Dr. Walid Hassan
77
HEART FAILURE Family Centered Approach International Medical Center Jeddah, Saudi Arabia Walid Hassan, MD, FACC, FAHA, FCCP, FACP Professor of Medicine IMANA/IMC December 28-29, 2014
description
Â
Transcript of Dr. Walid Hassan
HEART FAILURE Family Centered Approach
International Medical CenterJeddah, Saudi Arabia
Walid Hassan, MD, FACC, FAHA, FCCP, FACP
Professor of Medicine
IMANA/IMC December 28-29, 2014
الرحيم الرحمن الله بسمالعالمين رب لله الحمد
4
Walid Hassan, MD
NO DISCLOSURE
Key points Introduction
Heart Failure Internationally and in Saudi Arabia.
Evidence supporting HF Pathophysiology and Management.
Role of the HF Family.
Future plans of the HF management at IMC-JEDDAH
All Heart Talks The heart is most frequent organ
mentioned in:
The Glorious Qura’n Hadith “Prophet sayings” Poetry and literature by all
languages Relation to emotions
IBN EL NAFIS (1210-1288 A.D.)
Abu Al Hassan Ala Addin Abu Al Hasm
He said that heart has only two ventricles and explained the coronary circulation.
He discovered pulmonary circulation well before Harvey.
Referred to as
Avicenna the Second.
IN THE HISTORY OF MEDICINE
William Harvey in 1628IN THE HISTORY OF MEDICINE
The heart is a Unique Organ !
وآدآئه النسيجى تركيبه و خلقه فى فريد عضو
الوظيفى
فى معجزة ظواهرالقلب
و األمراض لمقاومة األورام
Preconditioning
Stunning
Hibernation
Rarity of Oncogenesis
Unique in Resistance to Ischemia, Diseases
and Tumors
Blood Emotions
?Hormones
ElectricalActivity
ElectroMagnetic
Neurological Activity
Cardiac Functions
القلب وظائف
HEART FAILURE EFFECT ON ORGANS
Heart Failure is a complex clinical syndrome that can result from any structural or functional cardiac or non-cardiac disorder that impairs the ability of the heart to respond to physiological demands for increased cardiac output. (European Society of Cardiology 2012)
HF EpidemiologyPrevalence: 22 millions HF patients in the world.
Incidence: 2 millions new HF cases diagnosed / year.
WHO, 2005
AHA, Heart & Stroke statistical update 2006
Mortality of HF
USA EUROPE0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
IncidenceMortality
WHO, 2005 AHA, Heart & Stroke statistical update 2006
Saudi Arabia64% of the Acute HF patients enrolled in the
registry have Chronic HF and are 10 years
younger than other patients enrolled in
international registries.
HEARTS Registry
European Journal of Heart Failure (2014)
IMC-JEDDAH
2012520 patients with BNP >400 pg/ml
2014
Surviving Patients: 360 Dead Patients: 160
The Prevalence, Clinical Characteristics, and Prognosis of 519 Elderly Patients with Heart Failure and Preserved Systolic Function. A Clinical Study with a 5 years Follow-up period
F.El Shaer , W.Hassan, et al.KFSH&RC Saudi Arabia.
ESC, WCC 2006 CHFJ 2009
61%
39%
0%
10%
20%
30%
40%
50%
60%
70%
Prevalence of DHF
PR
Risk factors for HF in all patients81.30%
46.10%
34.50% 33.00%
5.40%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Patients equal to or >65 yrs old
HTNDMHyperlipidIHDSmoker
Mainly Multi-organ failure & Septic shock
The process of failing of the human heart:review of the current knowledge of the mechanisms of heart failure.
Epidemiology of Heart FailureClinical criteria – Prevalence 2 %
Males Females; in 65+ Prevalence 7%
50% of LVSD is asymptomatic
HFREFHFPEF
Maggioni et all. Eur J Heart Fail 2013;15:808-17
Pathophysiology of HF Decreased cardiac output results in
End Diastolic Pressure (LVEDP), LVH, LVD Pulmonary Capillary Wedge Pressure (PCWP) The development of pulmonary edema
Activation of Neurohormonal Mechanism Renin-Angiotensin-Aldosterone- System (RAAS) Sympathetic Nervous System (SNS) Other circulating and paracrine effects
Counter-regulatory systems Natriuretic Peptide System (BNP, pro BNP)
Models of HF
1 •Hemodynamic
2 •Neuro hormonal
3 •Autonomic
4 •Microenvironmental
Cardiac RemodelingNa and H2O retention, PerformanceMyocyte hypertrophy, death, fibrosisDilated and spherical ventricle, thinned
Hemodynamic Model and targets
Factor Mechanism Therapeutic Strategy 1. Preload (work or stress the heart faces at the end of diastole)
increased blood volume and increased venous tone--->atrial filling pressure
-salt restriction-diuretic therapy-venodilator drugs
2. Afterload (resistance against which the heart must pump)
increased sympathetic stimulation & activation of renin-angiotensin system ---> vascular resistance ---> increased BP
- arteriolar vasodilatorsNTG, ACEI, Hydralazine
3. Contractility decreased myocardial contractility ---> decreased CO
-inotropic drugs (cardiac glycosides)
4. Heart Rate decreased contractility and decreased stroke volume ---> increased HR (via activation of b adrenoceptors)
Heart rate lowering (BB, Dig)
V-HEFT ICumulative Mortality from the Time of Randomization in the Three Treatment Groups
0
0.1
0.2
0.3
0.4
0.5
0.6
0 6 12 18 24 30 36 42Interval (months)
Cum
ulat
ive
Mor
talit
y R
ate
PlaceboPrazosinHyd-Iso
N Engl J Med 1986;314:1547-52
DIG Trial 6800 chronic
HFREF patients were randomized to digoxin and placebo
New Engl J Med 1997;336:525-33
Pathological Effects of RAAS
RAAS Axis and its Blockade
RAAS Blockade
AGTNG• Renin• Aliskire
n
AT-I• ACE• ACE-i
AT-II
• AT1R• ARB
ALDO• Renal• MRA
Bradykinin AT2 AT4 as
Vasoprotection
Sympathetic Nervous System
CO activates baroreceptors - SNSEffects of Circulating Epinephrine & NE
Increased Heart Rate Increased Blood Pressure Increased myocardial oxygen
demand Toxic effects on myocardium – cell
death Down regulation of 1 receptors in
heart Decrease in parasympathetic
activity
Effect of Norepinephrine in HF
Natriuretic Peptides in HF
HF Joint Neurohormonal ModelRAAS
Sympathetic System
BNP
Medical Therapy for HF: Magnitude of Benefit Demonstrated in RCTs
GDMT RR Reduction in Mortality
NNT for Mortality Reduction
(Standardized to 36 mo)
RR Reductionin HF
Hospitalizations
ACE inhibitor or ARB 17% 26 31%
Beta blocker 34% 9 41%
MRA 30% 6 35%
Hydralazine/nitrate 43% 7 33%
Levy W C et al. Circulation. 2006;113:1424-1433
+ CRT
Multidisciplinary Programs
Identified 3 crucial elements to success of multidisciplinary programs:
1. Specially trained nurses/MDs should be key components of any intervention
2. Importance of education provision to patients and family members.
3. Provision of available access to HF clinicians when needed.
McAlister and colleagues (2004)
Heart Failure Nurse
Cardiologists
Family
Laboratory
PharmacistsCardiac
Rehabilitation
Dieticians
ECG & Echo techs.
Information
technology
Primary health care
centers
Patients and
Caregivers
Role of the Heart Failure Nurse
Systematic review of 29 RCTs of HF multidisciplinary management programs:
43% REDUCTION in HF admissions
McAlister and colleagues (2004)
Heart Failure Nurse
Cardiologists
Family
Laboratory
PharmacistsCardiac
Rehabilitation
Dieticians
ECG & Echo techs.
Information
technology
Primary health care
centers
Patients and
Caregivers
Engaging family
In-patient assessment• Identify cognitive level• Determine the acuteness of their
disease
Assessment of learning
needs• To match a teaching strategy• Identify patient’s literacy
Assessment of learning
style• To fill missing information• Assess the home situation• Assess family member support and
participation
Family interview
Multidisciplinary ProgramFamily
Knowledge Empowerment Confidence
Self-manage
ment
Heart Failure NurseFamily
Education
Discharge planning
Education
Phone follow up within 3-7 days from discharge
Education
Heart Failure clinic
Assessment of knowledge about Heart Failure, and readiness to learnSelf-management education
Encourage diet and medication compliance, promote exercise, regular symptoms monitoring, and daily weight.
ConclusionsPatients seeking ED care for decompensated HF had inaccurate HF beliefs and poor self-care adherence. Lack of association between HF beliefs and self care (and trend of an inverse relationship) reflects a need for pre-discharge HF education, including an explanation of what HF means and how it can be better controlled through self-care behaviors Journal of Emergency
Medicine, 2014
Self-Family Management Education
Medication
compliance
Daily weighing
Salt and fluid
restriction
Activity and
exercise
Smoking cessation
Signs and symptoms of Heart Failure
Patient will assume
responsibilitychoose
healthier life style
Increase satisfaction
Promote patient active
involvement Improve
medication adherence
Ensures continuity
of care
Reduces disease related
complication
Maximizes individual’s
independence
Goals of the Heart Failure TT
Empowerment
Improve Quality of Life
Reduce mortality
Symptom management
Improve exercise tolerance
Prevent progression of disease
Reduce health care
cost
Reduce ER visits and
re-admission
rates
Schematic depiction of comprehensive heart failure care
Goodlin, S. J. J.A.C.C. 2009;54:386-396Copyright ©2009
Func
tion
Death
High
LowBegin to use hospital more often, self-care more difficult
Time ~ 2-5 years. Death usually seems “sudden”
Modified from Lunney JR et al. JAMA 2003: 289: 2387.
TerminalPhase
Heart failure
Transitions in life-limiting illness
Transitions
EarlyDisease
containmentMaintaining
function
DecompensationExperiencing life limiting illness
Decline and terminal
Transitions Transitions
Dependency and symptoms increase
Transitions Transitions
Death and bereavement
Time
Time of Diagnosis
McGregor and Porterfield 2009
Assess: Patient and their Illness experience
DISEASE
DIAGNOSIS
SPREAD
TREATMENT
BENEFITS
BURDENS
OTHERPROGNOSTICFACTORS
PATIENTEXPERIENCE (SUFFERING)
CULTUREBACKGROUND
NEEDS and PREFERENCES
GOALS of CAREVALUES,
BELIEFS
Assess: Goals of careGoals of care change over time and may include: Maintaining and improving function. Staying in control. Relief of suffering. Prolonging life for as long as possible or until a specific
event (time limited trials of care). Quality of life/ living well.
Assess: Goals of care (continued) Pain and symptom management. Strengthening relationships. Preferences for location of care.
1. Psychosocial care for person.
2. Psychosocial care for family.
3. Spiritual care. Preferences for location of death. Life closure/ dying well.
Communication: Vital for EOL care
Patient experiences Being seen. Being heard. Being met.
Family and caregivers’ experience Support in transitions.
Establish partnership with clear goals of care and a plan for the future.
Who supports HF End of Life care? Primary care physicians and HF Specialists Home and Community Care palliative teams Patients and families/caregivers Linking with...
Acute care hospitals and tertiary ambulatory services End of Life Care programs and services Local Hospice Societies and other community services
Produces patient- family centred interdisciplinary practice
Ambiguous dying
“There will not be a distinct terminal phase. The week we die will start out like any other and
some unpredictable calamity will occur. Amongst those of us with advanced heart failure,
we will have had a 50-50 chance to live for six months on the day before we died”
Joanne Lynn: Sick to Death and Not Going to Take it Anymore (2004)
Integrating the palliative approach
Improved survival
Needs of the family/caregivers
CONCLUSIONS
Integrated care: Shifting the focus in HFMeeting the majority of people’s health care needs by providing high quality, accessible, community based health care and support services Built around attachment to a family physician and an integrated health care team (HF nurse). Stronger voice for the patient, family and local community in the design and delivery of healthcare services. More focus on proactive management of chronic HF Pt to remain independent.
IMC Team players Patient and Family Family physician Community pharmacist Home Health / Community Care –
Nurses/rehab/home support Nurse practitioners, community RT Disease specific specialists / services Hospice palliative care consult teams
77
Walid Hassan, MD
NO DISCLOSURE
Thanks " .. نبأه لتعلمن و للعالمين ذكر اال هو ان
حين "بعد
