Congestive Heart Failure

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Congestive Heart Failure

• Kevin Grumbach, MD

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Incidence of CHF by Race(Detroit, MI 1989-1999)
W AA Other
W AA Other
W AA Other
W AA Other
Source McCullough et al, J Am Coll Cardiol, 2002
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Survival After Diagnosis of CHF
66
Alive
50
33
Years After Diagnosis
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2 Varieties of CHF

• Systolic dysfunction
• ejection fraction lt 35-40
• Diastolic dysfunction
• ejection fraction gt 35-40 but signs and symptoms
  of CHF
• Echocardiogram or Radionuclide Ventriculography
• aid in distinguishing

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• Managing CHF
• Due to Systolic Dysfunction
• A physiologic approach

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Counterproductive Responses toLow Cardiac Output
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Diuretic Treatment

• Furosemide (20 mg qd - 240 mg bid)
• Improve symptoms ? survival effect
• Titrate vs. weight, pedal edema
• K

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Major Technological Breakthrough in Care of CHF
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Afterload Reduction (Vasodilators)

• ACE Inhibitors
• Angiotensin Receptor Blockers
• Hydralizine and Nitrate
• Improve both symptoms and survival
• ACEI benefit if low ejection fraction even
  without overt CHF

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ACE Inhibitors and CHF Survival
Died
Class IV (1 year)
Class II (3.5 years)
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Blocking the effects of Neurohumoral Activation

• Beta-blockers
• Spironolactone

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Carvedilol Study
Died
Median Duration Rx 6.5 months
NEJM 1996 3341349
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CIBIS-II Trial Bisoprolol vs. Placebo 1.3 Year
Mortality
Number needed to treat 20 Source Lancet
19993539
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Spironolactone vs. Placebo2 Year Mortality
(Class IV CHF)
Number needed to treat 9 Source NEJM
1999341709
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Foxglove Digitalis Pupurea
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Digoxin

• Mainly third-line agent
• Research evidence (as 3rd line Rx)
• 1. Symptoms worsen when digoxin D/Cd
• 2. May reduce hospitalizations,
• but not mortality

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The Bottom LineSystolic Dysfunction

• ACE inhibitors first-line therapy (ARBs as
  alternative)
• Diuretics titrated to symptoms
• Beta-blocker
• Spironolactone if K tolerates
• Digoxin last resort
• Titrate ACEI, Beta-blocker to target doses

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Improving Pump Functionwith Surgical Treatment

• Transplantation
• Artificial Heart

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Managing CHF Due to Diastolic Dysfunction

• Less studied
• Improve LV compliance Rx HTN, LVH (beta
  blockers, ACEI, ARB, Ca blocker)
• Diuretics, low Na diet if volume overload
• Digoxin - no role

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CHF and the Chronic Care Model

• Delivery system redesign Team care and Case
  management
• Self-management
• Registries
• Proactive monitoring
• Clinical Information systems

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Qualitative Study of CHF Patients in NYC

• Patients had inadequate information about causes,
  symptoms, management and consequences of CHF.
• Patients did not appear to have the tools to
  prevent, recognize, or act to address the
  exacerbation of their conditions before their
  conditions deteriorated quite significantly.
• When symptoms worsened to the point where
  patients were aware of danger, they tended to
  have difficulty navigating systems and overcoming
  barriers to receiving care outside of an
  emergency room.

Source Horowitz CR et al. Soc Sci Med 200458631
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• I never do use salt, since my pressure went
  up on me years ago I dont use salt like when I
  cook I use like a bouillon cube
• If I was aware of how this CHF symptoms comes
  about, I would probably try to prevent it. But I
  am not aware

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• When you hear about having heart problems,
  youre supposed to feel maybe a pain in your
  left arm, maybe a pain in your chest, or
  pressure. I couldnt describe what I felt as
  pressure but I guess it must have been that, uh
  because I had to struggle in order to talk I
  guess it would have been more clear to me if I
  had chest pain and then I would have said okay,
  Ill call and say Im having chest pain but it
  didnt just seem to me like anything came
  together where I could call.

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Patient Model of CHF as Episodic Acute Illness
and Not Chronic Illness
Source Horowitz CR et al. Soc Sci Med 200458631
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Model of CHF as Chronic Condition
Source Horowitz CR et al. Soc Sci Med 200458631
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Harlem Nurse Management CHF Program

• RCT of patients in Harlem
• Recruited as outpatients
• Mean age 59
• 46 African American, 33 Latino
• Systolic dysfunction
• 60 NYHA Class III-IV
• Randomized to intervention of RN manager vs usual
  care (N203 X 2)

Source Sisk JE et al. Ann Int Med 2006145273
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RN Intervention

• Initial, 1-time in-person appointment
• Education, self-management counseling, prn social
  service referral
• Follow-up telephone calls
• Structured schedule (2, 4, 8, 12, 24 weeks) and
  prn
• Coordination with PCP
• Notes to PCP, Rx recommendations per protocol

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12 Month OutcomesHospitalizations/person-year
Adjusted difference -.13 (-.25, -.001)
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Quality of LifeHealth Status SF-12 Outcomes
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Whats Your Chronic Care Model for Patients With
CHF at FHC?