Health Care Delivery 3: Management of Heart Failure in TOC

Health Care Delivery 3: Management of Heart Failure in TOCDR. LARESSA BETHISHOU, PHARM.D, BCPSASSISTANT PROFESSOR OF PHARMACY PRACTICECHAPMAN UNIVERSITY SCHOOL OF PHARMACY

ObjectivesDescribe management of heart failure during TOCReview management of acute vs. chronic heart failureIn-class patient guided workup

Heart Failure in Transitions of CareHeart failure is a major public health problem associated with high morbidity and mortality among individuals 65 years and older.

It is the most common principal discharge diagnosis among Medicare beneficiaries and the third highest for hospital reimbursements.

In the single year of 2007, there were 1.4 million hospitalizations, more than 11 million office visits, and $17 billion in total spending attributable to HF alone.

The progressive and complicated nature of this disease, coupled with multiple comorbidities, often results in negative outcomes, the most costly being hospital readmissions.

Approximately 25% of patients admitted due to HF are readmitted within 30 days, and 34% are readmitted within 90 days of discharge

Hospital Readmission Reduction Program (HRRP)Program managed by the Center for Medicare and Medicaid services (CMS) which penalizes hospitals for excessive readmissionsEffective October 1, 2012All cause 30 day readmissionPenalty: Reduction in repayment of up to 3%Applicable conditions:

◦ 2012: Acute heart failure, MI, Pneumonia◦ 2014: Acute exacerbation of COPD, elective total knee or hip arthoplasty◦ 2015: Coronary artery bypass graft◦ 2016: Aspiration pneumonia

Exceptions include:◦ Planned admissions◦ Observational stays < 48 hours and 2 midnight

Improving HF Care TransitionsPhysiological, functional, social, cultural, and psychological patient characteristics and unmet needs may also affect HF rehospitalization.Readmissions may be attributed to multiple causes, including but not limited to medication management. Interventions◦ Medication reconciliation◦ Patient education◦ Follow-up and monitoring◦ Post-discharge interventions

◦ Phone calls, clinic-visits, multiple interventions◦ Interdisciplinary collaboration◦ F/U 7-10 days post discharge (guideline recommendation)

Medication ReconciliationCollect BPMH on admission◦ How is the patient actually taking vs prescribed?

Identify adherence issues and barriers◦ How will this impact our discharge medication list? ◦ What interventions will we need to implement to address barriers?

Discharge medication reconciliation

Ensure compliance with core measures

Core MeasuresThe Core Quality Measure Collaborative, led by the America’s Health Insurance Plans (AHIP) and its member plans’ Chief Medical Officers, leaders from CMS and the National Quality Forum (NQF), as well as national physician organizations, employers and consumers, worked hard to reach consensus on core performance measures.

Designed to be meaningful to patients, consumers, and physicians, the alignment of these core measure sets will aid in:

◦ promotion of measurement that is evidence-based and generates valuable information for quality improvement,

◦ consumer decision-making,◦ value-based payment and purchasing,◦ reduction in the variability in measure selection, and◦ decreased provider’s collection burden and cost.

CMS believes that by reducing burden on providers and focusing quality improvement on key areas across payers, quality of care can be improved for patients more effectively and efficiently.

HF Core Measures

Patient EducationIncludes basic principles about HF◦ Diet (eg, the role of dietary sodium and the importance of limiting fluid intake)◦ Signs and symptoms of HF exacerbations◦ Self-care expectations (daily weights)

Medication education and counseling

Patient education should be tailored to patient specific needs

Follow-up and monitoring instructions

Physician, nursing, and pharmacist collaboration

Chronic Heart FailureProgressive clinical syndrome

◦ Structural or functional impairment of heart◦ Impaired ability of ventricles to fill or eject blood◦ Systolic heart failure

◦ Heart failure with reduced ejection fraction (HFrEF)◦ Diastolic heart failure

◦ Heart failure with preserved ejection fraction (HFpEF)

Causes◦ CAD◦ Infarction◦ Hypertrophy

◦ Pulmonary hypertension◦ Volume overload

ACC/AHA STAGE NYHA Class Features

A None At high risk for heart failure but without structural heart disease or symptoms of heart failure

B I Structural heart disease but without symptoms of heart failure

C II-III Structural heart disease with prior or current symptoms of heart failure• II: Slight limitation• III: Marked limitation

D IV Refractory heart failure with symptoms present at rest

Classifications of heart failure

Acute decompensated heart failureNew or worsening signs or symptoms of heart failure

Causes◦ Nonadherence to medications, fluid, and sodium restrictions◦ ACS◦ Atrial fibrillation and other arrhythmias◦ Recent addition of negative inotropic drugs or drugs that increase sodium (NSAIDS, TZDs)◦ Infections◦ Pulmonary embolism

Drugs to avoid in heart failureNutritional supplements (LOE:B)

◦ coenzyme Q10, carnitine, taurine, and antioxidants

Hormonal therapies (LOE:C)◦ growth hormone or thyroid hormone

Antiarrhythmic drugs (LOE:B)

Calcium channel blocking drugs (LOE:B)◦ Except amlodipine

Nonsteroidal anti-inflammatory drugs (LOE:B)

Thiazolidinediones (LOE:B)

Long term use of inotropic drugs (LOE:C)

2021 Update to 2017 ACC Guidelines

Role of SGLT2 Inhibitors

Improving Care Coordination HF diagnosis and monitoring for progressionTreatment prescription, titration, and monitoringPatient and caregiver education on disease and treatment

Lifestyle education and monitoringSocial support assessment and treatmentCoordination of care for comorbidities

Barriers to AdherencePerceived lack of benefitComplex regimens, poor health literacy Functional and cognitive impairment

Challenges with comorbiditiesPolypharmacyCost and lack of access to care and resourcesPoor communication

Improving Medication AdherenceAddress adherence and initiate interventions in hospitalSet goals of therapy with patient (living longer, feeling better) and link to medicationsEducate patient in a way that works best for themProvide appropriate educational aidsSimplify regimens when appropriateConsider cost and provide patient supportCommunicate with other care providersReconcile medications at every encounterProvide adherence aids (pill boxes, alarms on phone)

Introducing Our Patient…AK is a 52-year-old white male newly diagnosed with heart failure with reduced ejection fraction (HFrEF) after presenting to the emergency department to evaluate dyspnea that has increased in severity over approximately 5 days. AK was subsequently admitted to a telemetry unit. His brain natriuretic peptide (BNP) was noted to be severely elevated (1305 pg/mL) and echocardiogram revealed left ventricular dysfunction with ejection fraction (EF) 25% to 30%. He was aggressively diuresed per protocol to dry weight. After a total of 3 days of acute care, he has stabilized with disposition to discharge home to self-care.

Please help AK prepare for discharge

CollectThe pharmacist assures the collection of the necessary subjective and objectiveinformation about the patient in order to understand the relevant medical/medication history and clinical status of the patient.

Take 10-15 minutes to collect subjective and objective information with your groups

SubjectiveChief complaint:◦ Dyspnea that increased in severity over 5 days◦ At discharge “I’m breathing more easily and my legs are much less swollen.”

AK is a 52-year-old white male newly diagnosed with heart failure with reduced ejection fraction (HFrEF) after presenting to the emergency department to evaluate dyspnea that has increased in severity over approximately 5 days. AK had noted dyspnea on exertion when performing routine activities of daily living, three-pillow orthopnea, nonproductive cough accompanied by general malaise, 4 kg weight gain, and +2 bilateral pitting edema with diminished pedal pulses upon presentation. He denied fever, chest pain, and hemoptysis. Additionally, he denied abdominal pain, nausea/vomiting, or diarrhea.

SubjectiveBrief history of present illness for each specific disease stateHeart Failure:T2DM:

HTN:Dyslipidemia:CAD/History of MI in 2017: What is the clinical presentation or relevant history for each of his active problems?

SubjectiveBrief history of present illness for each specific disease stateHeart Failure:◦ Newly diagnosed with heart failure with reduced ejection fraction (HFrEF)

◦ Dyspnea on exertion when performing routine activities of daily living, increased in severity over 5 days

◦ Three-pillow orthopnea, nonproductive cough accompanied by general malaise◦ 4 kg weight gain, +2 bilateral pitting edema◦ Admitted to a telemetry unit. ◦ His brain natriuretic peptide (BNP) severely elevated (1305 pg/mL)◦ Echocardiogram revealed left ventricular dysfunction with ejection fraction (EF) 25% to 30%. ◦ He was aggressively diuresed per protocol to dry weight. ◦ After a total of 3 days of acute care, he has stabilized with disposition to discharge home to self-care.

SubjectiveAllergies: No known drug allergiesPast Medical History◦ Type 2 diabetes mellitus (T2DM)◦ Hypertension (HTN)◦ Hyperlipidemia (HLD)◦ Coronary artery disease (CAD)◦ Myocardial infarction (MI) in

2017

SubjectiveHOME MEDICATIONS:

◦ Aspirin 81 mg PO daily◦ Dapagliflozin 10 mg PO daily◦ Lisinopril 10 mg PO daily◦ Metformin 1000 mg PO bid◦ Nitroglycerin 0.4 mg SL PRN chest pain (CP).

May repeat in 5 minutes if CP does not subside. Do not exceed 3 tablets in 15 minutes.

◦ Propranolol 40 mg PO bid◦ Rosiglitazone 4 mg PO daily◦ Semaglutide 0.5 mg SQ q week◦ Simvastatin 20 mg PO qHS

SCHEDULED “INPATIENT” MEDICATIONS

◦ Aspirin 81 mg PO daily◦ Insulin aspart per sliding scale◦ Furosemide 20 mg PO daily◦ Lisinopril 10 mg PO daily◦ Nitroglycerin 0.4 mg SL PRN CP. May repeat in

5 minutes if CP does not subside. Do not exceed 3 tablets in 15 minutes.

◦ Propranolol 40 mg PO bid◦ Atorvastatin 10 mg PO qHS

SubjectiveSurgical History

Placement of drug-eluting stents (DES) × 3 in 2017

Family History

Father: CAD

Mother: T2DM

Immunization

Up to date

Insurance

Medicaid

Social History

Widowed, retired school maintenance supervisor.

Lives independently but has three children who are supportive and visit frequently.

Denies tobacco use.

Drinks 4 to 5 alcoholic beverages on weekends.

Acute decompensated heart failure

Signs and symptomsCongestion

◦ Dyspnea on exertion◦ Fatigue◦ Fluid overload◦ Hypervolemic hyponatremia◦ Peripheral edema◦ Pulmonary congestion◦ Orthopnea◦ Paroxysmal nocturnal dyspnea◦ Pulmonary rales◦ JVD

Poor perfusion◦ Poor appetite◦ Worsened renal function◦ Decreased urine output◦ Cool extremities◦ Weak peripheral pulses◦ Altered mental status◦ Resting tachycardia◦ Decreased appetite

ObjectivePertinent vitals and labsConsider which values are out of range and what the significance of that value is

Review of systems:◦ Change of mental status and complaint of dizziness◦ Persistent coughing, shortness of breath and edema in both legs◦ Patient is warm to the touch◦ Frequent back aches she attributes to surgery one year ago

ObjectiveVital Signs:

◦ Temp 37°C, P 85, RR: 25, BP 142/98 mmHg, pO2 92%, Ht: 5ʹ8ʺ, Wt: 79 kg

General: Patient sitting up on hospital bed in no apparent distress.

Neurologic: A&O × 3.

HEENT: PERRLA.

Neck: JVD (−), carotid bruit not appreciated.

Respiratory: Wheezes (−), mild crackles noted in both lung fields, but improved from admission.

Cardiovascular: Rate and rhythm unremarkable upon auscultation.

Abdomen: Soft, nontender, nondistended, hyperactive bowel sounds.

Skin: Warm, pink, moist.

Extremities: +1 pitting pedal edema bilaterally; radial and pedal pulses evident.

Objective

ObjectiveChest X-Ray

One PA view chest radiograph was obtained and shows signs of potential interstitial pulmonary edema including enlarged and loss of definition of large pulmonary vessels, both Kerley’s A and Kerley’s B lines associated with cardiomegaly. Findings suggest bilateral pulmonary vascular congestion with mild interstitial edema.

Electrocardiogram

Normal sinus rhythm (NSR)

Echocardiogram

EF 25%−30%

Signs and symptoms (On Admission)Congestion



Signs and symptoms (On Discharge)Congestion



Assess and PlanThe pharmacist assesses the information collected and analyzes the clinical effects of the patient’s therapy in the context of the patient’s overall health goals in order to identify and prioritize problems and achieve optimal care.

The pharmacist develops an individualized patient-centered care plan, in collaboration with other health care professionals and the patient or caregiver that is evidence-based and cost-effective.

Take 25-30 minutes to assess your collected information, prioritize problems, set treatment goals, and assess current therapy. Develop a plan based on your assessment. Include actions to be taken, plan for monitoring and follow up, and patient education

Assessment: ADHFFor each disease state OR drug related problem:Goals of treatment◦ Resolve acute decompensation (decrease BNP, resolve clinical symptoms)◦ Optimize medications to provide mortality benefit and symptomatic relief◦ Reduce risk of future exacerbations

Assessment of current treatment: Evaluate acute vs chronic treatment◦ Newly diagnosed HFrEF◦ Patient had signs and symptoms of fluid overload, mostly resolved on discharge◦ EF: 25-30%◦ BNP: 1305 > 258◦ PTA: Lisinopril 10 mg daily, Propranolol 40 mg BID◦ In Hospital: Furosemide 20 mg daily, Lisinopril 10 mg daily, Propranolol 40 mg BID

Plan: ADHFFor each disease state OR drug related problem:Action(s) to be taken (medication change, goal changes, etc)◦ Continue Furosemide 20 mg PO Daily

Monitoring◦ Urine output, electrolytes, signs and symptoms of fluid overload◦ Kidney function, blood pressure

Patient education◦ Pharmacologic: Medication counseling◦ Non-pharmacologic: Lifestyle modifications, minimize NSAID use, sodium restriction

Follow up ◦ Daily monitoring of urine output, electrolytes, signs/symptoms of fluid overload, BNP

Assessment: ADHFFor each disease state OR drug related problem:Goals of treatment◦ Resolve acute decompensation (decrease BNP, resolve clinical

symptoms)◦ Optimize medications to provide mortality benefit and symptomatic

relief◦ Reduce risk of future exacerbations

Assessment of current treatment: ◦ What other medications does the patient need to be started on to

manage her heart failure?

MedicationsHOME MEDICATIONS:








Management: Guideline recommendationsRecommendation LOEDiuretics are recommended in patients with HFrEF with fluid retention CACE inhibitors are recommended to in all HFrEF patients, unless contraindicated, to reduce mortality

A

ARBs are reasonable as alternatives to ACE inhibitors as first-line therapy in HFrEF ARoutine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful

C

In patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality.

B-R

Use of 1 of the 3 beta blockers proven to reduce mortality is recommended for all stable patients

A

Management: Guideline recommendationsRecommendation LOEThe combination of hydralazine and isosorbide dinitrate is recommended for caucasians with NYHA class III–IV HFrEF on goal directed medical therapy (GDMT)

A

Digoxin can be beneficial in patients with HFrEF BStatins are not beneficial as adjunctive therapy when prescribed solely for HF ACalcium channel blocking drugs are not recommended as routine treatment in HFrEF

A

Aldosterone receptor antagonists are recommended in all patients, unless contraindicated, with LVEF of 35% or less to reduce morbidity and mortality

A

Assessment: CHFFor each disease state OR drug related problem:Goals of treatment

◦ Resolve acute decompensation (decrease BNP, resolve clinical symptoms)◦ Optimize medications to provide mortality benefit and symptomatic relief◦ Reduce risk of future exacerbations

Assessment of current treatment: Evaluate acute vs chronic treatment◦ Newly diagnosed HFrEF◦ Patient had signs and symptoms of fluid overload, mostly resolved on discharge◦ EF: 25-30%◦ P 85, RR: 25, BP 142/98◦ OK to start beta blocker for HR control and mortality benefit

◦ PTA: Lisinopril 10 mg daily, Propranolol 40 mg BID, Dapagliflozin 10 mg PO daily◦ In Hospital: Lisinopril 10 mg daily, Propranolol 40 mg BID

◦ Entresto preferred over ACE/ARB

Plan: CHFFor each disease state OR drug related problem:

Action(s) to be taken (medication change, goal changes, etc)◦ Change Propranolol 40 mg BID to Metoprolol 50 mg daily◦ Increase Lisinopril 10 mg daily to 20 mg daily◦ Entresto not covered by Medicaid, will require prior authorization◦ Continue Dapagliflozin 10 mg PO daily

Monitoring◦ Blood pressure, heart rate, serum creatinine, potassium

Patient education◦ Pharmacologic: Side effect◦ Non-pharmacologic: Counsel patient on triggers for Heart Failure

Follow up◦ Daily follow up, upon DC can follow up within 1-2 weeks with cardiologist◦ Titrate to target doses every 2 weeks as tolerated

The patient is experiencing mild hypokalemia (K=2.9). What medication is contributing and how can we help him?

Plan: CHFFor each disease state OR drug related problem:

Action(s) to be taken (medication change, goal changes, etc)◦ Change Propranolol 40 mg BID to Metoprolol 50 mg daily◦ Increase Lisinopril 10 mg daily to 20 mg daily◦ Entresto not covered by Medicaid, will require prior authorization◦ Continue Dapagliflozin 10 mg PO daily◦ Start patient on Potassium Chloride 10 mEq daily

Monitoring◦ Blood pressure, heart rate, serum creatinine, potassium

Patient education◦ Pharmacologic: Side effect◦ Non-pharmacologic: Counsel patient on triggers for Heart Failure

Follow up◦ Daily follow up, upon DC can follow up within 1-2 weeks with cardiologist◦ Titrate to target doses every 2 weeks as tolerated

Assessment: T2DMFor each disease state OR drug related problem:Goals of treatment◦ Control blood glucose

◦ A1C < 7%, FBG 70-130, RBG < 180◦ Prevent micro/macrovascular complications

Assessment of current treatment: ◦ Blood glucose currently controlled

◦ A1C=6.2%, Glucose=106◦ No subjective complaints

◦ PTA meds◦ Are PTA meds appropriate to resume on discharge?

◦ Inpatient meds: Insulin aspart sliding scale

Plan: T2DMFor each disease state OR drug related problem:

Action(s) to be taken (medication change, goal changes, etc)◦ Continue Dapagliflozin 10 mg PO daily (benefit in HF patients)◦ Continue Semaglutide 0.5 mg SQ q week (cardiovascular risk reduction)◦ Continue Metformin 1000 mg PO bid◦ Discontinue Rosiglitazone 4 mg PO daily (TZD in HF)

Monitoring◦ Blood glucose, A1C, kidney function

Patient education◦ Pharmacologic: Side effects◦ Non-pharmacologic: Diet, exercise, annual foot exam, eye exam

Follow up ◦ May require additional therapy◦ Post DC follow up within 1-2 weeks for T2DM management

Assessment: HTNFor each disease state OR drug related problem:Goals of treatment◦ BP < 130/80◦ Prevent cardiovascular events

Assessment of current treatment: ◦ Currently not controlled at 142/98◦ Medications need to be optimized for CHF management

◦ Lisinopril can be changed to Entresto if covered by insurance◦ Propranolol not appropriate for CHF mortality reduction◦ Newly started on furosemide for edema

Plan: HTNFor each disease state OR drug related problem:

Action(s) to be taken (medication change, goal changes, etc)◦ Increase lisinopril 10 mg daily to 20 mg daily as patients BP is high◦ DC propranolol and start Metoprolol XL 50 mg daily◦ Continue furosemide 20 mg daily

Monitoring◦ Blood pressure, electrolytes, HR

Patient education◦ Pharmacologic: SE of medications, counseling on medications to avoid which can worsen BP◦ Non-pharmacologic: Diet, exercise, pain management

Follow up ◦ Monitor blood pressure control◦ Titrate ACE and BB every 2 weeks as tolerated for target HR and BP

Assessment: DyslipidemiaFor each disease state OR drug related problem:Goals of treatment◦ Appropriate intensity statin ◦ Reduce risk of CV events

Assessment of current treatment: ◦ Home medication Simvastatin 20 mg daily◦ Patient currently on Lipitor 10 mg daily in hospital

◦ Moderate intensity statin◦ Therapeutic interchange

◦ History of MI + diabetes = high intensity statin needed◦ LDL 135

Plan: DyslipidemiaFor each disease state OR drug related problem:Action(s) to be taken (medication change, goal changes, etc)◦ Increase to Lipitor 40 mg daily◦ Continue Aspirin 81 mg daily (secondary risk prevention given history of MI)

◦ No indication for DAPT as MI in 2017◦ Continue NTG as needed

Monitoring◦ Side effects

Patient education◦ Diet, exercise

Follow up ◦ Follow up with PCP, not urgent

Discharge Medication List◦ Aspirin 81 mg PO daily◦ Atorvastatin 40 mg PO qHS◦ Dapagliflozin 10 mg PO daily◦ Furosemide 20 mg PO daily◦ Lisinopril 20 mg PO daily◦ Metformin 1000 mg PO bid◦ Metoprolol XL 50 mg daily◦ Nitroglycerin 0.4 mg SL PRN chest pain (CP). May repeat in 5 minutes if CP does not

subside. Do not exceed 3 tablets in 15 minutes.◦ Potassium Chloride 10 meQ PO daily◦ Semaglutide 0.5 mg SQ q week

PPCP: Implement and Follow-UpMedication reconciliation

Patient education◦ Limit sodium to 1.5 grams◦ Avoid medications that exacerbate HF (NSAIDS, TZDs◦ Contact provider for rapid weight gain (2-3 lbs in 1 day, > 5 lbs in one week)◦ Restrict fluid to 1.5-2 L per day

Ensure patient has appropriate follow-up◦ 1-2 weeks with cardiologist for newly diagnosed CHF◦ Titrate to target doses every 2 weeks as tolerated◦ F/U with PCP for management of chronic disease states

Ensure patient has adequate support◦ If prescribing Entresto, ensure cost is not an issue

At his follow-up with cardiology one week post discharge, case management has gotten approval for Entresto for the patient.How should the patient transition from lisinopril to Entresto?

What dose?

At his follow-up with cardiology one week post discharge, case management has gotten approval for Entresto for the patient.How should the patient transition from lisinopril to Entresto?

◦ 36 hours after discontinuing lisinopril to reduce risk of angioedema

What dose? ◦ Will depend on lisinopril dose◦ Lisinopril > 10 mg daily = Sacubitril 49 mg/valsartan 51 mg PO bid

Canvas QuizPlease complete the quiz on Canvas at the end of class (due by 4:00 pm)

Next Lecture: 5/20Anticoagulation Management in TOC

-All Class Patient Guided Lecture

-Canvas Quiz on DVT and anticoagulation

-Pre-Work: Review anticoagulation options for DVT management◦ Parenteral vs oral◦ Dosing (DVT vs other indications)◦ Renal vs hepatic dose adjustments◦ Drug interactions◦ Patient education

Discharge Counseling Video Peer ReviewPeer review now available on Canvas

Refer to APhA Rubric to grade

Enter final score and comments to explain any points which were deducted

Due by Tuesday 5/25 at 2:00 pm

Questions

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Health Care Delivery 3: Management of Heart Failure in TOC

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