Post on 26-Mar-2015
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
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