a hospital-based approach to achieving better health outcomes … · 2018-12-10 ·

This CME activity is provided by Integrity Continuing Education.This CEU/CNE activity is co-provided by Postgraduate Institute for Medicine and Integrity Continuing Education.

A Hospital-based Approach to Achieving Better Health Outcomes in Heart Failure

FacultyLee Goldberg, MD, MPH

Medical DirectorHeart Failure and Cardiac Transplant Program

Associate Professor of MedicineCardiovascular Medicine Division

University of PennsylvaniaPhiladelphia, Pennsylvania

Consultant: Respircardia

Faculty Disclosures

Utilize an evidence-based approach to the diagnosis and evaluation of patients with heart failure (HF) that is consistent with current guideline recommendations

Summarize current clinical evidence regarding the efficacy and safety of new pharmacologic therapies for the treatment of heart failure with reduced ejection fraction (HFrEF)

Implement guideline-directed medical therapy for patients with HF

Identify transitional care strategies to prevent disease progression and future hospitalizations among patients with HF

Learning Objectives

Heart Failure in the Hospital Setting

Trends in Primary HF Admissions and In-hospital Mortality (2001-2014)

Akintoye, et al. J Am Heart Assoc. 2017;6:e006955.

Rat

e of

Adm

issi

on (p

er 1

00,0

00 p

erso

ns)

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

600

550

500

450

400

350

% In

-hos

pita

l Mor

talit

y

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

5

4.5

4

3.5

3

2.5

2

1.5

Δ in trend in 2005 = -2.4 (95% CI: -4.4, -0.39); P=0.02

Δ in trend in 2009 = -1.0 (95% CI: -2.3, 0.30); P=0.14

Δ in trend in 2005 = 0.41 (95% CI: -1.3, 2.1); P=0.64

Δ in trend in 2009 = 3.2 (95% CI: 1.9, 5.4); P=0.002

Medicare Readmission Rates Among Patients Hospitalized for HF

Available at: http://kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/

Despite recent decreases, a significant percentage (22%) of patients hospitalized with HF are readmitted within 30 days.

24.5 24.7 24.8 24.7

23.0 22.722.019.9 19.9 19.8 19.7

18.3 17.817.0

18.2 18.3 18.4 18.517.6 17.3 16.9

151617181920212223242526

July 2005-June 2008

July 2006-June 2009

July 2007-June 2010

July 2008-June 2011

July 2009-June 2012

July 2010-June 2013

July 2011-June 2014

Nat

iona

l Ave

rage

R

eadm

issi

on R

ate

(%)

Performance (Measurement) Time Period

Heart FailureHeart AttackPneumonia

Diagnosis for Initial Hospitalization

30-Day Risk Standardized HF Mortality Rates Under HRRP

RSMR, risk standardized mortality rate; RSRR, risk standardized readmission rate; CMS, Centers for Medicare and Medicaid Services.Abdul-Aziz AA, et al, J Cardiac Fail. 2017;23:S5-S6.

While 30-day readmission rates have improved for HF, 30-day HF mortality rates have increased at more than half of US hospitals since the advent of Centers for CMS readmission penalties.

0.5

0.0

-0.5

-1.0

Cha

nge

in R

SMR

2016

vs

2013

(%)

Change in RSRR 2016 vs 2013 (%)

CHF

AMI

Decreased >-1.0

-1.0 to 1.0 Increased >1.0

Opportunities to Improve Patient Outcomes: Principles for Successful HF Treatment

GDMT, guideline-directed medical therapy.Adapted from: Yancey, et al. J Am Coll Cardiol. 2018;71(2):201-230.

Implement GDMT

I. Initiate and switch treatment as appropriate

II. Titration to optimal dose

Address Specific Care Challenges

I. ReferralII. Care coordinationIII. AdherenceIV. Specific patient

cohortsV. Cost of care

Manage Other Aspects of HF

I. Increasing complexity of disease

II. ComorbiditiesIII. Palliative/hospice

care

Patient Evaluation

A careful history and physical examination remain the cornerstones of assessment

Assessment for HF

ACCF/AHA Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239.

Patient history

Physical examination

Diagnostic laboratory

testing

Cardiac imaging

Invasive evaluation

Risk factors– Family history– Other conditions (eg, HTN, CAD/MI,

thyroid disease, & diabetes)

Duration of illness Symptoms

– Type– Severity

Recent/frequent prior hospitalizations for HF

Diet– Sodium intake

Medication– Discontinuation or nonadherence – Agents that may exacerbate HF

De novo HF indicators– Inadequate BP control– New-onset or poorly controlled AF– New ischemia– Metabolic, respiratory, & other stressors

Patient History

HTN, hypertension; CAD, coronary artery disease; MI, myocardial infarction; BP, blood pressure; AF, atrial fibrillation.ACCF/AHA Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239.

Shortness of breath Chronic coughing/

wheezing Edema Fatigue/lightheadedness Nausea/lack of appetite

Confusion/impaired thinking

Elevated HR

Symptoms of HF

HR, heart rate.

Available at: http://www.heart.org/HEARTORG/Conditions/HeartFailure/WarningSignsforHeartFailure/Warning-Signs-of-Heart-Failure_UCM_002045_Article.jsp#.V7YfgFsrL4Z.

Physical Examination Weight loss or gain BP (supine and upright) Pulse JVP at rest (sitting or standing)

and/or positive Kussmaul’s sign

Presence of extra heart sounds and murmurs

Size and location of PMI Presence of RV heave Pulmonary status: RR and

pleural effusion Hepatomegaly and/or ascites Peripheral edema Presence of cool lower

extremities

JVP, jugular venous pressure; PMI, point of maximal impulse; RV, right ventricular; RR, respiratory rate.ACCF/AHA Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239.

Recommendations for the Use of Biomarkers in the Evaluation of Patients with HF

Biomarker, Application Setting COR LOENatriuretic peptides

Diagnosis or exclusion of HF Ambulatory, Acute I A

Prognosis of HF Ambulatory, Acute I A

Achieve GDMT Ambulatory IIa B

Guidance for ADHF therapy Acute IIb C

Biomarkers of myocardial injuryAdditive risk stratification Acute, Ambulatory I A

Biomarkers of myocardial fibrosisAdditive risk stratification Ambulatory IIb B

Acute IIb A


Association Between Discharge BNP and Clinical Outcomes

OPTIMIZE-HF

BNP, brain natriuretic peptide.Kociol RD, et al. Circ Heart Fail. 2011;(4) 628-636.

CI UpperHR CI Lower

3

2.75

2.5

2.25

2

1.75

1.5

1.25

1300 800 1300 1800 2300 2800 3300 3800 4300

Discharge BNP

Haz

ard

Rat

io

Death at 1 Year

Haz

ard

Rat

io300 800 1300 1800 2300 2800 3300 3800 4300

Discharge BNP

Death or hospitalization at 1 Year2

1.9

1.8

1.7

1.6

1.5

1.4

1.3

1.2

1.1

1

NT-proBNP Reduction Lowers the Rate of CV Death or HF-related Hospitalization

NT-proBNP, N-terminal pro b-type natriuretic peptide.Zile MR, et al. J Am Coll Cardiol. 2016;68:2425-36.

Ris

k of

Prim

ary

Endp

oint

Af

ter

1 M

onth

0 1 2 3Years

0.5

0.4

0.3

0.2

0.1

0.0

Did not achieve NT-proBNP ≤1000 pg/mL

AchievedNT-proBNP ≤1000 pg/mL

Stage Characteristics Class Characteristics

A Significant risk factors for HF No known structural heart disease No signs or symptoms of HF

None

B Structural heart disease No signs or symptoms of HF I No functional limitation

C Structural heart disease Prior or current symptoms of HF

IIIIIIIV

No functional limitation Symptoms with activity beyond

ADLs Symptoms with ADLs Symptoms of HF at rest

D Refractory HF requiring specialized

interventions (eg, transplant, VAD, palliative care/hospice, and experimental therapies)

IV Symptoms of HF at rest

ACCF/AHA Stages and NYHA Functional Classes of HF

ACCF/AHA, American College of Cardiology Foundation/American Heart Association; VAD, ventricular assist device; ADLs, activities of daily living.ACCF/AHA Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239.

HF Type by Ejection Fraction

*HFrEF has been defined across different guidelines by left ventricular ejection fraction 35%, <40%, and 40%.

EF, ejection fraction; HFpEF, heart failure with preserved ejection fraction.ACCF/AHA Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239; Tannenbaum S, et al. Curr Opin Cardiol. 2015;30(3):250-258.

HF

HFrEF(Systolic HF)

HFpEF(Diastolic HF)

EF ≤40%* EF ≥50%

Focus on risk factor controlPharmacologic and nonpharmacologic therapies

Treatment Options for HFrEF

Conventional Guideline-recommended Pharmacologic Treatments

() For select patients.ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; NYHA, New York Heart Association.ACCF/AHA Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239.

TherapyNYHA Class

1 2 3 4

ACE inhibitors, ARBsBeta-blockersAldosterone antagonistsDiureticsDigoxin

Hydralazine and isosorbide dinitrate

()

()

() () ()

() ()()

Newer Therapies for the Treatment of HF

*The metallopeptidase neprilysin hydrolyzes natriuretic peptides.RAAS, renin-angiotensin-aldosterone system; NP, natriuretic peptide.von Lueder TG, et al. Pharmacol Ther. 2014;144(1):41-49; DiFrancesco D. Circ Res. 2010;106(3):434-446; Rosa GM, et al. Expert Opin Drug Metab Toxicol. 2014;10(2):279-291. Corlanor [prescribing information]. Amgen; 2015.

Therapy Mechanism of Action

Ivabradine• Selective inhibition of sinus node If channel (decreases HR)• Does not affect cardiac ionotropy and can be used with a

beta blocker

AngiotensinReceptor–Neprilysin

Inhibitor (ARNI)

• Angiotensin receptor blockade + inhibition of neprilysin*(inhibits RAAS and augmenting NP activity)

Impact of Ivabradine Treatment on CV Death or Hospital Admission for Worsening HF

Swedberg K, et al. Lancet. 2010;376(9744):875-885.

0 6 12 18 24 30Months

Patients with Primary Composite Endpoint (%)

Placebo (937 events)Ivabradine (793 events)

HR 0.82 (95% CI 0.75–0.90), P<.0001

0 6 12 18 24 30Months

Patients with First Hospital Admission for Worsening HF (%)

30 Placebo (672 events)Ivabradine (514 events)

HR 0.74 (95% CI 0.66–0.83), P<.0001

40

30

20

0

1010

20

0

CV, cardiovascular; HR, hazard ratio; CI, confidence interval.

Ivabradine Added on to Standard of Care Therapy Reduces the Risk of Hospitalizations for HF

Borer JS, et al. Eur Heart J. 2012;33(22):2813-2820.

HospitalizationIvabradine(N=3241)

Placebo(N=3264)

HR (95% CI) P value

First 514 (16%) 672 (21%) 0.75 (0.65–0.87) P<.001

Second 189 (6%) 283 (9%) 0.66 (0.55–0.79) P<.001

Third 90 (3%) 128 (4%) 0.71 (0.54–0.93) P<.012

0.4 0.6 0.8 1.0 1.2Favors Ivabradine Favors Placebo

Heart Rate Reduction with Ivabradine Improves Outcomes Independently of HF Duration

Bohm M, et al. Eur J Heart Fail. 2018;20:373–381.

Patie

nts,

%

0 6 12 18 24 30 36Time from Randomization, Months

50

40

30

20

10

0

Log rank P <.0001

Placebo

Patie

nts,

%

0 6 12 18 24 30 36Time from Randomization, Months

50

40

30

20

10

0

Log rank P <.0001

Ivabradine

Effect of ARNI Treatment on the Risk of Death or First-time Hospitalization for HF

McMurray JJ, et al. N Engl J Med. 2014;371(11):993-1004.

HR, 0.80 (95% CI, 0.71–0.89)P<.001

0 180 360 540 720 900 1080 1260Days Since Randomization

Cum

ulat

ive

Prob

abili

ty


1.0 Primary Endpoint

HR, 0.80 (95% CI, 0.73–0.87)P<.001

Cum

ulat

ive

Prob

abili

ty


1.0 Death From CV CausesC

umul

ativ

e Pr

obab

ility


1.0 Hospitalization for HF

HR, 0.79 (95% CI, 0.71‒0.89)P<.001

Cum

ulat

ive

Prob

abili

ty 1.0 Death from Any Cause

HR, 0.84 (95% CI, 0.76‒0.93)P<.001

EnalaprilARNI

0.60.50.40.30.20.10.0

0.60.50.40.30.20.10.0

0.60.50.40.30.20.10.0

0.60.50.40.30.20.10.0

ARNI Treatment Reduces the Incidence of Hospital Readmissions

Desai AS, et al. J Am Coll Cardiol. 2016;68(3):241-248.

21

13.4

30.5

20.317.8

9.7

27.8

17.1

0

5

10

15

20

25

30

35

30-day All-cause 30-day HF 60-day All-cause 60-day HFReadmission

EnalaprilARNI

Inve

stig

ator

-Rep

orte

d H

ospi

taliz

atio

ns

Asso

ciat

ed w

ith R

eadm

issi

on (%

)

ARNI Treatment Reduces CV Death and HF Hospitalization Across the LVEF Spectrum

LVEF, left ventricular ejection fraction.Solomon SD, et al. Circ Heart Fail. 2016;9(3):e002744.

Favors ARNI Favors Enalapril

OverallP interaction = 0.87

≤28>28 to 33≥33

Primary Endpoint

Hazard Ratio


.5 .75 1 1.25 1.5

CV Death


≤28>28 to 33≥33

Hazard Ratio


.5 .75 1 1.25 1.5

.5 .75 1 1.25 1.5


≤28>28 to 33≥33

HF Hospitalization

Hazard Ratio

All-Cause Death


≤ 28> 28 to 33≥ 33

Hazard Ratio


.5 .75 1 1.25 1.5

How Should Newer Therapies Be Incorporated into GDMT?

Yancey, et al. J Am Coll Cardiol. 2018;71(2):201-230.

HFrEF Stage C Treatment

ACEI / ARB ANDbeta blocker with diuretic as needed

Titrate

Diuretics

Add

Hydralazine + isosorbide

dinitrate

Switch

ARNI

Add

Aldosterone Antagonist

Add

Ivabradine

For patients with persistent volume

overload, NYHA class II-IV

For persistently symptomatic African

Americans, NYHA class III-IV

For patients stable on ACEI/ARB,

NYHA class II-III

For patients with eGFR≥30 mL/min/1.72 m2,

K+ <5.0 mEq/dL,NYHA class II-IV

For patients with resting HR ≥70, on maximally tolerated beta blocker dose in sinus rhythm,

NYHA class II-III

Multi-center, patient-level, randomized, open-label study Patient population (N=~450)

– Reduced LVEF of 35% – HR 70 bpm – Discharged following stabilization from acute HF

Predischarge initiation of ivabradine or usual care Post-discharge follow-up at 7-14 days, 6 weeks,

and 180 days HR, systolic BP, and quality of life to be assessed

PRIME-HF: When Should Therapy Be Initiated?

Available at: https://clinicaltrials.gov/ct2/show/NCT02827500

Testing and Medication Titration for Patients with HFrEF

*BNP/NT-proBNP, complete blood count, basic metabolic panel, liver function tests, iron and thyroid studies, HbA1c, x-ray, echocardiogram, coronary angiogram, cardiac MRI, biopsy, other imaging.Yancey et al. J Am Coll Cardiol. 2018;71(2):201-230.

Consider initial evaluation studies*

End-intensification/ maintenance

Assess response to therapy and cardiac remodeling

Serial evaluation and titration of medications

Lack of response/instability

Referral for advanced care

Intensification 2-4 months

(1-4 week cycles)

Stabilization ~3 months

When to Refer Patients for Advanced HF Care: I-NEED-HELP

Yancey, et al. J Am Coll Cardiol. 2018;71(2):201-230.

IV inotropes

NYHA IIIB/IV or persistently elevated natriuretic peptides

End-organ dysfunction

Ejection fraction ≤35%

Defibrillator shocks

Hospitalizations >1

Edema despite escalating diuretics

Low blood pressure, high heart rate

Prognostic medication - progressive intolerance or down-titration of GDMT

Therapies for HFrEF Under Investigation

Effects of Omecamtiv Mecarbil on Cardiac Function and Structure

Teerlink JR, et al. Lancet. 2016;388:2895-903.

COSMIC-HFC

hang

e in

Sys

tolic

R

ejec

tion

Tim

e (m

s) 302520151050

-5

P=0.0007

P<0.0001A

Cha

nge

in

LVES

D(m

m) 0

-1-2-3-4-5

P=0.1732

P=0.0027

C

Placebo 25 mg Fixed Dose PK TitrationStudy Group

Cha

nge

in H

eat R

ate

(bea

ts p

er m

in) 2

10

-1-2-3-4

P=0.2177

P=0.0070

E

Cha

nge

in S

trok

e Vo

lum

e (m

l)

6420

-2-4

P=0.0036P=0.0217

B

Cha

nge

in

LVED

D(m

m)

1.51.00.5

0-0.5-1.0

P=0.1899

P=0.0128

D

Cha

nge

in N

T-pr

oBN

PC

once

ntra

tion

(ng/

L) 1000

500

0

-500

-1000Placebo 25 mg Fixed Dose PK Titration

Study Group

P=0.0205P=0.0069

F

Effect of Vericiguat Treatment in Patients with Worsening HFrEF

Gheorghiade M, et al. JAMA. 2015;314(21):2251-2262.

SOCRATES-REDUCED

Rat

io o

f Geo

met

ric M

eans

for C

hang

efr

om B

asel

ine

of N

T-pr

oBN

PLe

vel 1.3

1.2

1.1

1.0

0.9

0.8

0.7

0.6

0.51.25 mg 2.5 mg 2.5 to 2.5 to Pooled

5 mg 10 mg 2.5/5/10 mg

Vericiguat Group

P<.02

P<.05

Prop

ortio

n of

Pat

ient

s Ex

perie

ncin

g th

eC

ompo

site

of C

V D

eath

and

HF

Hos

pita

lizat

ion

0 28 56 84Day

0.25

0.20

0.15

0.10

0.05

0

1.25 mg2.5 mg2.5 to 5 mg2.5 to 10 mgPooled 2.5/5/10 mg groups

PlaceboVericiguat

Treatment of HFpEF

Increasing incidence

Frequent in elderly female patients

Comorbidities include obesity, CAD, DM, AF, and hyperlipidemia

HTN is the most important cause (60%-89% prevalence)

Represents a growing proportion of patients with HF requiring hospitalization

Significance of HFpEF

DM, diabetes mellitus.


Efficacy of Spironolactone Treatment of HFpEF Across the LVEF Spectrum

Solomon SD, et al. Eur Heart J. 2016;37:455–462.

TOPCAT Trial

P = 0.02In

cide

nce

Rat

e

40 50 60 70 80Ejection Fraction (%)

8

6

4

2

0

Primary Outcome

P = 0.79

Inci

denc

e R

ate 8

6

4

2

0

HF Hospitalization


P = 0.002

Inci

denc

e R

ate 8

6

4

2

0

CV Death


P = 0.004

Inci

denc

e R

ate 8

6

4

2

0

All-Cause Death


ARNI for the Treatment of Patients with HFpEF: PARAGON-HF

Solomon, et al. JACC Heart Fail. 2017;5(7):471-482.

Sequential Single-Blind Run-In Period

Eligible patients who meet tolerability criteria at each safety/tolerability check visit are switched to the next study period

Randomized Double-Blind Long-Term Follow-Up Period

Follow-up visits occurred at 4, 16, 32, and 48 weeks and every 12 weeks thereafter. All patients are followed until target number of primary composite (CV deaths and total HF hospitalizations) occur or 26 months after randomization of the last patient elapse, whichever occurs last.

Screening period

Valsartan single-blind run-in

Sacubitril/Valsartan single-blind run-in

-2 weeks 1-4 weeks* 2-4 weeks† Sacubitril/Valsartan at a target dose of 97/103 mg bid

Valsartan at a target dose of 160 mg bid

N~4800

Safety/tolerabilitycheck

Safety/tolerability checkand randomizations (if eligible)

*Eligible patients are exposed to valsartan 80 mg bid for 1 to 2 weeks. Patients on low pre-study angiotensin converting enzyme inhibitors or angiotensin receptor blocker doses or those with tolerability concerns are first started on valsartan 40 mg bid 1 to 2 weeks and then up-titrated to valsartan 80 mg bid for 1 to 2 weeks.†Patients tolerating valsartan 80 mg bid for 1 to 2 weeks are switched to sacubitril/valsartan 49/51 mg bid for 2 to 4 weeks.

Management of Comorbidities

Target an optimal BP of <130/80 mm Hg in those with HTN and at increased risk (stage A HF)

Titration of GDMT to attain SBP <130 mm Hg in patients with HFrEF and HTN

Titration of GDMT to attain SBP <130 mm Hg in patients with HFpEF and persistent HTN after management of volume overload

Management of Hypertension in Patients with HF

BP, blood pressure; SBP, systolic blood pressure.

Yancey CW, et al. Circulation. 2017;136(6):e137-e161.

Use of Intravenous Iron for Patients with Symptomatic HF and Iron Deficiency

Ponikowski P, et al. Eur Heart J. 2015;36:657–668.

Odd

s R

atio

(95%

CI)

6 12 18 24 30 36 42 48 52Weeks Since Randomization

4

3.5

3

2.5

2

1.5

1

0.5

0Plac

ebo

bette

rFC

Mbe

tter

Self-reported Patients Global Assessment

P=0.29

P=0.035 P=0.047

P=0.001 P=0.001

NYHA Functional Class

Odd

s R

atio

(95%

CI)

6 12 18 24 30 36 42 48 52Weeks Since Randomization

12

10

8

6

4

2

0

Plac

ebo

bette

rFC

Mbe

tter

P=0.067P=0.093

P=0.004

P<0.001P<0.001

Impact of Intravenous Iron Therapy on Hospitalization Due to Worsening HF

Ponikowski P, et al. Eur Heart J. 2015;36:657–668.

Hos

pita

lizat

ion

Rat

e (p

er 1

00 S

ubje

cts)

0 90 180 270 360Time in Days

30

20

10

0

Placebo FCM

Log-rank testP=0.009

Benefits of Phrenic Nerve Stimulation in the Treatment of Central Sleep Apnea

Costanzo M, et al. Am J Cardiol 2018;121:1400–1408.

12 Months Active AHI Reduced ≥50%

SubgroupTreatment

% (n/N) Proportion (95% CI)Age

<65 58% (18/31)65 to <75 67% (10/15)≥75 100% (8/8)

SexFemale 71% (5/7)Male 66% (31/47)

Heart failureNo 61% (14/23)Yes 71% (22/31)

NYHA ClassI 60% (3/5)II 71% (10/14)III 75% (9/12)

DefibrillatorNo 69% (24/35)Yes 63% (12/19)

AHI severityModerate (15 - <30) 57% (4/7)Severe (≥30) 68% (32/47)

Prior SDB therapyNo 66% (21/32)Yes 68% (15/22)

Atrial fibrillationNo 66% (23/35)Yes 68% (13/19)

0 25 50 75 100

Improving Outcomes Through Effective Transitional Care

Obstacles to Effective Transitions of Care in HF

HCPs, health care providers; TOC, transitions of care. AHA Scientific Statement. Circ Heart Fail. 2015;8(2):384-409.

TOCConcerns

HCP Communication

• Poor handoff among HCPs• Insufficient patient

education

Medical Management

• Reconciliation issues• Unclear instructions• Transportation issues

Non-medication signs/symptoms (S/S) Management

• Nonadherence to diet, activity, exercise, & fluid management

• Not recognizing S/S requiring medical attention • Primary HCP is unclear about who to contact for

assistance

Follow-up Appointment

• No appointment scheduled within 7 days • Lack of transportation• HCP failure to follow GDMT• Patient unsure of location• Patient unaware

Frequency of Discharge Summary Transmission to Follow-up Providers

0

10

20

30

40

50

60

70

80

90

100

Site11

Site20

Site14

Site21

Site2

Site3

Site10

Site18

Site5

Site29

Site17

Site9

Site4

Site12

Site22

Site25

Site15

Site28

Site16

Site24

Site6

Site1

Site13

Site8

Site26

Site23

Site7

Site19

Site27

Dis

char

ge S

umm

arie

s Tr

ansm

itted

to

Fol

low

-up

Phys

icia

n (%

)

Sites

Salim Al-Damluji M, et al. Circ Cardiovasc Qual Outcomes. 2015;8(1):77-86.

Intervention Impact EvidenceHome-visiting programs and multidisciplinary HF (MDS-HF) clinic interventions

All-cause 3 to 6 months readmission High

Structured telephone support (STS) interventions

HF-specific and all-cause readmissions

High (HF-specific)Moderate (all-cause)

Home-visiting programs HF-specific readmission and composite end point* Moderate

Home-visiting programs, MDS-HF clinics, and STS interventions Mortality Moderate

High-intensity home-visiting program All-cause 30 day readmission and composite end point* at 30 days Low

Telemonitoring and primarily educational interventions

Did NOT reduce readmissions or mortality Low

Systematic Review of Transitional Care Interventions

*All-cause readmission or deathFeltner C, et al. Annals Intern Med. 2014;160(11):774-784.

Sytematic Review of Transitional Care Interventions Cont’d

Intervention Impact EvidenceHome-visiting programs and multidisciplinary HF (MDS-HF) clinic interventions

All-cause 3 to 6 months readmission High

Structured telephone support (STS) interventions

HF-specific and all-cause readmissions

High (HF-specific)Moderate (all-cause)

Home-visiting programs HF-specific readmission and composite end point* Moderate

Home-visiting programs, MDS-HF clinics, and STS interventions Mortality Moderate

High-intensity home-visiting program All-cause 30 day readmission and composite end point* at 30 days Low

Telemonitoring and primarily educational interventions

Did NOT reduce readmissions or mortality Low

AHA Recommended Strategies for Improving Transitional Care in HF Patient education Phone follow-up (48-72

hours) Early postdischarge

follow-up visit (7-10 days) Early assessment after

admission

Medication reconciliation Caregiver inclusion Home visits Handoff communication

to post-hospital providers

AHA Scientific Statement. Circ Heart Fail. 2015;8(2):384-409.

Recognition of escalating symptoms/concrete plan for response Activity/exercise Indications, use, and need for medication adherence Daily weight monitoring Modification of risk factors for HF progression Diet End-of-life considerations Follow-up Discharge instructions

Enhanced HF Patient Education: What Domains Should Be Covered?

Available at: http://www.heart.org/idc/groups/heart-public/@private/@wcm/@hcm/@gwtg/documents/downloadable/ucm_428949.pdf

Lee KK, et al. Med Care. 2016; 54(4): 365–372.

Risk of 30-Day Readmission by PostdischargeFollow-up Contact

Type

of F

irst

Cont

act Telephone

Clinic

Num

ber o

f Co

ntac

ts > 2 Contacts

1 or 2 Contacts

Tim

e to

Firs

t Co

ntac

t 8-30 Days

1 to 7 Days

No Contact

12.1%

10.7%

7.3%

13.1%

8.9%

12.0%

29.3%

Unadjusted Risk of 30-Day Readmission

Case Evaluations

Judy is a 68-year-old woman who presents to the ED for acute distress due to breathlessness and uncontrolled coughing. She reports that over the past 4 months, she has had some difficulty climbing stairs and breathing when lying down (having to sit back up to catch her breath). Judy’s medical history includes a remote history of smoking and alcohol consumption. She is dyslipidemic and moderately obese.

Case Evaluation #1: Patient Description

ED, emergency department.

Case Evaluation #1: Question 1

A. Blood testing for BNP/NT-proBNPB. Invasive hemodynamic monitoringC. Endomyocardial biopsy

Judy’s physical exam confirms dyspnea on exertion and reveals significant ankle edema. Her BP = 130/86 mm Hg, HR = 90 bpm, JVD 12 cm, and she has a positive Kussmaul sign. Which of the following tests would you order to further aid in your diagnosis?

A. B. C.

0% 0%0%

:8


A. Maintain current treatment regimenB. Switch to ARNIC. Switch to ivabradine

Judy is diagnosed with NYHA III Stage C HFrEF. Following stabilization, she is initiated on a regimen that includes lisinopril and carvedilol. At her 3 month follow-up, clinical and laboratory assessments indicate that she is stable with her current treatment plan. Which of the following would you recommend for Judy?

A. B. C.

0% 0%0%

:8


A. 12 hoursB. 36 hoursC. 3 days

If you were to switch Judy to ARNI, how long would wait before initiating ARNI after discontinuing lisinopril?

A. B. C.

0% 0%0%

:8

Jim is a 73-year-old man who presents with breathlessness over the past 2 days. His history includes 3 prior hospital admissions for worsening HF over 2 years. He has difficulty with ADLs. Previous echocardiograms have shown moderate LV systolic dysfunction (EF 26%, PASP 55 mm Hg, EDD 6.7 cm). Physical exam reveals BP 98/78 mm Hg, HR100 bpm, RR 25/min, S4, and displaced point of maximal impulse. Jim’s EMR reveals that he has a history of iron deficiency as well. His current medications include aspirin, furosemide, enalapril, and carvedilol.

Case Evaluation #2: Patient Description

PASP, pulmonary artery systolic pressure; S4, fourth heart sound; EMR, electronic medical record.


A. Addition of ARNI to Jim’s current treatment regimen

B. Increase the dose of carvedilolC. Switch Jim from enalapril to

ivabradine

Which of the following changes to Jim’s therapeutic regimen would you recommend for Jim?

8A. B. C.

0% 0%0%

8


A. Dietary iron supplementationB. Intravenous iron therapyC. Erythropoietin therapy D. No therapy

What type of intervention, if any, would you consider for the treatment of Jim’s iron deficiency?

8A. B. C.

0% 0%0%

8

Despite recent progress in the reduction of HF-related readmission rates, the health outcomes of many patients with HF remain suboptimal

Optimal management of HF requires thorough and accurate patient evaluation along with the implementation of guideline-directed medical therapy to control symptoms and improve prognosis

New treatment options have expanded the range of strategies toachieve therapeutic goals and demonstrated the capacity to significantly improve patient outcomes over standard therapy

Summary

For patients with symptoms of HF, apply a multifaceted evaluation approach to identify underlying causes and risk for disease progression

Implement guideline-directed medical therapy for all patients with HF

Consider treatment using a newer agent with a novel mechanism of action for any patients who remain symptomatic despite their current regimen as well as those who are stable but may benefit from a switch in therapy

Prior to discharge, evaluate patients’ clinical status, comorbid conditions, and current medication regimen, and adjust the care plan accordingly

Schedule timely follow-up and ensure adequate communication of the care plan to the nursing home team, home healthcare team, PCP, or family caregiver

Clinical Pearls

Questions and Answers

Thank You!

a hospital-based approach to achieving better health outcomes … · 2018-12-10 ·

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