1 Multi-Disciplinary Heart Failure Management Connie Keibler, MSN, ARNP Western Washington Medical Group, Cardiology

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3 Heart Failure Outlook 5 million Americans have Heart Failure 1/2 million new diagnosis of HF annually $27 Billion annual health care burden 250,000 deaths from HF annually Leading cause of hospitalization for those over 65 years old

4 Heart Failure Hospitalization $14 Billion spent annually for those admitted to the hospital in Acute Decompensated Heart Failure 3.5 million hospitalizations annually 1/3 of those admitted for ADHF are re- admitted within 90 days A hospital visit for ADHF results in 60 day mortality rates between 8 and 20% Increased mortality risk persists for 6 mos.

5 Heart Failure Future

6 Heart Failure Mortality 250, 000 deaths annually 1/2 of those diagnosed with Heart Failure die within 5 years

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8 Heart Failure Risk Common Causes –Ischemic heart Disease –Diabetes –Hypertension –Valvular Heart Disease –ETOH Abuse –Obesity –Cigarette Smoking –Hyperlipidemia –Physical Inactivity –Sleep Apnea Less Common Causes –Familial Hypertrophic CM –Postpartum CM –Thyroid Abnormality –Connective Tissue Disorders –Toxin Exposure –Myocarditis –Sarcoidosis –Hemochromatosis –Medication Exposure

9 Heart Failure-A Syndrome Heart failure is a constellation of symptoms and signs produced by a complex circulatory and neuro-hormonal response to cardiac dysfunction Heart failure is a complex clinical syndrome that can results from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.

10 Clinical Classifications Backward –Inability of the ventricle to eject its contents, resulting in elevated filling pressures Forward – decreased cardiac output and inadequate tissue perfusion

11 Clinical Classifications Left-Sided –Left Ventricle is weakened or overloaded Results in pulmonary congestion Right-Sided –Right Ventricle is impaired Results in systemic venous overload May occur independently from conditions affecting the right ventricle only Left-Sided failure usually is the cause of right- sided failure

12 Clinical Classifications Systolic: –Impaired ability of the heart to contract –Weakened muscle, enlarged heart size –Inability of heart to empty –Left ventricular ejection fraction (LVEF) < 40–45% Diastolic: –inability of the heart to relax is impaired –Stiff, thickened myocardial wall but normal size –Inability of heart to fill –LVEF  45%

13 Clinical Classifications Acute –sudden onset with associated signs and symptoms Chronic –secondary to slow structural changes occurring in the stressed myocardium Acute Decompensated –sudden exacerbation or onset of symptoms in chronic heart failure

14 Clinical Classifications Heart Failure is a Symptomatic Disorder New York Heart Association-Functional Classification Class I: No abnormal symptoms with activity Class II: Symptoms with normal activity Class III: Marked limitation due to symptoms with less than ordinary activity Class IV: Symptoms at rest and severe limitations in functional activity

15 Clinical Classifications Heart Failure is a Progressive Disorder ACC/AHA Stages of HF Stage A--Presence of risk factors for heart failure Stage B--Presence of structural heart disease but no Symptoms Stage C--Presence of structural heart disease along with signs and symptoms Stage D--Presence of structural heart diseases and advanced signs and symptoms

16 ACC/AHA 2005 Guidelines

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18 HF Hospitalization 1/3 of those admitted for ADHF are re- admitted within 90 days 1/2 of all HF Hospital Re-Admissions are Avoidable A hospital visit for ADHF results in 60 day mortality rates between 8 and 20%

19 Clinical Predictors A Multivariate Analysis using the ADHERE Data Identified the Following Most Significant Predictors of Mortality: –Bun –Systolic BP –HR –Age

20 Seattle Heart Failure Model Age Gender Ischemic Etiology NYHA Ejection Fraction Systolic BP Cholesterol Hemoglobin % Lymphocyte Count Uric Acid Sodium Use of –K-Sparing Diuretic –Statin –Allupurinol –Diuretic Multivariate risk model using the following Predictors of Survival at Baseline and after Interventions

21 Reasons for Re-Admission Compliance with Medication Compliance with Diet, Specifically Sodium Delays in Seeking Medical Attention

22 JACHO Quality of Care Indicators DC Instructions Assessment of LV Function ACEI or ARB at Discharge Smoking Cessation Advice/Counseling

23 JACHO Quality of Care Indicators Education better absorbed when the patient is stable and adapted to living with HF OPTIMIZE-HF found that DC Instructions did not have an effect on Mortality or Re days. Missing continuity of Care in the Community Home Care Heart Failure Clinics Primary Care

24 Barrier to HF Management Cognitive Impairment Complex Self Care Management Lack of Motivation –Poor Physical Capacity –Depression –Anxiety Multiple Co-Morbidities Psychosocial/Financial Concerns Physical Limitations Multiple Heath Care Providers and Lack of Shared Communication

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26 Heart Failure Management Improve Access to Appropriate Cost- Effective Health Care Prevent Hospitalization Improve QOL Improved Survival Control Health Care Costs Goals

27 Multi-Disciplinary HF MGMT Fluid Management Education Intensity of Care Access Characteristics Strategy must outline and follow clinical rationale based on practice guidelines that define target care patterns for patients.

28 Systematic Review Literature Review 74 Trials and 30 Meta- Analysis Shared Key Elements –One to One Patient Education –Symptom Monitoring and Strategies for Self- Management

29 Self-Management of HF Compliance with evidence based medications Adopt a low-sodium diet Reduce fat and cholesterol in diet Restrict fluid intake if indicated Stop smoking Eliminate alcohol consumption Increase activity/exercise Monitor daily weight

30 Self-Management of HF AND Notify health care provider of signs and symptoms of worsening heart failure –pain in jaw, neck, or chest –increased SOB –increased fatigue –dizziness of syncope –swelling in feet, ankles, legs, or abdomen –palpitations –tachycardia –weight gain –decreased exercise capacity

31 Deventer-Alkmaar HF Study Physician and Nurse Directed HF Clinic vs. Usual Care –1 year intervention –9 scheduled visits 3 telephone 6 office 1 week after discharge Verbal and written education Optimized Rx Easy Access Advice for self-care

32 Deventer-Alkmaar HF Study 51% risk reduction in Primary End-Point –Hospitalization for worsened HF and/or All Cause Mortality –NNT - 5 Improved EF at 1 Year Improved NYHA Class Significant Improvement in QOL Scores

33 Multi-Disciplinary Management Quick and sustained improvements 6 wk intervention Cost savings of $67,804 Comprehensive inpatient education, discharge planning, and outpatient support vs. usual care* Multi-Disciplinary Team Physician Champion Advanced Practice Nurse or PA Nurse Educator Home Health Nurse Dietician Physical Therapy Social Services Pharmacist

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35 Nursing Nursing is a profession focused on assisting individuals, families, and communities in attaining, maintaining, and recovering optimal health and functioning. Modern definitions of nursing define it as a science and an art that focuses on promoting quality of life as defined by persons and families, throughout their life experiences from birth to care at the end of life.

36 Collaborative practice is intended to combine the knowledge and skills of several health professionals to maximize the efficiency of both the clinicians and the health care system. Collaborative practice brings together health care professionals with different and complimentary knowledge and skills to increase the scope of and access to patient services. Collaborative Practice Shared responsibility and outcomes

37 Collaborative Practice Correct and accurate transfer of vital patient information Effective team collaboration that produces positive patient care outcomes Behaviors that aid and encourage respect, trust and credibility among team members Expected Outcomes

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39 Just One Day EL 89 y/o female CAD, S/P MI Ischemic CM/EF 20/NYHA Class III DM Type II Chronic Renal Insufficiency/GFR 38 Parox Afib on Amiodarone Dyslipidemia ICD/DDD SB 70 y/o Male SSS Chronic Afib Idiopathic CM/EF 30/NYHA Class I HTN DS 76 y/o Male CAD w/ recent MI/Stent Ischemic CM/EF 45/NYHA Class II Diabetes/Poorly controlled/HgA1C 10 HTN Dyslipidemia Chronic renal insufficiency LO 87 y/o Male CM/EF 24/NYHA Class III HTN Dyslipidemia Chronic Alcoholism Chronic Afib Chronic renal insufficiency/GFR 37

40 Just One Day MG 59 y/o Male CAD Ischemic CMEF 36 CAD Ischemic CMEF 36 PVD/BKA Anemia Legally Blind Hypothyroidism HTN ICD RK 59 y/o Male CAD Ischemic CM/EF 15/NYHA Class III COPD On-going smoking HTN Dyslipidemia ICD/BIV Pacing Hypothyroidism Hx ETOH abuse/Depression

41 Cardiac Rhythm Management Small improvements in hemodynamics =significant improvements in HF symptoms symptoms. Optimizing hemodynamics has long been a target of therapy in HF.

42 Cardiac Rhythm Management Risk Reduction CRT Diagnostics HR Trends HR Variability Patient Activity Intrathoracic Impedance Arrhythmias Remote Monitoring

43 Cardiac Rhythm Management Identify and recognize cardiac device patients who are eligible for monitoring Download device data Analyze/interpret the data Use the data to guide therapy Establish a collaborative model and cooperative environment between the EP team and HF Goals for Heart Failure Management

44 Quality of Life Issues End of Life Issues And

45 Challenges are what make life interesting; overcoming them is what makes life meaningful. -Joshua J. Marine I am only one, But still I am one. I cannot do everything, But still I can do something; And because I cannot do everything I will not refuse to do the something that I can do. - Edward Everett Hale

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