Title: Canadian Cardiovascular Society Recommendations on Heart Failure: Focus on the Elderly
1Canadian 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
2Disclosures
- Consultant and speaker fees from Janssen-Ortho,
Novartis, and Pfizer - Research support from the Canadian Institutes of
Health Research, Novartis
3The Demographic Imperative
4The Elderly HF patient
- Generally excluded from clinical trials
- treatment by extrapolation
- Multiple co-morbidities
- Concurrent geriatric syndromes common
- frailty
- functional impairment
- cognitive impairment
- depression
5Objectives
- Using illustrative case, review
- therapies
- assessment and management of frail elderly HF
patient - transitional care
6A 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)
7Assessment 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
8Investigations
- hemoglobin 105, normocytic, mild neutrophilia
- glucose 22.1
- creatinine 130, electrolytes normal
- TSH, calcium, urine normal
- ECG LBBB
- chest x-ray cardiomegaly, pulmonary oedema
9Course 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
10Recommendation (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)
11Recommendation (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)
12ACE-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
13ACE-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
14ACE 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
15ACE 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
16Beta-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
17Other 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
18Practical 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
19Course 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
20Discharge planning
- cognition MoCA 16/30
- home care referral
- home assessment
- personal support worker
- children / spouse given HF education
- medication dosette
21Recommendation (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)
22The 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
23The 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?)
24In 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
25Course 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)
26Heart 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
27Clinical 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
28Caregiving 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
29Could this have been prevented?
30Transitional 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.
31Self 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
32Recommendation
- 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)
33Recommendation
- 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.
34Practical 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.
35Recommendations
- 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.
36Case 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
37Lessons 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)
38Final 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