICAL EXTREME

2010 HFSA GUIDELINES: EVALUATION OF HEART FAILURE HISTORY AND PHYSICAL PA AND LATERAL CHEST X-RAY EKG ECHOCARDIOGRAM LABS ISCHEMIA EVALUATION

2010 HFSA GUIDELINES: LAB EVALUATION OF HEART FAILURE LABS CBC ELECTROLYTES, BUN, CREATININE, GLUCOSE FASTING LIPID PANEL LIVER FUNCTION TEST Ca AND Mg THYROID FUNCTION URINALYSIS URIC ACID BNP

2009 ACCF/AHA OR 2010 HFSA GUIDELINES: ISCHEMIA EVALUATION ANGINA + HF: CATH HF + OBJECTIVE EVIDENCE OF ISCHEMIA: CATH HF + HIGH PROBABILITY OF CAD: CATH HF + KNOWN CAD: CATH HF + LOW PROBABILITY OF CAD: STRESS OR CATH HF + YOUNG PATIENT: CATH TO R/O CONGENITAL CORONARY ANOMALY

DISCHARGE PLANNING Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues: Details regarding medications, dietary sodium restriction, and recommended activity level Follow up by phone or clinic visit early after discharge to reassess volume status Medication and dietary adherence

DISCHARGE PLANNING Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues: (Strength of Evidence=C) Alcohol moderation and smoking cessation Monitoring of body weight, electrolytes, and renal function Consideration of referral for formal disease management

UNM SOLUTION HEART FAILURE EDUCATOR: LORENA BEEMAN, RN PAGER: 951-3113 PHONE: 307-1242 ALL INPATIENT EDUCATION GOALS MET CARDIAC REHABILITATION CONSULT PHONE: 272-2396 EXERCISE AND OUTPATIENT EDUCATION GOALS MET CORE MEASURES ORDERED ON EVERY PATIENT SMOKING CESSATION IF SMOKED WITHIN THE PAST YEAR LVEF ASSESSED IF NOT WITHIN THE PAST 6 MONTHS ACEI/ARB OR CONTRAINDICATION DOCUMENTED FOR LVEF <40% MEDICATION RECONCILIATION

UNM SOLUTION HEART FAILURE CONSULT SERVICE 24-7 PAGER: 951-0049 HEART FAILURE CLINIC REFERRAL BEFORE DISCHARGE CALL THE CLINIC 24-7 AT 925-6002 AND LEAVE MESSAGE NAME, TELEPHONE NUMBER, DATE OF DISCHARGE, MRN 72 HOUR TELEPHONE CALL DOCUMENTED CLINIC VISIT WITHIN 7 CALENDAR DAYS OF DISCHARGE HEART FAILURE POWER PLAN

IF DR. STEVENSON WERE TO DISCHARGE A PATIENT: MANN’S HEART FAILURE: A COMPANION TO BRAUNWALD’S HEART DISEASE, SECOND EDITION (2011) EDITED BY DOUGLAS MANN, M.D. CHAPTER 48: “MANAGEMENT OF ACUTE DECOMPENSATED HEART FAILURE” BY LYNNE WARNER STEVENSON, M.D.

TEXTBOOK DISCHARGE: CLINICAL STATUS GOALS No discharge until dry weight achieved Bring the home scale to the hospital before discharge This facilitates immediate disclosure of lack of home scale Blood pressure range is defined Walking without dyspnea or dizziness

TEXTBOOK DISCHARGE : STABILITY GOALS 24 hours without changes in oral regimen for heart failure > 48 hours off IV inotropic agents, if used Even fluid balance on oral diuretics Renal function stable or improving

TEXTBOOK DISCHARGE : DISCHARGE REGIMEN Estimated diuretic dose, with plan for first escalation if needed ACEI/ARB or documented contraindication Beta blocker discharge dose, plans for outpatient initiation, or documented contraindication Anticoagulation for atrial fibrillation unless contraindicated

TEXTBOOK DISCHARGE: PATIENT/FAMILY EDUCATION Sodium restriction Fluid limitation if indicated Medication schedule Medication effects Exercise prescription

TEXTBOOK DISCHARGE : HOME INSTRUCTIONS Monitoring of symptoms and weights Instructions regarding when and whom to call Scheduled call to patient within 3 days Clinic appointment within 7 calendar days of discharge and information handed off to monitoring physician