Heart Failure and Palliative Care: Not Always a Good Fit
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(NT-proBNP) and greater strength capacities in chronic HF patients. We investi- gated the prognostic role of body fat mass and related anthropometric measure- ments in ADHF patients. Methods: We prospectively evaluated 121 consecutive ADHF patients. Patients underwent echocardiography, cardiopulmonary exercise, blood analysis, right knee extension strength measurement, and evaluation of body fat and muscle mass using bioimpedence analysis (BIA, available in 93 pa- tients). Cardiovascular (CV) event was defined as composite of all-cause mortality, readmission due to heart failure aggravation, and heart transplantation. Results: Mean age of study population was 59.8 6 15.1 years (61 male, 65.6%). Compared with patients in lowest fat mass tertile (! 13.3 kg), those in upper fat mass tertiles had higher body mass index (BMI), waist circumference (WC), hip circumference (HC), muscle strength, lower ventilation to carbon dioxide production slope (VE/ VCO2), and lower NT-proBNP level. Fat mass showed strong correlation with BMI (r50. 735, P ! 0.001), WC (r50.705, P ! 0.001), waist-hip ratio (WHR, r50.804, P ! 0.001) and moderate correlation with muscle strength (r50.251, P50.018), VE/VCO2 (r5-0.252, P 5 0.018) but no correlation with muscle mass (r50.105, P 5 0.316) and peak oxygen uptake (VO2, r 5 0.112, P 5 0.297). CV event occurred in 24 patients (25.8%) during median follow-up of 157 days (Interquartile range 42-449). Kaplan-Meier plot showed that lowest fat mass tertile was associated with higher CV event rate compared to upper tertiles (32.3% vs 22.6%, Log rank P 5 0.018, Figure 1). In age and sex adjusted Cox pro- portional hazard model, fat mass, WHR, and BMI predicted CV event but muscle mass did not The prognostic value of fat mass (HR 0.90 [0.82-0.99], P 5 0.049) and WHR (HR 0.88 [0.77-0.99], P50.042) remained significant after further adjustment for potential predictors including peak VO2, VE/VCO2, muscle strength, hemoglobin level, and log-transformed NT-proBNP. Conclusion: Decreased fat mass and waist-hip ratio were independently associated with poor prognosis in ADHF patients whereas muscle mass was not. In context of cardiac cachexia and obesity paradox, adiposity may provide protective role in prognosis of patients with ADHF. 148 Utilizing Evidence-Based Methods to Exam Actual Salt Content in Diet with Heart Failure Patients Hsin-Yi Lin 1 , Yu-Tzu Dai 2 , Chii-Ming Lee 3 , Pey-Rong Chen 4 ; 1 National Taiwan University Hospital, Taipei, Taiwan; 2 National Taiwan University, Taipei, Taiwan; 3 National Taiwan University Hospital, Taipei, Taiwan; 4 National Taiwan University Hospital, Taipei, Taiwan Objective: Non-adherence with sodium restriction is a major factor that precipitates hos- pitalization for heart failure (HF) . Clinicians have difficulty in the objective assessment of diet adherence. In our study, we used questionnaire, and evidence-based objective param- eters to evaluate diet preferences of HF patients. To identify diet control adherence behavior in heart failure patient. Design: A cross-sectional with purposive sampling tech- nique. Patient and Setting: The study enrolled 98 HF patients in a medical center in Taiwan. Questionnaires were collected by face-to-face interview. Turnip soup with 5 different levels of salt content ( 0g/dL, 0.21g/dL, 0.42g/dL, 0.63g/dL, 0.83g/dL) was used to assess taste perception and preference. Results: Average salt restriction behavior score was 2.07 6 0.66 (scores range from 1-5 points), identifing low adherence in low salt diet control behavior. In the objective assesment, only 52% comply with the low-salt taste, indicating patients have low salt diet control adherence behavior. Conclusion: The objective salty turnip soup taste closely correlated with the findings collected from ques- tionnaire. Salty taste measurement to assess the adherence of diet control, together with questionnaire, can help HF patients to understand and to to improve their diet adherence. Keywords: heart failure, self-efficacy, adherence barriers, diet control behavior, salty taste. 149 Symptom Burden in Patients Hospitalized for Decompensated Heart Failure Rabeea F. Khan 1 , Nathan E. Goldstein 2 , Sarwat I. Chaudhry 1 ; 1 Yale School of Medicine, New Haven, CT; 2 Mount Sinai School of Medicine, New York, NY Background: Heart failure (HF) is one of the most common reasons for hospital- ization and the leading cause of 30-day readmissions. There is great interest in developing strategies to reduce hospital utilization in this large and growing patient population. Aside from classic HF symptoms of dyspnea and fatigue, other symp- toms reported include decreased appetite, pain and anxiety. These symptoms may be amenable to treatment and patients hospitalized with HF may benefit from intensive symptom management in the form of palliative care. There is limited data in the HF population about symptom burden both during hospitalization and shortly after hospital discharge, as well as patients’ perceptions of palliative care. Hypothesis: Patients discharged from the hospital after acute decompensated HF will exhibit a high burden of residual symptoms one week post-discharge. Methods: Patients hospitalized for HF were enrolled in this prospective cohort study. Patients were interviewed about symptom burden using the Edmonton Symp- tom Assessment System (ESAS) during the hospital admission and 7 days post- discharge. Patients were also questioned about existing knowledge of palliative care, and then - after a brief, standardized explanation of the goals of palliative care - patients were queried about their interest in receiving palliative care services. Results: Fifty-nine patients were enrolled; mean age was 71.6 (SD 12.8 years) 50.8% were female and 72.9% had NYHSA class III/IV HF. Frequent symptoms reported during the hospital interview were fatigue (86.4%; mean 5.20, SD 2.9), shortness of breath (74.6%%; mean 4.27, SD 3.2), anxiety (61.0%; mean 3.20, SD 3.1) and pain (44.1%, mean 2.42, SD 3.1). Frequent symptoms reported in the follow-up interview were fatigue (89.8%%; mean 5.27, SD 2.8), shortness of breath (86.4%%; mean 4.00, SD 2.4), pain (64.4%; mean 3.22, SD 3.0), and anxiety (62.7%; mean 2.78, SD 2.7). While only 20.3% of patients had heard of ‘palliative care,’ after a standardized explanation, 49.2% were interested in receiving palliative care services while hospitalized. Conclusions: Patients hospitalized for HF experi- ence a high burden of symptoms, including not only those usually associated with HF such as dyspnea and fatigue, but also anxiety and pain. These symptoms are common during hospitalization and the majority of patients appear to experience troublesome symptoms shortly after discharge as well. Given that symptoms frequently drive health care utilization, integration of palliative care into routine HF management is a promising strategy to reduce hospital utilization. 150 Heart Failure and Palliative Care: Not Always a Good Fit Birgit A. Siceloff 1 , Corrine Jurgens 2 ; 1 New York Presbyterian at Cornell, New York, NY; 2 Stony Brook University, Stony Brook, NY Background/Purpose: Despite evidence that palliative care reduces high symptom burden of heart failure (HF), few patients are referred to or receive palliative services. The purpose of this study was to explore HF health professional’s knowledge, attitude and experience integrating palliative care with this population. Method: Focus groups were conducted with 28 interdisciplinary health care professionals caring for HF patients in a large urban medical center. Focus groups lasted 35-60 minutes and were audio recorded and transcribed verbatim. Using qualitative methodology, data was analyzed using a 2-phase coding strategy. Results: All participants agreed palliative care is beneficial, but identified several barriers to successfully integrating palliative care into HF care. Barriers include delivery of palliative care by a separate health care team, complicating communication and coordination of care. Many prac- titioners report resistance from patients when they consulted palliative care, thereby introducing a new team. Practitioners expressed concern that advanced therapies of HF management conflicts with concepts of palliative care. Insufficient insurance and palliative care options also are frequently not available in outpatient settings which fails to bridge gaps between hospital and home. A consistent theme was dif- ficulty timing discussions of end of life and goals of care. Patient resistance to accept- ing limitations of current medical interventions was problematic. Conclusions and implications: Including palliative care as an approach to improve care of HF patients was viewed as unsuccessful overall. Patient resistance and difficulty coordinating care between two different teams was a major obstacle. Dissemination of palliative care into homecare and training HF practitioners in provision of palliative care are potential solutions. 151 The Development and Preliminary Implementation of a Protocol for the Outpatient Weaning of Milrinone David Patrick, Rebecca Radke, Leslie Jaggers, Hassan Sayegh, Victor Corrigan, Kenneth Taylor; Piedmont Healthcare, Atlanta, GA Introduction: In patients with end-stage heart failure, continuous infusions of paren- teral positive inotropes such as milrinone may be used in an outpatient setting as a short-term bridge to more definitive interventions such as MCS or cardiac transplan- tation (a Class IIa recommendation), or as long-term palliative therapy for symptom Figure 1. S60 Journal of Cardiac Failure Vol. 20 No. 8S August 2014
Transcript of Heart Failure and Palliative Care: Not Always a Good Fit
Figure 1.
S60 Journal of Cardiac Failure Vol. 20 No. 8S August 2014
(NT-proBNP) and greater strength capacities in chronic HF patients. We investi-gated the prognostic role of body fat mass and related anthropometric measure-ments in ADHF patients. Methods: We prospectively evaluated 121 consecutiveADHF patients. Patients underwent echocardiography, cardiopulmonary exercise,blood analysis, right knee extension strength measurement, and evaluation ofbody fat and muscle mass using bioimpedence analysis (BIA, available in 93 pa-tients). Cardiovascular (CV) event was defined as composite of all-cause mortality,readmission due to heart failure aggravation, and heart transplantation. Results:Mean age of study population was 59.8 6 15.1 years (61 male, 65.6%). Comparedwith patients in lowest fat mass tertile (! 13.3 kg), those in upper fat mass tertileshad higher body mass index (BMI), waist circumference (WC), hip circumference(HC), muscle strength, lower ventilation to carbon dioxide production slope (VE/VCO2), and lower NT-proBNP level. Fat mass showed strong correlation with BMI(r50. 735, P ! 0.001), WC (r50.705, P ! 0.001), waist-hip ratio (WHR,r50.804, P ! 0.001) and moderate correlation with muscle strength (r50.251,P50.018), VE/VCO2 (r5-0.252, P 5 0.018) but no correlation with musclemass (r50.105, P 5 0.316) and peak oxygen uptake (VO2, r 5 0.112, P 50.297). CV event occurred in 24 patients (25.8%) during median follow-up of157 days (Interquartile range 42-449). Kaplan-Meier plot showed that lowest fatmass tertile was associated with higher CV event rate compared to upper tertiles(32.3% vs 22.6%, Log rank P 5 0.018, Figure 1). In age and sex adjusted Cox pro-portional hazard model, fat mass, WHR, and BMI predicted CV event but musclemass did not The prognostic value of fat mass (HR 0.90 [0.82-0.99], P 5 0.049)and WHR (HR 0.88 [0.77-0.99], P50.042) remained significant after furtheradjustment for potential predictors including peak VO2, VE/VCO2, musclestrength, hemoglobin level, and log-transformed NT-proBNP. Conclusion:Decreased fat mass and waist-hip ratio were independently associated with poorprognosis in ADHF patients whereas muscle mass was not. In context of cardiaccachexia and obesity paradox, adiposity may provide protective role in prognosisof patients with ADHF.
148Utilizing Evidence-Based Methods to Exam Actual Salt Content in Diet withHeart Failure PatientsHsin-Yi Lin1, Yu-Tzu Dai2, Chii-Ming Lee3, Pey-Rong Chen4; 1National TaiwanUniversity Hospital, Taipei, Taiwan; 2National Taiwan University, Taipei, Taiwan;3National Taiwan University Hospital, Taipei, Taiwan; 4National Taiwan UniversityHospital, Taipei, Taiwan
Objective: Non-adherencewith sodium restriction is a major factor that precipitates hos-pitalization for heart failure (HF) . Clinicians have difficulty in the objective assessment ofdiet adherence. In our study, we used questionnaire, and evidence-based objective param-eters to evaluate diet preferences of HF patients. To identify diet control adherencebehavior inheart failure patient.Design: A cross-sectional with purposive sampling tech-nique. Patient and Setting: The study enrolled 98 HF patients in a medical center inTaiwan. Questionnaires were collected by face-to-face interview. Turnip soup with 5different levels of salt content ( 0g/dL, 0.21g/dL, 0.42g/dL, 0.63g/dL, 0.83g/dL) wasused to assess taste perception and preference. Results: Average salt restriction behaviorscore was 2.07 6 0.66 (scores range from 1-5 points), identifing low adherence in lowsalt diet control behavior. In the objective assesment, only 52% comply with the low-salttaste, indicating patients have low salt diet control adherence behavior. Conclusion: Theobjective salty turnip soup taste closely correlated with the findings collected from ques-tionnaire. Salty taste measurement to assess the adherence of diet control, together withquestionnaire, can help HF patients to understand and to to improve their diet adherence.Keywords: heart failure, self-efficacy, adherence barriers, diet control behavior,salty taste.
149Symptom Burden in Patients Hospitalized for Decompensated Heart FailureRabeea F. Khan1, Nathan E. Goldstein2, Sarwat I. Chaudhry1; 1Yale School ofMedicine, New Haven, CT; 2Mount Sinai School of Medicine, New York, NY
Background: Heart failure (HF) is one of the most common reasons for hospital-ization and the leading cause of 30-day readmissions. There is great interest indeveloping strategies to reduce hospital utilization in this large and growing patientpopulation. Aside from classic HF symptoms of dyspnea and fatigue, other symp-toms reported include decreased appetite, pain and anxiety. These symptoms maybe amenable to treatment and patients hospitalized with HF may benefit fromintensive symptom management in the form of palliative care. There is limiteddata in the HF population about symptom burden both during hospitalizationand shortly after hospital discharge, as well as patients’ perceptions of palliativecare. Hypothesis: Patients discharged from the hospital after acute decompensatedHF will exhibit a high burden of residual symptoms one week post-discharge.Methods: Patients hospitalized for HF were enrolled in this prospective cohortstudy. Patients were interviewed about symptom burden using the Edmonton Symp-tom Assessment System (ESAS) during the hospital admission and 7 days post-discharge. Patients were also questioned about existing knowledge of palliativecare, and then - after a brief, standardized explanation of the goals of palliativecare - patients were queried about their interest in receiving palliative care services.Results: Fifty-nine patients were enrolled; mean age was 71.6 (SD 12.8 years)50.8% were female and 72.9% had NYHSA class III/IV HF. Frequent symptomsreported during the hospital interview were fatigue (86.4%; mean 5.20, SD 2.9),shortness of breath (74.6%%; mean 4.27, SD 3.2), anxiety (61.0%; mean 3.20,SD 3.1) and pain (44.1%, mean 2.42, SD 3.1). Frequent symptoms reported inthe follow-up interview were fatigue (89.8%%; mean 5.27, SD 2.8), shortness ofbreath (86.4%%; mean 4.00, SD 2.4), pain (64.4%; mean 3.22, SD 3.0), and anxiety(62.7%; mean 2.78, SD 2.7). While only 20.3% of patients had heard of ‘palliativecare,’ after a standardized explanation, 49.2% were interested in receiving palliativecare services while hospitalized. Conclusions: Patients hospitalized for HF experi-ence a high burden of symptoms, including not only those usually associated withHF such as dyspnea and fatigue, but also anxiety and pain. These symptoms arecommon during hospitalization and the majority of patients appear to experiencetroublesome symptoms shortly after discharge as well. Given that symptomsfrequently drive health care utilization, integration of palliative care into routineHF management is a promising strategy to reduce hospital utilization.
150Heart Failure and Palliative Care: Not Always a Good FitBirgit A. Siceloff1, Corrine Jurgens2; 1New York Presbyterian at Cornell, New York,NY; 2Stony Brook University, Stony Brook, NY
Background/Purpose: Despite evidence that palliative care reduces high symptomburden of heart failure (HF), few patients are referred to or receive palliative services.The purpose of this study was to explore HF health professional’s knowledge, attitudeand experience integrating palliative care with this population. Method: Focusgroups were conducted with 28 interdisciplinary health care professionals caringfor HF patients in a large urban medical center. Focus groups lasted 35-60 minutesand were audio recorded and transcribed verbatim. Using qualitative methodology,data was analyzed using a 2-phase coding strategy. Results: All participants agreedpalliative care is beneficial, but identified several barriers to successfully integratingpalliative care into HF care. Barriers include delivery of palliative care by a separatehealth care team, complicating communication and coordination of care. Many prac-titioners report resistance from patients when they consulted palliative care, therebyintroducing a new team. Practitioners expressed concern that advanced therapies ofHF management conflicts with concepts of palliative care. Insufficient insuranceand palliative care options also are frequently not available in outpatient settingswhich fails to bridge gaps between hospital and home. A consistent theme was dif-ficulty timing discussions of end of life and goals of care. Patient resistance to accept-ing limitations of current medical interventions was problematic. Conclusions andimplications: Including palliative care as an approach to improve care of HF patientswas viewed as unsuccessful overall. Patient resistance and difficulty coordinatingcare between two different teams was a major obstacle. Dissemination of palliativecare into homecare and training HF practitioners in provision of palliative care arepotential solutions.
151The Development and Preliminary Implementation of a Protocol for theOutpatient Weaning of MilrinoneDavid Patrick, Rebecca Radke, Leslie Jaggers, Hassan Sayegh, Victor Corrigan,Kenneth Taylor; Piedmont Healthcare, Atlanta, GA
Introduction: In patients with end-stage heart failure, continuous infusions of paren-teral positive inotropes such as milrinone may be used in an outpatient setting as ashort-term bridge to more definitive interventions such as MCS or cardiac transplan-tation (a Class IIa recommendation), or as long-term palliative therapy for symptom
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