Post on 07-Aug-2020
Heart Failure / Transplantation
Heart Failure / Transplantation
Congestive Heart Failure: The Challenges of Transitioning from
Hospital to Community
Stuart J. Smith MD FRCP©
Director, Heart Failure Services
Medical Director, Cardiac Transplantation & Mechanical Circulatory Support
Western University
Faculty/Presenter Disclosure
•Faculty: Stuart J Smith MD FRCP©
•Relationships with commercial interests:–Grants/Research Support:
–Aztra-Zeneca , Novartis ,
–Speakers Bureau/Honoraria:
–Novartis, Servier, Abbott , Medtronics, Bayer
–Consulting Fees: Novartis ,
–Other: N/A
Objectives:
• Review our current understanding of congestive heart failure from epidemiology to management
• Introduce the concept of “transition of care “ as it applies to CHF
• Discuss possible approaches that may help improve transition of care from hospital to community.
• Explore the potential roles of family physicians in the transition of care.
275,000 people living in Ontario with HF
83% of people with HF are 65+ years of age
66,000 hospitalizations that included HF (with Avg LOS 12 days)
25,000 hospitalizations with main diagnosis of HF (with Avg LOS 9 days)
50,000 Outpatient/ER visits
770,000 days in hospital / year
In-hospital mortality rate: 12.5%
30-day readmission rate: 16.0%
The Burden of Heart Failurein Ontario
Quick Facts
6
Data source: CIHI DAD/NACRS FY 2015/16
Note- data represents Ontario residents with valid HCN, age 20+ years using acute care services
Wodchis et al., CMAJ 2016
Case: Any diagnostic code is : "I255*" "I500*" "I501*"
"I509*"
Heart failure is a major health threat in Canada and worldwide
About 600,0003 and 26 million1 adults have HF in
Canada and worldwide respectively.
The prevalence rising to ≥10% among persons >70 yearsof age.2
Prevalence
About 50,0003 and 960,0003 new cases of HF are diagnosed annually in Canada and in USA respectively.
Incidence
1). Ponikowski et al. ESC Heart Fail 2014;1:4-25; 2.) Ponikowski et al. Eur Heart J 2016;37:2129–2200; 3.) Mamas et al. Eur J Heart Fail. 2017;19(9):1095-1104
MED/ENT/0374
Heart Failure (Ontario Context )
(Source: HQO, 2017)
• The prevalence of HF varies significantly across regions in Ontario
• There is a two-fold difference in prevalence from the lowest at 134 per 10,000 people in Mississauga Halton LHIN, to the highest at 253 per 10,000 people in the North East LHIN
Mortality rate is higher for heart failure than many cancers
1.) Mamas et al. Eur J Heart Fail. 2017;19(9):1095-1104; 2.) Benjamin et al. Circulation 2017;135(10):e146-e603; 3.) Roger et al. JAMA 2004;292:344–50
Survival rates in men
0.0
0.2
0.4
0.6
0.8
1.0
0 2 4 6 8
Years since diagnosis
Surv
ival
Prostate cancer
Lung cancer
Colorectal cancer
Bladder cancer
Heart failure
Breast cancer
Colorectal cancer
Lung cancer
Ovarian cancer
Heart failure
0.0
0.2
0.4
0.6
0.8
1.0
0 2 4 6 8
Years since diagnosis
Surv
ivalWhy are heart failure patients not managed with
the same urgency as patients diagnosed with cancer?
The mortality rate for patients with chronic HF is as high as 50% at 5 years post-diagnosis1,2,3
Survival rates in women
MED/ENT/0374
HF is one of the most common causes of hospitalization for patients aged >65 years in developed countries1
Nearly 44% of all HF patients are readmitted within 1 year after discharge2
Length of stay for HF hospitalization ranges between 5–10
days3
In the USA, 30-day re-admission rates are >25%4
In Europe, re-admission rates are ~24% at 12 weeks5
Heart failure leads to frequent hospitalizations
1. Bui et al. Nat Rev Cardiol 2011;8:30–41; 2. Maggioni et al. Eur J Heart Fail 2013;15:808–17; 3. Ponikowski et al. ESC Heart Fail 2014;1:4-25; 4. Kociol et al. Am Heart J 2013;165:987–94; 5. Cleland et al. Eur Heart J 2003;24:442–63
MED/ENT/0374
The risk of rehospitalization is very high after an acute event, especially in the first 30 days
1. A.P. Maggioni et al. Eur J Heart Fail. 2013 Jul;15(7):808-17.2. Yancy et al. Circulation. 2013;128:e240-e327, originally published October 14, 2013.
• Patients were readmitted at least once for any cause during the 1-year follow-up in 43.9% of the cases1
• Hospitalizations due to HF accounted for 56.4% of the total hospitalizations1
1-yearrehospitalization
rate
30-dayrehospitalization
rate
30-day readmission rate for all-cause rehospitalization is approximately 25%2
Total1
Hospitalized patients (n = 1,892) n = 1,892
All-cause death, % 17.4
CV death, % 66.4
Non-CV death, % 9.7
Unknown, % 23.9
All-cause hospitalization, % 43.9
HF hospitalization, % 24.8
All-cause death or HF hospitalization, %
35.8
Ambulatory patients (n = 3,226) n = 3,226
All-cause death, % 7.2
CV death, % 54.5
Non-CV death, % 16.3
Unknown, % 29.2
All-cause hospitalization, % 31.9
HF hospitalization, % 13.3
All-cause death or HF hospitalization, %
17.6
MED/ENT/0374
Heart Failure (Ontario Context )
(Source: HQO, 2017)
• Heart Failure Hospitalization rates also vary significantly across regions in Ontario
• From a high of 306 per 100,000 in the NW LHIN, to a low of 123 per 100,000 in the MH LHIN
• 6200 hospitalizations that included HF
• 2100 hospitalizations with main diagnosis of HF
• 4200 Outpatient/ER visits
• 69,000 days in hospital
• 85% of people with HF are 65+ years of age
• In hospital mortality rate: 13.6%
• 30 day readmission rate: 17.8%
The Burden of Heart Failure in South West LHIN Acute care utilization
Quick Facts - FY 1516
13
Data source: CIHI DAD/NACRS FY 2015/16
Case: Any diagnostic code is : "I255*" "I500*" "I501*" "I509*"
Note- data represents Ontario residents with valid HCN, age 20+ years using acute care services
Worsening chronicheart failure ( 75%)
De novo heartfailure ( 23%)
Advanced/ end-stageheart failure (2%)
Fonarow GC. Rev Cardiovasc Med. 2003; 4 (Suppl. 7): 21
Cleland JG et al. Eur Heart J. 2003; 24: 442
The Major Reason for Heart Failure
Hospitalizations
Risk increases after every ADHF episode
1. Gheorghiade et al. Am J Cardiol 2005;96:11G–17G; 2. Setoguchi et al Am Heart J 2007;154:26026; 3. Benjamin et al. Circulation 2017;135(10):e146-e603; 4. Roger et al. JAMA 2004;292:344–50
Clin
ica
l sta
tus
Compensated
Chronically
decompensated
Acutely
decompensated
50% mortality rate at 5 years3,4
Disease
Progression
Adapted from1
Death
0.01st
hospitalization(n=14,374)
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
2ndhospitalization
(n=3,358)
3rdhospitalization
(n=1,123)
4thhospitalization
(n=417)
Median survival (50% mortality) and 95% confidence limits in patients with
HF aftereach HF hospitalization.2
Med
ian
Surv
ival
(ye
ars)
MED/ENT/0374
GAPS IN Heart Failure Care
Diagnosis and
Optimized
Treatment
• Understanding the
diagnosis
• Tailoring the plan
to the diagnosis
and the patient
Patient Issues
( Social issues , Cognitive issues
, co-morbidities, financial issues ,
access to care )
Post Discharge Care
• Transition of Care
• Community Providers
• Access to Specialist Care
Acute Care
• Hospital Care
• Access to
Specialist Care
Definition of Heart Failure
HF is a clinical syndrome characterized by typical 1
symptoms (e.g. breathlessness, ankle swelling and
fatigue) that may be accompanied by 2 signs (e.g.
elevated jugular venous pressure, pulmonary
crackles and peripheral oedema) caused by a 3 structural and/or functional cardiac abnormality,
resulting in a reduced cardiac output and/or elevated
intra-cardiac pressures at rest or during stress.
*** This definition restricts itself to stages at which heart failure symptoms are apparent AND makes no mention of EF
Heart Failure is a “syndrome” , not a disease .
Critical Care Western
Clinical Heart
Failure
Systolic Heart
Failure (LVEF < 40%) HFREF
Heart Failure with Preserved EF (
LVEF 45-50%) HFPEF
Ischemic
(66%)
Non-
Ischemic
(24%)
Other
(10%)
Wide Differential……..
~40% ~60%
Diagnosis – same algorithm
Treatment
Not Evidence
BasedEvidence
Based
Developing a Practical Treatment Plan
Getting More than Just the EF from the ECHO Report !
HF with LV Dysfunction
• EF ≤ 40 %
• Mild, mod or severe LV dysfunction ? Dilated ?
• Segmental or global ?
• Atrial enlargement?
• Valvular Regurg: MR ,TR
• Pul Ht RVSP > 40 - 50
• Right Sided Filling Pressures ie IVC > 2 cm
HF with Preserved Heart Function ( HFPEF)
• EF > 40-45% - 55%
• Degree of LVH
• Severity of atrial enlargement
• Valvular regurg: MR, TR
• Pul HT RVSP > 40-50
• Right Sided Filling Pressures ie IVC > 2 cm
American Heart Association “Approach to Heart Failure Management”
Patient Priority AND Priority of Care :
Decongest , Decongest , Decongest !
For both HFREF and HFPEF
Clinical Trials in HFPEF
DIURETICS Plus :
20
15
10
5
0
HFREF
Improved Survival with Each Addition of a New HF Therapy
ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; CI = confidence interval; CIBIS-II = Cardiac Insufficiency Bisoprolol Study II; CHARM = Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity; HF = heart failure; HR = hazard ratio; RRR = relative risk reduction; SOLVD = Studies of Left Ventricular Dysfunction
1. SOLVD Investigators. N Engl J Med 1991; 325:293-302. 2. CIBIS-II Investigators. Lancet 1999; 353:9-13. 3. Weir et al. Eur J Heart Fail 2008; 10:157-63.
25
Diuretic
digoxin
Diuretic
digoxin
ACEI
Diuretic
digoxin
ACEI
Diuretic
digoxin
ACEI
β-blocker
Diuretic
digoxin
ACEI
β-blocker
Diuretic
digoxin
ACEI
β-blocker
ARB
SOLVD (1991)1
RRR 23%
CIBIS-II (1999)2
RRR 34%
CHARM-Added (2003)3
(β-blocker subgroup)
RRR 33%
Re
sid
ua
l risk
One
-yea
r all-
cause m
ort
alit
y (
%)
NatriureticPeptide (NP )
System
Renin –Angiotensin Aldosterone
System ( RAAS)
Heart Failure• Cardiac Output•LV filling pressure• Volumes• atrial filling pressure
• Vasodilatation• Naturesis• diuresis• renin release
• LV remodeling
Inactive NPs
Reninproduction
ATGN AG I
AG II
AT1receptor AT2 receptor
Vasoconstriction• aldosterone• BP
Vasodilatation• naturesis• BP
ACE
✗Valsartan
Neprilysin✗LBQ657
(active)
Sacubitril(pro-drug)
Added Improvement In Mortality with Sacubitril/Valsartan versus Current Standard of Care (ACEis/ARBs)
10%
20%
30%
40%
ACEinhibitor
Angiotensinreceptorblocker1
0%
% D
ecre
ase in C
V M
ort
alit
y
17%
20%
Sacubitril /Valsartan
15%
Effect of ARB vs placebo derived from CHARM-Alternative trial
Effect of ACE inhibitor vs placebo derived from SOLVD-Treatment trial
Effect of Sacubitril/Valsartan vs ACE inhibitor derived from PARADIGM-HF trial
McMurray et al. Eur Heart J 2015;36(7):1434.439
Ivabradine reduces likelihood of HF Hospital Readmissions
Hospitalization expressed per patient for all patients and for patients actually hospitalized during the trial
Ivabradine (n = 3241)
Placebo (n = 3264)
P-value
Hospitalizations for worsening heart failure (number of patients)
No hospitalization 2,727 (84%) 2,592 (79%)
1 hospitalization 325 (10%) 389 (12%)
2 hospitalizations 99 (3%) 155 (5%)
≥3 hospitalization 90 (3%) 128 (4%)
Hospitalizations for worsening heart failure (number of events)
Total number of hospitalization events 902 1,211 0.0002
Number of events per patient
Whole population 0.3 0.4
Patients with ≥1 hospitalization 1.8 1.8
Therapeutic Approach to Patients with HFREF
Ezekowitz et al. Canadian Journal of Cardiology 33 (2017) 1342e1433
No
n-p
harm
acolo
gic the
rapies
(teach
ing se
lf-care, e
xercise
)
Diu
reti
cs t
o r
elie
ve c
on
gest
ion
Titr
ated
to
min
imu
m e
ffec
tive
do
se t
o m
ain
tain
eu
vole
mia
Ad
va
nc
e C
are
Pla
nn
ing
an
d D
oc
um
en
tatio
n
of G
oa
ls o
f Care
Patient with LVEF ≤ 40% and Symptoms
Triple Therapy ACEI (or ARB if ACEI intolerant), BB, MRATitrate to target doses or maximum tolerated evidence-based dose
NYHA I
Continue triple therapy
NYHA II-IVSR, HR ≥ 77 bpm
ADD ivabradine and SWITCH ACEI or ARB
to SAC/VAL for eligible patients
NYHA II-IVSR with HR < 77
bpm or AF or pacemaker
SWITCH ACEI or ARB to SAC/VAL for eligible patients
REASSESS SYMPTOMS
REASSESS SYMPTOMS AND LVEF
Four Key Emerging Themes
Challenging HF Care in Canada
Hayes SM, et al. BMC Health Serv Res. 2015 ;15(1):290.
Challenges in Promoting A Holistic Approach to Heart Failure Management
Ambulatory (Screening / Prevention)
Emergency Hospitalization Transition Ambulatory (Home, Long-term care)
Challenges in the risk assessment and early diagnosis of heart failure
OUTCOMES
Challenges in ensuring effective and consistent transitional care
Challenges with optimal treatment and management of HF patients by primary care providers
Success will only come with some sort of
“Transition of Care” Plan
Re-hospitalization risk among patients hospitalized for heart failure
Picture from: Desai AS and Stevenson LW. Circulation 2012;126(4):501-61. Greene et al. Nat Rev Cardiol 2015;12:220–29; 2. Langenickel et al. Drug Discov Today: TherStrateg 2012;9:e131–9
Red indicates period of highest risk for readmission immediately after discharge and
just before death
During patient transition
• From close supervision by the hospital cardiology team
• To less frequent ambulatory monitoring at home after discharge
Persists high risk of
• Hemodynamic instability1,2
• Neuro-hormonal over-activation1,2
Median time from hospital discharge
Rea
dm
issi
on
rat
e
Initialdischarge Death
Transition phase
Plateauphase
Palliation and
priorities
MED/ENT/0374
Inpatient Outpatient
The heart failure patient journey
Monitoring
Treatment adjustmentand/or intensification
Acute treatment
Initiate or reviseongoing HF treatment
In-hospital monitoring
Diagnosis
Pre-discharge, discharge and transition to home or care facility
ED PRESENTATION and/or HOSPITALIZATION
PRESENTATION
Device or cardiac transplantation
Diagnosis
Initial treatment choice
Referral
MED/ENT/0374
Better “Transition of Care” =
Better Patient Outcomes• Importance of Follow-up Care:
– A study of 3,136 patients in Alberta with Heart Failure found those
who received regular cardiovascular follow-up visits with a family
physician had better outcomes
Ezekowitz JA, et al. Impact of specialist follow-up in outpatients with congestive heart failure. CMAJ 2005;172:189-94.
Kaplan–Meier Survival Curves For Care Received, by Ambulatory Specialty
1.0
0.9
0.8
0.7
0.6
00 60 120 180 240 300 360
Cu
mu
lati
ve S
urv
ival
Days of Follow-up
Log-rank = 127.55p<0.0001
No follow-up care
Combined care (both specialist and family physician)
Care by family physician only
“Transition of Care” Strategies
• Dependent upon your resources but you need to be imaginative
• ~ 50% of readmissions occur within the 1st 10 days post discharge
• Strategies for Consideration:
• Educational packages for daily weights , etc
• Phone Call on Day 3 by….• Arrange Homecare to go in• Early follow-up with FMD
• Early Transitional Care Clinic• Early follow-up in HF Clinic• Automated Phone Call System • Implanted Devices
eg CardioMems , built into PPM/ICD
Channelling Our Efforts to Decrease 30 Day HF
Readmission Rates : Which Approach ?
Kociol R D et al. Circ Heart Fail 5:680-687 (2012)
Seamless “Transition of Care” not as simple as it sounds ….
HF is Very Complex but these are the Factors that We See that Drive the Problem
• Social ( lives alone , financial issues ,etc)
• Psychological ( Lack insight , anxiety)
• HF but one component of a patient with multiplesignificant co-morbidities
• No transition of care ie no specialist follow-up
• No Family Physician or FMD not involved
• Very Advanced Heart Failure
• Types of Patients : HFPEF >> HFREF
• Lack of specialists or specialists willing to see HF patients
People living in South West LHIN using acute care services related
to heart failure
FY 2016-2017
40
Factors That Affect Programs Moving Forward
Administration Issues(Lack of Plan , Lack of realistic vision , Not
Working with the Physicians / Nurses, Decisions driven by other things )
Physical Plant Issues( Space issues , Lack of Planning , “Squatters
Rights “ etc)
Physician & Nursing Issues( Practice Style issues , Work load ,
Unrealistic Expectations , Not Working with Administration , Not
working with each other )
Financial Issues( Lack of Money , “Shell Game”,)
1. Variations in access to care; sharing of EMR
2. < 5% patients receive palliative care
3. Small and solo practices4. Patients don’t have a FM
MD5. Wait times too long6. Referral criteria not
consistent7. Not funded by MOHLTC8. Hi proportion of ED Visits
and readmissions9. 3 Month readmission
rate varies 25-50%10. Poor “transition of care”
by specialist /FMD11. LTC patients hi users of
ER and lack access to recommended Rx.
Current Model : Heart Failure Care in London
Low Intermediate High
CCAC Services Palliative Care
LHSC HF Navigator RN Case Management
Connecting Care to Home:Transitional HF Care Program
SJHC HF Clinic
LHSC Transitional HF Clinic LHSC Advanced HF Clinic
Transplant / VAD Clinic /etc
EHMRG Score - UH Emergency Department/ Heart Failure Admission / Physician
SJHC Rapid Access HF Clinic
( seen within 48-72 hr)
Patient admitted for treatment of heart failure
Advanced Pul Ht(with Dr S Mehta /
Dr R Davey )
Integrated Congestion Assessment in the HF Patient Journey
Current HF Management:
Why aren’t current parameters working?
Graph adapted from Adamson PB, et al. Curr Heart Fail Reports, 2009.46
Conceptual Design of the Spoke-Hub-Node Model of Integrated Heart Failure Care
Ashlay Huitema et al ; Can J Cardiol 34: 863-870 (2018)
Do the “simple things” well !
Additional Slides
Heart Failure Service 2017
Clinical Service( Wards , CCU )
SJHC Heart Failure Clinic DAILY
UH Pre / Post-Transplant / VAD
HF Clinics (2 / week )
CC2H Transitional HF Clinics
• UH (low-Intermediate)• SJHFC ( Hi Risk )
[ Advanced Inpatient HF
Consult Service ]
Clinical Research “Undifferentiated” HF Intake Clinics ( 4
/ week )Resident
Education• Graphics Rounds• HF Journal Club • Supervise Projects
Collaborate• EP• Multiple Myeloma• Palliative Care• [ Mitra-Clip , etc ]• Pulmonary Ht• Upgrading of CCU• ECHO /Imaging
Transplant / VAD Program
Development of Regional Hub & Spoke Model
• Large Referral Centres• [ Small Hospitals in LHIN ]
HF Technical Skills
• Cath• ECHO• CPET• Axillary IABP
Note = [ provide on prn basis due to manpower]
Critical Care Western
Target Weight 150 poundsFurosemide 40 mg prn
Weight Furosemide Dose
152 lbs or less No Furosemide
153 lbs Furosemide 40 mg po once
daily
154 lbs Furosemide 40 mg po BID
** call HFC after 3 days
155 lbs or more Furosemide 80 mg po BID
**call HFC after 3 days
COACH : Comparison of Outcomes and Access to Care for Heart Failure
Adamson PB et al. J Am Coll Cardiol. 2003; 41: 565
Pressure Change Hospitalization
Days Relative to the Event
Baseline -7 -6 -5 -4 -3 -2 -1 Recovery
Ch
ang
e (%
)
-10
0
10
20
30
40
RV Systolic Pressure
Estimated PA Diastolic
Pressure
Heart Rate
Congestion Precedes Hospitalization
Point of Care Ultrasoundfor Acute Assessment of HF Patients
Using Handheld U/S
to Detect Pulmonary Congestion
Detection of B Lines ( also known
as Comets)
Confirmation of Volume
Overload ( Elevated Right
Sided Filling pressures )
Quantification of Right Atrial Pressures
Opportunities• Collaboration with Pulmonary Hypertension
• Collaboration with ? IM , ? FHT , Palliative Care
• Collaboration with Oncology ( Cardio-Onc)
• Increasing role of Cardiac Rehab for HF , VADS and Post Heart Transplants
• As part of Teams involved in Hi Cost , Hi Tech treatment options ( eg Mitra Clip , etc)
• “Clinical Research”
• “Systems Research” – ie Demo project for MOH – “Hub and Spoke” with rural hospitals and FHT’s in LHIN
Current and Future Framework for Congestion Detection
Girerd et al : JACC HF 6: 273 -285 ( April 2018)
Possible Decongestion Targets at Discharge from Hospital
Girerd et al : JACC HF 6: 273 -285 ( April 2018)
Initial Model : Heart Failure Care in London
Low Intermediate High
CCAC Services Palliative Care
SJHC HF Clinic
LHSC Pre Heart Transplant / VAD
Clinic
Referral HF Post Admission / Emergency Department / Physician
Patient admitted for treatment of heart failure