MultiDisciplinary Heart Failure Management

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Multi-Disciplinary Heart Failure Management

• Connie Keibler, MSN, ARNP
• Western Washington Medical Group, Cardiology

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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

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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.

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Heart Failure Future
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Heart Failure Mortality

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

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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

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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.

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Clinical Classifications

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

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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

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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) 4045
• Diastolic
• inability of the heart to relax is impaired
• Stiff, thickened myocardial wall but normal size
• Inability of heart to fill
• LVEF ? 45

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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

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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

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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

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ACC/AHA 2005 Guidelines
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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

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Clinical Predictors

• A Multivariate Analysis using the ADHERE Data
  Identified the Following Most Significant
  Predictors of Mortality
• Bun
• Systolic BP
• HR
• Age

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Seattle Heart Failure Model
Multivariate risk model using the following
Predictors of Survival at Baseline and after
Interventions

• Age
• Gender
• Ischemic Etiology
• NYHA
• Ejection Fraction
• Systolic BP
• Cholesterol
• Hemoglobin

• Lymphocyte Count
• Uric Acid
• Sodium
• Use of
• K-Sparing Diuretic
• Statin
• Allupurinol
• Diuretic

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Reasons for Re-Admission

• Compliance with Medication
• Compliance with Diet, Specifically Sodium
• Delays in Seeking Medical Attention

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JACHO Quality of Care Indicators

• DC Instructions
• Assessment of LV Function
• ACEI or ARB at Discharge
• Smoking Cessation Advice/Counseling

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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-hospitalization
  _at_ 60-90 days.
• Missing continuity of Care in the Community
• Home Care
• Heart Failure Clinics
• Primary Care

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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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Heart Failure Management
Goals

• Improve Access to Appropriate Cost-Effective
  Health Care
• Prevent Hospitalization
• Improve QOL
• Improved Survival
• Control Health Care Costs

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Multi-Disciplinary HF MGMT
Characteristics

• Fluid Management
• Education
• Intensity of Care
• Access

Strategy must outline and follow clinical
rationale based on practice guidelines that
define target care patterns for patients.
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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

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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

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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

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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

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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

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Multi-Disciplinary Management
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

• Quick and sustained improvements
• 6 wk intervention
• Cost savings of 67,804

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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.
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Collaborative Practice
Shared responsibility and outcomes
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.
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Collaborative Practice
Expected Outcomes

• 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

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Just One Day
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Just One Day
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Cardiac Rhythm Management

• Small improvements in
• hemodynamics significant
• improvements in HF symptoms
• symptoms.
• Optimizing hemodynamics has
• long been a target of
• therapy in HF.

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Cardiac Rhythm Management

• Risk Reduction
• CRT
• Diagnostics
• HR Trends
• HR Variability
• Patient Activity
• Intrathoracic Impedance
• Arrhythmias
• Remote Monitoring

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Cardiac Rhythm Management
Goals for Heart Failure 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

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Quality of Life Issues
And
End of Life Issues
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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 somethingAnd
because I cannot do everythingI will not refuse
to do the something that I can do.- Edward
Everett Hale
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References
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References
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