Post-discharge Heart Failure Management

Ceyhun Ceyhan MD, FESCCeyhun Ceyhan MD, FESC

The 80% of hospitalisations for HF occur in individuals aged

more than 65 years.

Circulation. 2008;117(4):e25-e146

Five-year survival following a first admission for heart failure

Readmission after hospital discharge

Am Heart J. 2000 Jan;139(1 Pt 1):72-7.

within 6 months

The readmission rates rise with time

J Am Geriatr Soc. 1990;38(12):1290-5

Am J Cardiol. 2005;96:86G-89G.

Each hospitalisation effect myocardial and/or renal damage

Discharge planning…

General topicsExplanation of HFExpected symptoms and symptoms of worsening

HFPsychological responses

Dietary recommendations

Activity and exercise

Medications

Discharge planning…

Should be initiated within 24-48 hours after hospital admission.

Criteria for clinical stability with chronic heart failure

Freedom from evidence of congestion Angina absent or present in stable exertional pattern Stable vital signs No syncope or other recurrent symptomatic

arrhythmias Stability of non-cardiovascular disease Stable renal functions Compliance with medical regimen Social support Absence of serious depression or dementia

Education

Education of pts with HF is essential aspect of pts care

that promote clinical stability.

The education modules should be self-contained and

written in easy to understand language. Each module

should be provided practical information on a specific

topic that is useful to both patients and their families.

Education

Physicians, advanced practice nurses, home

health nurses and dietitians all play important

roles in this process.

Education

Although 80% of the patients knew they should limit the amount of salt in their diet,

only one-third regularly avoided salty foods.

Approximately 40% of the patients did not recognize

the importance of weighing themselves daily.

Arch Intern Med. 1999;159(14):1613–1619

Self-management

As up to 50% of hospital admissions may be

preventable with an effective strategy to

reduce admissions is to improve self

management.

JAMA 2000; 19:2469–75

Self-management

Optimal self management of chronic illness

involves the patient engaging in activities that

promote their health, control the impact of

their illness on their daily life, adherence to

medication regimens and medical

appointments is closest to optimal.

JAMA 2000; 19:2469–75

The ineffective management programs were less likely to follow the

guidelines.

Eur Heart J. 2006;27(5):596-612

It is common practice to withdraw a β-

blocker when patients are admitted to

hospital because of worsening CHF

Keep BB Stop BB

During hospitalization

 Durations (days) 11.5±8.3 10.4 ± 9.7

 Deaths (n) 1 (HF) 2 (HF)

After 3 months

 Deaths, % 9 8

 Re-hospit, (%) 40 47

  For HF (%) 22 32

  For arrhythmia (%) 3 4

B-CONVINCEDB-CONVINCED: Beta-blocker CONtinuation Vs. INterruption in patients with

Congestive heart failure hospitalizED for a decompensation episode

Eur Heart J. 2009;30(18):2186-92

The Recommendations of ESC Guideline

When Worsening symptoms/signs occur:

If increasing congestion – increase dose of diuretic and/or halve dose of beta-blocker

If marked fatigue (and/or bradycardia—see below) – halve dose of beta-blocker

ESC Heart Failure Guideline 2008

Keep BB

The Recommendations of ESC Guideline

In severe situations, temporary

discontinuation can be considered. Low-

dose therapy should be re-instituted and up-

titrated as soon as the patient's clinical

condition permits, preferably prior to

discharge.

Keep BB

ESC Heart Failure Guideline 2008

The Recommendations of ESC Guideline

In patients admitted to hospital due to

worsening HF, a reduction in the β-blocker

dose may be necessary.

Keep BB

ESC Heart Failure Guideline 2008

Activity and Exercise

Pts should be encouraged to

stay as active as possible, including

sexual activity and a moderate exercise (aerobic

training) program.

BMJ  2004;328:189

Medications

The one of the major cause of re-hospitalisation

and heart failure exacerbation is lack of

compliance with prescribed medications.

Arch Intern Med. 1988;148(9):2013-6 Am J Crit Care. 1998;7(3):168-74

Adherence to guidelines is a predictor of outcome in

chronic heart failure: the MAHLER survey the MAHLER survey

Eur Heart J 2005;26:1653-1659

The cost of hospital readmissions is lower in the intervention group by $460

($153 per pt/month)

VaccinationsVaccinations

Pulmonaryinfection

Others

A further case series showed that 12% of

hospitalizations in HF pts were due to

pulmonary infection.

VaccinationsVaccinations

Patients with chronic

HF should receive

one pneumococcal vaccination

and

an annual influenza vaccination.

Reasons for non-compliance with therapeutic regimen

Lack of knowledge

Poor motivation

Lower self-efficacy

Comorbidities

Forgetfulness

Decreased support from family or caregivers

J Cardiovasc Nurs. 1997;11(4):75-84

Medications

Pts should be taught the name of each drug and its

purpose, dosage, frequency and significant side

effects.

A medication schedule may also minimize to

potential for drug interactions.

Alternative medications should not be

taken

without consulting the healthcare team.

P=0.012.

Discharge Education Improves Clinical Outcomes in Patients With Chronic Heart Failure

Circulation. 2005;111:179-185

Heart Failure Heart Failure ClinicsClinics

Patients who received regular cardiovascular follow-up visits with a physician had fewer visits to emergency department, fewer

admitted to hospital and 1-year mortality is

lower.

both specialist and family physician

family physician only

no physician visits

Written materials and videotapes

are not replacement

for one-to-one education.

Impact of heart failure management unit on heart failure-

related readmission rate and mortality

Archives of cardiovascular disease, 2010;103(2):90-6

Meta-analysis showed a significant reduction in all cause admission

(relative risk 0.87, 95% confidence interval (CI)

0.79 to 0.95, p< 0.002)However, significant heterogenity

(p< 0.002) was found

J Am Coll Cardiol, 1999; 33:1560-1566

PacifiCare and Alere Medical to Provide Congestive Heart Failure Patients Innovative AlereNet CHF

Management System.

Daily electronic home monitoring

system

Patients initiate the monitoring process each morning by simply

standing on the DayLink(R) monitor, located in their home.

A phone line to the Alere Network automatically transmits the

information to a central call station monitored by cardiac-trained nurses who analyze trends that may reveal

a change in the patient's health status. If indicated, the patient's

doctor is notified, and the need for clinical intervention is assessed

before an expensive hospital admission or emergency room visit

is required.

AlereNet CHF Management System is representing a 56.2% difference in

mortality

Am Heart J 2003;146(4):705-12.

the Weight Monitoring in Heart Failure (WHARF) trial

The number of patients needed to treat in order to save one life

was 9.7

The cost per patient for the Home Health Monitor is $408/month

Effect of Home-Based Telemonitoring Using Mobile Phone Technology on

the Outcome of Heart Failure Patients After an Episode of Acute

Decompensation: Randomized Controlled Trial

the MOBIle TELemonitoring in Heart Failure Patients Study

(MOBITEL)

The telemonitoring equipment consisted of three commercially available components:

(1) a mobile phone (Nokia 3510, Finland),

(2) a weight scale with 0.1 kg accuracy and

electronic display (Soehnle creta, Germany), and

(3) a sphygmomanometer for fully automated

measurement of blood pressure and heart rate

(BosoMedicus, Bosch&Sohn, Germany).

J Med Internet Res 2009;11(3):e34

Tele group patients were asked to measure vital

parameters (blood pressure, heart rate, body

weight) on a daily basis at the same time,

preferably in the morning after emptying the

bladder and before dressing and taking

medication.

J Med Internet Res 2009;11(3):e34

Study physicians had access to a secure website providing both numerical and

graphical depiction of data for each patient. Whenever necessary, study physicians could

contact patients using the mobile phone

J Med Internet Res 2009;11(3):e34

Trend chart of vital parameters of a typical patientTrend chart of vital parameters of a typical patient

Providing elderly patients with an adequate user interface for daily data acquisition remains a challenging component of

such a concept. J Med Internet Res 2009;11(3):e34

Factors predicting

early post-discharge mortality include

Age,

Serum creatinine,

Reactive airway disease,

Liver disease,

Lower systolic blood pressure,

Lower serum sodium,

lower admission weight, and depression

Am Heart J. 2008 Oct;156(4):662-73.

Multidisciplinary interventions

to patients with heart failure

not only reduces hospital admission

but also is an effective method for

reducing mortality.

Intervention costs were higher with more complex

programs ($8383 per patient per year) versus

less complex programs ($1695 per patient per

year).

Journal of Cardiac Failure 2007;13(1):56-62

Hit-P inTPost-discharge Heart Failure

Monitorization Program in Turkey

The patients are randomized (2:1) blinded to

control and investigation group.

Intensive education about HF before discharging, by experienced cardiologist

and nurseUsing a teaching booklet

End-points

Primary end-point:

Cardiovascular death or hospitalisasiton

Secondary end-point;

All cause of hospitalisations

hospitalisation related to worsening HF

Admission to emergency unite

Any cause of death

Thank YouThank You

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