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BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE. FINISHING WELL: WHEN TO DISCHARGE THE ADHF PATIENT . DISCLOSURES. NONE. 2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES .

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BART COX, M.D., FACC

DIRECTOR, ADVANCED HEART FAILURE PROGRAM

ASSOCIATE PROFESSOR OF MEDICINE

UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE

FINISHING WELL: WHEN TO DISCHARGE THE ADHF PATIENT

2010 heart failure society of america guidelines
2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES
  • Journal of Cardiac Failure 2010; 16:e1-e194
aha statistics 2010
AHA STATISTICS 2010
  • > 1 million ADHF admissions /year
  • HF complicates the admission diagnosis in another 2 million admissions / year
  • In- hospital mortality for ADHF 4%
  • 90 day readmission rate for ADHF: >50%
  • Admission LVEF > 40%: 40- 50%
  • Cost of HF: $37 billion/year (most of cost is hospitalization)
what s wrong with readmission
WHAT’S WRONG WITH READMISSION?
  • If readmitted within 30 days: no reimbursement
  • Readmission increases the chances of readmission
  • Readmission increases mortality
markers of risk of readmission from escape adhere and effect
MARKERS OF RISK OF READMISSION FROM ESCAPE, ADHERE, AND EFFECT
  • BNP
  • BUN AND CREATININE
  • CARDIAC ARREST OR MECHANICAL INTUBATION
  • SERUM Na
  • AGE
  • SBP
  • RESPIRATORY RATE
  • COMORBID CONDITIONS
  • HEART RATE
markers of 6 month readmission risk escape
MARKERS OF 6 MONTH READMISSION RISK: ESCAPE
  • BNP > 500 (HIGH) AND > 1300 (HIGHER
  • BUN > 40 (HIGH) AND >90 (HIGHER)
  • DIURETIC DOSE > 240 mg/day FUROSEMIDE
  • SERUM Na < 130
  • INABILITY TO TOLERATE BETA BLOCKERS
  • AGE >70
  • 6 MINUTE WALK < 300 FEET
2010 hfsa guidelines hospital discharge
2010 HFSA GUIDELINES: HOSPITAL DISCHARGE
  • It is recommended that criteria in the following table be met before a patient with Heart Failure is discharged from the hospital. (Strength of Evidence = C)
discharge criteria for all heart failure patients
DISCHARGE CRITERIA FOR ALL HEART FAILURE PATIENTS
  • Exacerbating factors addressed
  • Near optimal volume status observed
  • Transition from IV to PO diuretic successfully completed
  • Patient and family education completed, including clear discharge instructions
  • LVEF documentation
discharge criteria for all heart failure patients1
DISCHARGE CRITERIA FOR ALL HEART FAILURE PATIENTS
  • Smoking cessation counseling initiated
  • Near optimal pharmacologic therapy achieved, including ACEI and beta blocker (for patients with reduced LVEF) or intolerance documented
  • Follow up clinic visit scheduled, usually for 7-10 days
hospital discharge
HOSPITAL DISCHARGE
  • In patients with advanced Heart Failure or recurrent admissions for Heart Failure, additional criteria listed in the following table should be considered. (Strength of Evidence = C)
criteria should be considered for patients with advanced hf or recurrent hf admissions
CRITERIA SHOULD BE CONSIDERED FOR PATIENTS WITH ADVANCED HF OR RECURRENT HF ADMISSIONS
  • Oral medication regimen stable for 24 hours
  • No IV vasodilator or inotropic agent for 24 hours
  • Ambulation before discharge to assess functional capacity after therapy
  • Plans for post discharge management (scale present in home, visiting RN or telephone follow up within 3 days after discharge)
  • Referral for disease management, if available
2010 hfsa guidelines precipitating factors
2010 HFSA GUIDELINES: PRECIPITATING FACTORS
  • It is recommended that patients admitted with ADHF undergo evaluation for the following precipitating factors:
    • Atrial fibrillation or other arrhythmias
    • Exacerbation of hypertension
    • Myocardial ischemia/infarction
    • Exacerbation of pulmonary congestion
    • Anemia
    • Thyroid disease
    • Significant drug interaction
    • Other less common factors
common and uncommon precipitating factors associated with adhf hospitalization
COMMON AND UNCOMMON PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION
  • Dietary and medication related causes
  • Progressive cardiac dysfunction
  • Cardiac causes not primarily myocardial in origin
  • Non-cardiac causes
  • Adverse cardiovascular effects of medications
precipitating factors associated with adhf hospitalization dietary and medication related causes
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: DIETARY AND MEDICATION RELATED CAUSES
  • Dietary indiscretion - excessive salt or water intake
  • Nonadherence to medications
  • Iatrogenic volume expansion
precipitating factors associated with adhf hospitalization progressive cardiac dysfunction
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: PROGRESSIVE CARDIAC DYSFUNCTION
  • Progression of underlying cardiac dysfunction
  • Physical, emotional, and environmental stress
  • Cardiac toxins: alcohol, cocaine, chemotherapy
  • Right ventricular pacing
slide17
PRECIPITATING FACORS ASSOCIATED WITH ADHF HOSPITALIZATION: CARDIAC CAUSES NOT PRIMARILY MYOCARDIAL IN ORIGIN
  • Cardiac arrhythmias
    • Atrial fibrillation with RVR
    • VT
    • Marked bradycardia
    • Conduction abnormalities
  • Uncontrolled hypertension
  • Myocardial ischemia or infarction
  • Valvular disease: progressive MR
precipitating factors associated with adhf hospitalization noncardiac causes
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: NONCARDIAC CAUSES
  • Pulmonary disease - PE, COPD
  • Anemia - bleeding, BM suppression, relative lack of erythropoietin
  • Systemic infection - especially pulmonary infection, UTI, viral illness
  • Thyroid disorders
precipitating factors associated with adhf hospitalization adverse cv effects of medication
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION- ADVERSE CV EFFECTS OF MEDICATION
  • Cardiac depressant medications
  • Nondihydropyridine calcium antagonists
  • Type Ia and Icantiarrhythmic agents
  • Sodium retaining medications
  • Steroids
  • NSAID, COX-2 inhibitors, pregabalin, thiazolidinediones
precipitating factors my hearts die
PRECIPITATING FACTORS: MY HEARTS DIE
  • MYOCARDIAL DISEASE PROGRESSION
  • HIGH OUTPUT CAUSES/ HYPERTENSION
  • EMBOLISM (PE)
  • ARRHYTHMIAS
  • REDUCTION OF THERAPY
  • THE DEVELOPMENT OF A SYSTEMIC ILLNESS /TOXINS
  • SECOND HEART DISEASE
  • DRUGS, DEPRESSANTS, DOC
  • INFECTION, INFLAMMATION, ISCHEMIA, INFARCT
  • EXCESS IN ENVIRONMENTAL, EMOTIONAL, OR PHYSICAL EXTREME
2010 hfsa guidelines evaluation of heart failure
2010 HFSA GUIDELINES: EVALUATION OF HEART FAILURE
  • HISTORY AND PHYSICAL
  • PA AND LATERAL CHEST X-RAY
  • EKG
  • ECHOCARDIOGRAM
  • LABS
  • ISCHEMIA EVALUATION
2010 hfsa guidelines lab evaluation of heart failure
2010 HFSA GUIDELINES: LAB EVALUATION OF HEART FAILURE
  • LABS
    • CBC
    • ELECTROLYTES, BUN, CREATININE, GLUCOSE
    • FASTING LIPID PANEL
    • LIVER FUNCTION TEST
    • Ca AND Mg
    • THYROID FUNCTION
    • URINALYSIS
    • URIC ACID
    • BNP
2009 accf aha or 2010 hfsa guidelines ischemia evaluation
2009 ACCF/AHA OR 2010 HFSA GUIDELINES: ISCHEMIA EVALUATION
  • ANGINA + HF: CATH
  • HF + OBJECTIVE EVIDENCE OF ISCHEMIA: CATH
  • HF + HIGH PROBABILITY OF CAD: CATH
  • HF + KNOWN CAD: CATH
  • HF + LOW PROBABILITY OF CAD: STRESS OR CATH
  • HF + YOUNG PATIENT: CATH TO R/O CONGENITAL CORONARY ANOMALY
discharge planning
DISCHARGE PLANNING
  • Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues:
    • Details regarding medications, dietary sodium restriction, and recommended activity level
    • Follow up by phone or clinic visit early after discharge to reassess volume status
    • Medication and dietary adherence
discharge planning1
DISCHARGE PLANNING
  • Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues: (Strength of Evidence=C)
    • Alcohol moderation and smoking cessation
    • Monitoring of body weight, electrolytes, and renal function
    • Consideration of referral for formal disease management
unm solution
UNM SOLUTION
  • HEART FAILURE EDUCATOR: LORENA BEEMAN, RN
    • PAGER: 951-3113
    • PHONE: 307-1242
    • ALL INPATIENT EDUCATION GOALS MET
  • CARDIAC REHABILITATION CONSULT
    • PHONE: 272-2396
    • EXERCISE AND OUTPATIENT EDUCATION GOALS MET
  • CORE MEASURES ORDERED ON EVERY PATIENT
    • SMOKING CESSATION IF SMOKED WITHIN THE PAST YEAR
    • LVEF ASSESSED IF NOT WITHIN THE PAST 6 MONTHS
    • ACEI/ARB OR CONTRAINDICATION DOCUMENTED FOR LVEF <40%
    • MEDICATION RECONCILIATION
unm solution1
UNM SOLUTION
  • HEART FAILURE CONSULT SERVICE 24-7
    • PAGER: 951-0049
  • HEART FAILURE CLINIC REFERRAL BEFORE DISCHARGE
    • CALL THE CLINIC 24-7 AT 925-6002 AND LEAVE MESSAGE
        • NAME, TELEPHONE NUMBER, DATE OF DISCHARGE, MRN
    • 72 HOUR TELEPHONE CALL DOCUMENTED
    • CLINIC VISIT WITHIN 7 CALENDAR DAYS OF DISCHARGE
  • HEART FAILURE POWER PLAN
if dr stevenson were to discharge a patient
IF DR. STEVENSON WERE TO DISCHARGE A PATIENT:
  • MANN’S HEART FAILURE: A COMPANION TO BRAUNWALD’S HEART DISEASE, SECOND EDITION (2011)
    • EDITED BY DOUGLAS MANN, M.D.
    • CHAPTER 48: “MANAGEMENT OF ACUTE DECOMPENSATED HEART FAILURE” BY LYNNE WARNER STEVENSON, M.D.
textbook discharge clinical status goals
TEXTBOOK DISCHARGE: CLINICAL STATUS GOALS
  • No discharge until dry weight achieved
    • Bring the home scale to the hospital before discharge
      • This facilitates immediate disclosure of lack of home scale
  • Blood pressure range is defined
  • Walking without dyspnea or dizziness
textbook discharge stability goals
TEXTBOOK DISCHARGE : STABILITY GOALS
  • 24 hours without changes in oral regimen for heart failure
  • > 48 hours off IV inotropic agents, if used
  • Even fluid balance on oral diuretics
  • Renal function stable or improving
textbook discharge discharge regimen
TEXTBOOK DISCHARGE : DISCHARGE REGIMEN
  • Estimated diuretic dose, with plan for first escalation if needed
  • ACEI/ARB or documented contraindication
  • Beta blocker discharge dose, plans for outpatient initiation, or documented contraindication
  • Anticoagulation for atrial fibrillation unless contraindicated
textbook discharge patient family education
TEXTBOOK DISCHARGE: PATIENT/FAMILY EDUCATION
  • Sodium restriction
  • Fluid limitation if indicated
  • Medication schedule
  • Medication effects
  • Exercise prescription
textbook discharge home instructions
TEXTBOOK DISCHARGE : HOME INSTRUCTIONS
  • Monitoring of symptoms and weights
  • Instructions regarding when and whom to call
  • Scheduled call to patient within 3 days
  • Clinic appointment within 7 calendar days of discharge and information handed off to monitoring physician