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Canadian Cardiovascular Society Recommendations on Heart Failure: Focus on the Elderly

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Title: Canadian Cardiovascular Society Recommendations on Heart Failure: Focus on the Elderly


1
Canadian Cardiovascular SocietyRecommendations
on Heart FailureFocus on the Elderly
  • Symposium on Changes and Challenges in Geriatric
    Care
  • Waterloo, May 7, 2008

George Heckman MD MSc FRCPC
2
Disclosures
  • Consultant and speaker fees from Janssen-Ortho,
    Novartis, and Pfizer
  • Research support from the Canadian Institutes of
    Health Research, Novartis

3
The Demographic Imperative
4
The Elderly HF patient
  • Generally excluded from clinical trials
  • treatment by extrapolation
  • Multiple co-morbidities
  • Concurrent geriatric syndromes common
  • frailty
  • functional impairment
  • cognitive impairment
  • depression

5
Objectives
  • Using illustrative case, review
  • therapies
  • assessment and management of frail elderly HF
    patient
  • transitional care

6
A typical atypical presentation
  • 83 year old woman confusion and falls for 3 days
  • ischemic cardiomyopathy (EF 25)
  • diabetes, hypertension, gout, mild chronic renal
    failure
  • meds
  • furosemide 80 mg bid
  • ramipril 2.5 mg od
  • amlodipine 10 mg od
  • ibuprofen 200 mg prn
  • lorazepam 1 mg qhs prn, gravol (for sleep)

7
Assessment salient features
  • Physical exam
  • O2 sat 78 on room air, RR 40
  • atrial fibrillation with rate 100-110
  • high JVP, leg edema
  • bibasilar crackles
  • S3
  • Neurological exam
  • delirious, no focal deficits

8
Investigations
  • hemoglobin 105, normocytic, mild neutrophilia
  • glucose 22.1
  • creatinine 130, electrolytes normal
  • TSH, calcium, urine normal
  • ECG LBBB
  • chest x-ray cardiomegaly, pulmonary oedema

9
Course in hospital
  • Diagnoses delirium and heart failure
  • Oxygen and diuresis
  • Medications optimized
  • ramipril 10 mg od
  • bisoprolol 2.5 mg od initiated
  • metformin initiated
  • warfarin
  • amlodipine, gravol, NSAID discontinued, lorazepam
    reduced

10
Recommendation (2006)
  • Heart failure therapies in elderly heart failure
    patients should be similar to those in younger
    patients, although their use may depend primarily
    on concomitant conditions (level 1, class B)

11
Recommendation (2007)
  • Beta-blockers should be initiated as soon as
    possible after diagnosis of heart failure,
    including during the index hospitalization,
    provided that the patient is clinically stable.
    Clinicians should not wait until hospital
    discharge to start a beta-blocker in stabilized
    patients (class I, level B)

12
ACE-I and HF in elderly Observational data
  • Fewer deaths, hospitalizations
  • including with chronic renal insufficiency
  • Administrative database, LTC age 85 yrs
  • slower functional decline vs. digoxin
  • Retrospective cohort,1220 hospital pts, 79 years
  • greater cognitive improvement in hospital,
    dose-response observed
  • Philbin Am J Cardiol 96 Arling Ann Long Term
    Care 98 Ahmed J Am Geriatr Soc 02 Hutcheon
    Heart 02 Gambassi Arch Intern Med 00 Zuccala
    Eur Heart J 05

13
ACE-I in frail older HF patients
  • RCT 60 geriatric day hospital pts with HF
  • aged 81/- 6 years yrs
  • NYHA II-III, LV systolic dysfunction
  • perindopril 2 to 4 mg daily vs. placebo
  • Improved 6 minute walk at 10 weeks
  • perindopril 37.1 m vs. 0.3 m in placebo
    (plt0.001)
  • Hutcheon Heart 02

14
ACE inhibitors and depression
  • Cross-sectional survey 1223 LTC pts, 245 with HF
  • 85.9 7.5 years
  • Antidepressants prescribed to 101 of HF pts
  • HF pts with history of depression less likely to
    receive antidepressants if appropriate ACE
    inhibitor doses
  • OR 0.11 (0.02-0.76)
  • Heckman et al J Am Geriatr Soc 2006

15
ACE inhibitors and insomnia
  • Cross-sectional Irish primary care survey
  • 353 pts with HF, 72 yrs
  • 18 getting ACE inhibitors, most low dose
  • HF pts more likely to get
  • hypnotics 14.7 vs. 8.3 (plt0.001)
  • insomnia 11.8 vs. 6.9 (plt0.001)
  • Connolly Pharmacoepi Drug Safety 1998

16
Beta-blockers
  • Cardiovascular Health Study
  • 950 pts, incident HF, 80/-6 yrs
  • lower mortality HR 0.74 (0.56-0.98)
  • SENIORS RCT (Nebivolol)
  • 2128 pts 70 yrs and over, f/u 2 years
  • Systolic AND Diastolic failure
  • lower death/CV hospitalization HR 0.86
    (0.74-0.99)
  • Geriatric outcomes??
  • Chan Am Heart J 2005 Flather Eur Heart J 2005

17
Other heart failure therapies
  • Exercise may improve cognition
  • Digoxin high normal levels associated with
    benzodiazepine use in LTC
  • Angiotensin blockers, aldosterone antagonists,
    nitrates and hydralazine no geriatric data
  • Rehab cardiac and / or geriatric
  • Heckman J Am Geriatr Soc 2006 Arnold Liu Can J
    Cardiol 06 Tanne Int J Cardiol 05

18
Practical tips
  • HF medications start low and titrate slowly
  • Monitor orthostatic vitals (supine and standing)
  • As ACE-I and Beta-blocker optimized
  • consider reducing diuretic dose if patient stable
  • reassess need and dose of other vasodilators,
    such as long-acting nitrates, if no longer
    clinically needed

19
Course in hospital
  • Slow to mobilize
  • significant deconditioning
  • Geriatric consultation GRU admission
  • function, strength, endurance improve
  • medications optimized further
  • bisoprolol titrated to 10 mg od
  • spironolactone 25 mg
  • metformin 1000 mg bid

20
Discharge planning
  • cognition MoCA 16/30
  • home care referral
  • home assessment
  • personal support worker
  • children / spouse given HF education
  • medication dosette

21
Recommendation (2006)
  • Frail elderly HF patients should be referred to a
    geriatrician for comprehensive geriatric
    assessment (level 1, class B)
  • Elderly or frail heart failure patients who
    present with acute illness should be assessed for
    evidence of delirium and, before discharge,
    cognitive impairment (class IIa, class C)

22
The post-discharge chasm
  • 86 yo male hospitalized mid-August 2007 with
    abdominal pain and distension
  • Past history
  • Previous MI, CABG x 2 (1998), EF 40 (2006)
  • Type II diabetes, hyperlipidemia
  • Atrial fibrillation
  • Chronic renal failure (baseline creatinine 115)
  • Previous hernia repair, cholecystectomy

23
The Case
  • Ascites from right-sided heart failure
  • 1.5 litres drained, no malignant cells
  • LVEF 25, regional wall motion abnormalities
  • In retrospect, patient had been getting more
    dyspneic over the past year (which was attributed
    to age?)

24
In hospital medications
  • Metoprolol 37.5 mg bid
  • Ramipril 5 mg od
  • Atorvastatin 20 mg
  • Digoxin 0.0625 mg od
  • Metolazone 2.5 mg od
  • Furosemide 120 mg bid
  • ECASA 81 mg od
  • Discharged on these
  • Repaglinide 0.5 mg
  • Slow-K 8 mg tabs bid
  • Septra 1 od (SBP prophylaxis)
  • Warfarin 2 mg od
  • Prevacid 30 mg bid

25
Course in hospital
  • Diuresed slowly but steadily
  • Able to walk up 24 steps, laps around the ward
  • Discharged Sept. 3, 2007 with home care (PSW),
    bedside commode, shower bench and walker
  • Referred to heart function clinic (earliest
    appointment October 3, 2007)

26
Heart function visit
  • Significant decline since discharge
  • Seen by internist in interim
  • reduces Metolazone to Monday/ Wednesday/ Friday
  • Wife reports patient had
  • increasing fatigue, weakness (6 steps with
    difficulty)
  • in bed most of the time since discharge
  • anorexic, weight loss of 5-6 kg
  • no chest pain or dyspnea

27
Clinical assessment
  • Looks tired
  • BP 90/45 sitting, radial pulse barely palpable
    standing
  • HR 55, atrial fibrillation
  • Heart sounds and chest unremarkable
  • JVP flat, mucous membranes dry, no ascites
  • Labs
  • Creatinine 385, urea 61.3, Sodium 131, Cl 90, K
    5.1
  • Digoxin 2.6 mmol/L
  • CBC, calcium, albumin normal, CXR nothing acute

28
Caregiving situation
  • Wife frail finding it difficult to help him dress
  • not enough time to look after daily household
    issues
  • Live in a side-split, 6 steps up and down
  • Patient has had
  • memory loss for past 3-5 months
  • recent low mood, passive death wishes
  • Couple isolated, daughter 1.5 hours away

29
Could this have been prevented?
30
Transitional Care
  • Processes to facilitate safe / timely transfer of
    patients from one level of care to another
  • Multidisciplinary APN, MD, others
  • Focus on enhanced self-care
  • Multiple f/u methods, including home visits
  • Cost-effective
  • Targets high risk HF patients
  • previous hospitalizations, multiple comorbidities
    or medications
  • frail elderly
  • depression, limited social support

Arnold JMO, Howlett JG, Ducharme A et al. Can J
Cardiol 200824(1)21-40.
31
Self Care components
  • Maintenance adherence to treatment and positive
    health practices
  • diet, medications, exercise, daily weights
  • Management more active process
  • recognize subtle changes in status
  • evaluate their significance
  • take appropriate action
  • evaluate effects of action

32
Recommendation
  • Patients and caregivers should be educated while
    in hospital and soon after discharge on
  • Signs and symptoms of worsening HF
  • Self management skills
  • Factors that may aggravate heart failure
  • Reasons for and appropriate use of medications
  • (Class I, Level C)
  • Effective means of communication and
    collaboration between patient, caregiver and
    health care providers should be identified
  • (Class I, Level B)

33
Recommendation
  • A written summary should be provided to the
    patient at the time of discharge and to the
    primary care physician within 48 hours of
    discharge, covering
  • Diagnoses
  • Significant interventions in hospital
  • In-hospital complications
  • Medications at discharge (including prescriptions
    and explicit instructions for adjustment)
  • Plans for follow-up, including delineation of the
    roles of each caregiver
  • (Class IIa, Level B)

Arnold JMO, Howlett JG, Ducharme A et al. Can J
Cardiol 200824(1)21-40.
34
Practical tips
  • RN/APNs with training and expertise in enhancing
    patient and caregiver HF management skills may
    assess the patient in hospital and then follow
    them at home
  • The goals and directions of care should be shared
    and openly discussed among the patients health
    care professionals any differences in
    perspective/opinion should be identified and a
    best solution agreed upon
  • Personal contact with the referring or primary
    care physician should be considered at or before
    discharge

Arnold JMO, Howlett JG, Ducharme A et al. Can J
Cardiol 200824(1)21-40.
35
Recommendations
  • Health care institutions serving HF patients
    should provide resources for or access to
    appropriate disease management care for patients
    recently discharged from hospital with a primary
    diagnosis of HF
  • (Class I, Level C)
  • These have been shown to improve adherence to
    therapy, reduce readmission/resource use rates
    and may improve mortality and quality of life

Arnold JMO, Howlett JG, Ducharme A et al. Can J
Cardiol 200824(1)21-40.
36
Case resolution
  • Patient re-hospitalized from October 3-13, 2007
  • cardiac medications adjusted
  • treated for depression
  • MMSE 24/30, abnormal clock (cognitive impairment)
  • At discharge
  • enhanced home care for bathing and dressing
  • wife and daughter taught about fluid management
    and how to seek medical help if deterioration
  • seen in HF clinic within 2 weeks of discharge,
    followed since
  • referred to geriatric day hospital for outpatient
    rehabilitation
  • close follow-ups no re-hospitalization

37
Lessons to be learned
  • Classic patient fits the bill of at risk
    senior
  • Multiple functional deficits
  • Polypharmacy
  • Limited social support system
  • 2 total number of chronic health conditions
  • Transitional care is imperative
  • This patient fell through a 4 week crack/black
    hole
  • avoidable 11 day hospital readmission (at about
    1000/day, for a grand total of 11,000.00)

38
Final thoughts
  • Frail elderly are growing segment of HF
    population
  • multiple health issues require multidisciplinary
    approach
  • usual treatments apply, benefits on geriatric
    outcomes
  • Health care institutions (hospitals, LIHNs, CCAC)
    must collaborate to provide adequate HF
    management capacity to support primary care
  • multidisciplinary
  • heart function clinics
  • transitional care programs
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