1. Care Coordination for Heart Failure Patients
Karol E. Watson, MD, PhD, FACC
Professor of Medicine/Cardiology
Co-director, UCLA Program in Preventive Cardiology
Director, UCLA Barbra Streisand
Women’s Heart Health Program
Los Angeles, CA

2. Disclosure
Financial relationships with commercial interests listed below are not relevant to the CME activity:
Dr. Watson serves as a consultant/speakers bureau member for Boehringer Ingleheim, and a consultant for Amgen

3. The burden of heart failure
21 MILLION adults worldwide are living with heart failure
This number is expected to rise.1,2
ECONOMIC BURDEN
In 2012, the overall worldwide cost of heart failure was nearly $108 BILLION.3
MORTALITY
50% of heart failure patients die within 5 years from diagnosis4
The burden of heart failure
Just looking at these numbers suffices to convince about the burden of heart failure:
21 million adults are currently estimated to suffer from heart failure1,2
Most HF patients have 3 or more comorbidities3
Heart failure is the NUMBER 1 cause of hospitalization for patients aged >65 years4
50% of heart failure patients die within 5 years from diagnosis5
Heart failure did cost 108 billion US dollars in 2012 worldwide6
Mozaffarian D et al. Circulation. 2015;131(4):e29-e322.
Mosterd A et al. Heart. 2007;93(9):
Cowie MR et al. Oxford PharmaGenesis; Accessed February 18, 2015.
Fauci AS et al. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
Cook C et al. Int J Cardiol. 2014;171(3):
1. Mozaffarian D et al. Circulation. 2015;131(4):e29-e322.
2. Mosterd A et al. Heart. 2007;93(9):
3. Cook C et al. Int J Cardiol. 2014;171(3):
4.  Fauci AS et al. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.

4. Learning Objectives
Discuss trends in heart failure readmissions and strategies to reduce re-hospitalizations
Discuss evidence – based management of chronic Heart Failure and adverse drug events (ADE) associated with HF medications

5. Why are we talking about Readmissions?

6. 1 in 5 Medicare beneficiaries were rehospitalized within 30 days
Estimated cost to Medicare: $17.4 Billion (2004)
Jencks et. al. NEJM, 2009

7. Affordable Care Act: Reducing Readmissions
3026: Community Based Care Transitions – 5-year Medicare pilot program available to hospitals identified by the HHS Secretary as having high readmission rates. Under the program, hospitals must engage in at least one evidence based care transition intervention (BOOST?)
3501: By Oct. 1, 2011, the Director of the Agency for Healthcare Research and Quality shall establish the Center for Quality Improvement and Safety, which will support the Director to “identify, develop, evaluate, disseminate, and provide training in innovative methodologies and strategies for quality improvement practices in the delivery of health care services that represent best practices (referred to as 'best practices') in health care quality, safety, and value
399KK: Quality Improvement Program for Hospitals with a High Severity Adjusted Readmissions
3025: Hospital Readmissions Reduction Program. AHA opposes penalties against hospitals

8. Phillips et al. JAMA 2004;291:

9. Important elements for reducing readmissions
Assess risk of readmission based on accepted risk factors
Risk Assessment
High rate of readmissions due to ADEs, drug omissions, and poor adherence
Controlling Medications
Use teachback tools; clear patient instructions; empower patient to navigate healthcare system
Patient Education/Self Management
Anticipate needs; Clear home plan; Involve PCP and cardiologist
Clear Care Plan,
Follow up appointments made before hospital d/c; Clear plan to share relevant information
Communication and Care Coordination

10. Risk Factors for Readmissions

11. Important elements for reducing readmissions
Assess risk of readmission based on accepted risk factors
Risk Assessment
High rate of readmissions due to ADEs, drug omissions, and poor adherence
Controlling Medications
Use teachback tools; clear patient instructions; empower patient to navigate healthcare system
Patient Education/Self Management
Anticipate needs; Clear home plan; Involve PCP and cardiologist
Clear Care Plan,
Follow up appointments made before hospital d/c; Clear plan to share relevant information
Communication and Care Coordination

12. Controlling medications is essential
110 patients recently discharged from an academic medical center.
Patients received a phone call from a pharmacist within 2 days of discharged and asked how they were feeling and if they understood all of their medications
Pharmacists corrected any medication related problems
Pharmacists communicated problems to the care team
Am J Med 2001; 111 (9B) 26X

13. Controlling medications is essential
Patient satisfaction
Control – 61%
Intervention – 86% p=0.007
ED visits within 30 days
Control – 24%
Intervention – 10% p=0.005
Hospital Readmissions
Control 25%
Intervention 15% p = 0.07
A key finding was that 19% of patients had difficulty obtaining all of their discharge medications
Am J Med 2001; 111 (9B) 26X

14. Important elements for reducing readmissions
Assess risk of readmission based on accepted risk factors
Risk Assessment
High rate of readmissions due to ADEs, drug omissions, and poor adherence
Controlling Medications
Use teachback tools; clear patient instructions; empower patient to navigate healthcare system
Patient Education/Self Management
Anticipate needs; Clear home plan; Involve PCP and cardiologist
Clear Care Plan,
Follow up appointments made before hospital d/c; Clear plan to share relevant information
Communication and Care Coordination

15. All patients with Heart Failure should purchase a scale

16. Home Daily Weights
The vascular bed can hold 10 pounds of fluid before it starts to seep out into the tissues
2 pounds = 1 quart of water extra in the circulation
Usual recommendation:
Report a 2-pound weight gain in 1 day or a 3-pound gain in 1 week

17. Heart Failure Teaching
Monitor Daily weights
Same time
Same place
Same scale
2 lb. increase in 24 hours or 3 lb. increase in 1 week is significant
Patients can be taught to adjust their diuretic dose / K+ based on changes in weight
Dietary sodium restriction (2-3 gm/d)
Routine fluid restriction is NOT necessary
Don’t forget to address weight reduction 17

19. Important elements for reducing readmissions
Risk Assessment
Assess risk of readmission based on accepted risk factors
High rate of readmissions due to ADEs, drug omissions, and poor adherence
Controlling Medications
Use teachback tools; clear patient instructions; empower patient to navigate healthcare system
Patient Education/Self Management
Anticipate needs; Clear home plan; Involve PCP and cardiologist
Clear Care Plan
Follow up appointments made before hospital d/c; Clear plan to share relevant information
Communication and Care Coordination

20. Follow-up by Physician Type
GWTG HF Follow up after Hospital Admissions
Follow-up by Physician Type
Hernandez et al. JAMA , May 5, 2010 – Vol. 303, No. 17

21. GWTG HF Follow up after Hospital Admissions
4.7% of patients died in the 30 days after discharge
30-day mortality was significantly lower among patients admitted to hospitals which had a high rate of early follow-up with a cardiologist
Hernandez et al. JAMA , May 5, 2010 – Vol. 303, No. 17

22. Important elements for reducing readmissions
Risk Assessment
Assess risk of readmission based on accepted risk factors
High rate of readmissions due to ADEs, drug omissions, and poor adherence
Controlling Medications
Use teachback tools; clear patient instructions; empower patient to navigate healthcare system
Patient Education/Self Management
Anticipate needs; Clear home plan; Involve PCP and cardiologist
Clear Care Plan,
Follow up appointments made before hospital d/c; Clear plan to share relevant information
Communication and Care Coordination

23. Preventing HF Readmissions: a team effort
Patient
Cardiologist
Primary Care Provider
Heart Failure Nurse
Pharmacist
Family
Others?

24. As HF readmissions are reduced, HF care must remain optimal
JACC Volume 70, Issue 15, October 2017

25. Learning Objectives
Discuss trends in heart failure readmissions and strategies to reduce re-hospitalizations
Discuss evidence – based management of chronic Heart Failure and adverse drug events (ADE) associated with HF medications

26. Heart Failure (HFrEF) Management
Medications used in virtually all HFrEF patients
diuretics (most patients will need)
ß blockers
ACE inhibitors / ARBs or sacubitril/valsartan
Medications used in select HFrEF patients
Aldosterone antagonists
Hydralazine / Isosorbide
Digoxin
Ivabradine

27. Diuretics
Accepted Clinical Benefit: Diuretics relieve symptoms of dyspnea and edema
BUT
No good randomized trials
Activate RAAS and SNS
Electrolyte abnormalities
Over diuresis can lead to Renal Failure
High Doses correlate with poorer prognosis
Aim for minimum effective dose to control symptoms

28. 3 key Neurohumoral systems affect HF
SNS
RAAS
Vasoconstriction
Blood pressure
Sympathetic tone
Aldosterone
Hypertrophy
Fibrosis
RAAS activity
Vasopressin
Heart rate
Contractility
β-blockers
Natriuretic peptide system
Vasodilation
Natriuresis/diuresis
An imbalance occurs in three key neurohumoral systems
Overactivation of the RAAS and SNS is detrimental in HFrEF and underpins the basis of therapy. Activation of the natriuretic peptide system is protective, which can counterbalance the adverse effects due to overactivation of the other two systems.
1. McMurray et al. Eur J Heart Fail. 2012;33:1787–847;
Figure references: Levin et al. N Engl J Med 1998;339:321–8; Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42; Kemp & Conte. Cardiovascular Pathology 2012;365–371; Schrier & Abraham N Engl J Med 1999;341:577–85
Abbreviations
ACEI=angiotensin-converting-enzyme inhibitor; Ang=angiotensin; ARB=angiotensin receptor blocker; AT1 = angiotensin II type 1; HF=heart failure; HFrEF=heart failure with reduced ejection fraction; MRA=mineralocorticoid receptor antagonist; NEP=neprilysin; NPs=natriuretic peptides; NPRs=natriuretic peptide receptors; RAAS=renin-angiotensin-aldosterone system; SNS=sympathetic nervous system
Figure references: Levin et al. N Engl J Med 1998;339:321–8; Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42 Kemp & Conte. Cardiovascular Pathology 2012;365–71 Schrier & Abraham. N Engl J Med 1999;341:577–85

29. -Blockers
Over 10,000 patients evaluated in long-term placebo-controlled clinical trials (carvedilol, bisoprolol, metoprolol)
Decrease in all-cause mortality by 30%-35% (P<.0001)
Decrease in combined risk of death and hospitalization by 35%-40% (P<.001); effect shown in 6 individual trials
Effect shown in patients already receiving ACE-I

30. ß Blockers
Generic Name
Trade Name
Initial Daily Dose
Target Dose
Mean Dose in Clinical Trials
Bisoprolol
Zebeta
1.25 mg qd
10 mg qd
8.6 mg/day
Carvedilol
Coreg
3.125 mg bid
25 mg bid
37 mg/day
Coreg CR
80 mg qd
Metoprolol CR/XL
Toprol XL
mg qd
200 mg qd
159 mg/day
Contra-indications: severe, brittle reactive airways disease
Cautions: current or recent HF exacerbations; heart block
Troublesome interactions: other rate reducing medications

31. Even low doses of B-blockade can have a dramatic effect
Ejection Fraction* ‡ 8
P<.001 † 6 †
LVEF (EF units) 4 2
The MOCHA trial in mild to moderate HF showed that clinical benefits with carvedilol begin at 6.25 mg bid.1
As this slide depicts, EF increased incrementally as the dose of carvedilol was increased.
Placebo
6.25 mg bid
12.5 mg bid
25 mg bid
Carvedilol
Patients receiving diuretics, ACE inhibitors, ± digoxin; follow-up 6 months; placebo (n=84), carvedilol (n=261).
*Results from the Multicenter Oral Carvedilol Heart Failure Assessment (MOCHA) trial (n=345).
†P.005 vs placebo.
‡P.0001 vs placebo.
Adapted from Bristow MR et al. Circulation. 1996;94:2807–2816.
1Bristow MR et al. Carvedilol produces dose-related improvements in left ventricular function and survival in subjects with chronic heart failure. MOCHA Investigators. Circulation. 1996;94:

32. ACE Inhibitors ~ 7000 patients evaluated in controlled clinical trials
Improvement in cardiac function, symptoms, and clinical status; equivocal effects on exercise tolerance
Decrease in all-cause mortality by 20%-25% (P<.001) and decrease in combined risk of death and hospitalization by 30%-35% (P<.001)
Garg and Yusuf, JAMA May 10;273(18):

33. ACE Inhibitor Adverse Effects
Hypotension
Renal Insufficiency
Hyperkalemia
Cough (20 %)
Angioedema
With captopril especially: neutropenia, nephrotic syndrome, skin rash, taste disturbances (SH group- related)
pregnancy risk category C (D in second and third trimesters)

34. Classification of Drug Risks in Pregnancy
Controlled studies show no risk or adequate, well-controlled studies have failed to show risk. B
Animal findings show risk but human findings do not, or animal findings are negative with no human studies done. C
Risk cannot be ruled out. Human studies are lacking. Animal studies show risk or are lacking as well. D
Evidence of risk. Investigational or post-marketing data shows risk to fetus. However, benefits may outweigh risk. X
Contraindicated in pregnancy. Studies have shown fetal risks which clearly outweigh any possible benefit to the patient.

35. ACE Inhibitor Drug : Drug Interactions
Digoxin: may increase digoxin level by 15% to 30%.
Iithium :increase lithium levels and symptoms of toxicity possible (monitor).
Potassium sparing diuretics , K supplements may cause hyperkalemia .(monitor pts closely).
Drug-food:
salt substitutes containing K : increase K level .

36. Angiotensin Receptor Blockers (ARBs)
Recommendations
ARBs are recommended in patients with HF and reduced LVEF who are ACEI intolerant
DO NOT USE ACE-I and ARBs TOGETHER
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult

37. ARB Adverse effects
Drugs in this class are usually tolerated.
Advantage over ACEIs is the low incidence of cough.
Angioedema is also rare.
Headach.
Fatigue.
Hyperkalemia.
pregnancy risk category C (D in second and thrid trimesters)
Cough is improved by switching ACE inhibitor to ARB

38. ARB Drug : Drug Interactions
Drug-drug: K sparing diuretics , K supplements may cause hyperkalemia .(monitor pts closely).
Drug-food: salt substitutes containing K : increase K level .
DO NOT USE ACE-I and ARBs TOGETHER

39. Background: Neprilysin Inhibition (NI)
Natriuretic peptide system
Renin-angiotensin system
Natriuretic Peptides
Sacubitril X
ACE-I
ARB X
Neprilysin
Angiotensin I
Inactive Fragments
Angiotensin II
Vasodilation
Natriuresis/diuresis
Vasoconstriction
Adapted from Bonow RO, et al. Global Cardiology Science and Practice. 2014; 34: dx.doi.org/ /gcsp

40. Angiotensin Receptor Neprilysin Inhibition (ARNI)
Sacubitril: Prodrug that inhibits neprilysin leading to increased levels of natriuretic peptides
Valsartan: Direct antagonism of angiotensin II receptors inducing vasoconstriction through aldosterone, catecholamine, arginine vasopressin release

41. Sacubitril/Valsartan (ARNI)
Tablet comes in 3 doses
24mg/26mg
49mg/51mg
97mg/103mg
Indicated to reduce the risk of cardiovascular death and hospitalization for heart failure (HF) in patients with chronic heart failure (CHF) (NYHA class II-IV) and reduced ejection fraction
Recommended starting dose: 49 mg/51 mg BID
Target dose: 97 mg/103 mg BID

42. ARNI Precautions
Side Effects
Hypotension
Hyperkalemia
Increase serum creatinine
Angioedema
Cough
Contraindications
History of angioedema with previous ACE or ARB therapy
Use of ACE inhibitors within 36 hours of dose
Use with aliskirin
Pregnancy
allow a 36 hour washout period when switching from or to an ACE inhibitor

43. Reducing Heart Failure Readmission
Readmission of patients with heart failure is common and costly.
Reducing HF Readmissions Is a national priority
Reducing Readmissions Requires a team approach
Hospitals that fail to reduce Readmissions will be penalized
Reducing Readmission is just good medicine