Pharmacologic Considerations for Reducing Hospital Readmission in Geriatric Patients with Heart...

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Pharmacologic Considerations for Reducing Hospital Readmission in Geriatric Patients with Heart Failure

Pharmacologic Considerations for Reducing Hospital Readmission in Geriatric Patients with Heart FailureBarbara J. Zarowitz, Pharm.D.Chief Clinical Officer, Vice President of Clinical ServicesOmnicare, Inc., andAdjunct Professor of Pharmacy PracticeCollege of Pharmacy and Health SciencesWayne State University

November 2013ObjectivesTo identify the key pathophysiologic mechanisms operative in patients with heart failure;To differentiate characteristics of heart failure in persons older than 80 years of age compared to younger patients;To select strategies of heart failure management recommended in current evidence-based guideline;To identify pharmacokinetic and pharmacodynamics features of older persons with heart failure;To determine important pharmacologic considerations of heart failure medications in older persons;To select the most common reasons for readmission of heart failure patients to the hospital and strategies to mitigate the risk of rehospitalization; andUsing a case-based approach, to select appropriate interventions to optimize the care of older patients with heart failure.

2Heart Failure Clinical Program Omnicare, Inc. 20132DisclosuresDr. Zarowitz is an employee of Omnicare, Inc., and holds Omnicare stockShe has been awarded numerous research grants for Omnicare Senior Health Outcomes from:AbbVieAmgenAstellasAvanirGlaxoSmithKlineMylanOptimerSanofi-aventisSavient

Case Presentation83 year old Caucasian male, Clcr 63 mL/min, dry weight of 160 lb (72.2 kg) who presented to the nurse practitioner with complaints of shortness of breath and productive coughing for the last 4 weeksBP-90/64, HR-100, RR-20, T-98.6PMH: NYHA stage IV HF, glaucoma, coronary artery disease, hypertension, ocular strokesHPI: hospitalized the previous year twice for syncope associated with heart failure. Cardiac arrest during one hospitalization following administration of ramipril 2.5 mgCXR: no infiltratesLabs: WBC wnl

MedicationDoseFrequencyaspirin EC81 mgonce dailyclopidogrel75 mgonce dailyfurosemide 40 mgonce dailymetoprolol50 mgtwice dailymirtazapine30 mg at bedtimezolpidem5 mgat bedtimesimvastatin40 mgat bedtimespironolactone25 mgonce dailydigoxin0.0625 mgonce dailyVitamin D31,000 units (2 tabs)once dailyVitamin E400 unitsonce dailylatanoprost1 drop each eyeat bedtimefurosemide 40 mgwt 162 = no dose40 mgwt 163 - 167, 1 tab40 mg (2 tabs)wt 168, 2 tabs40 mg (2 tabs)wt 169, 2 tabs twice daily40 mg (4 tabs)wt 170, 2 tabs twice daily5Heart Failure PathophysiologyWhat is Heart Failure?6So lets begin by discussing what heart failure is thereby look at the impact heart failure has on the patient and us as healthcare professionals. 7Definition of HF7Inability of the heart to pump blood to the body sufficient to meet the bodys demandsResults from structural or functional cardiac disorder Impaired ability of the ventricle to fill with or eject blood Omnicare, Inc. 2013So what is heart failure? HF is the inability of the heart to pump blood to the body sufficient to meet the bodys demands. And this results from either structural or functional cardiac disorders such that there is an impaired ability of the ventricle of the heart to either fill or eject blood. Pathophysiology of Heart FailureCausal FactorsMyocardial DamageMyocardial FailureSVR (afterload) Blood Volume (preload)Cardiac output LV end diastolic pressureCompensatory ResponsesRAA SNSANFVasopressin8The pathophysiology of heart failure is similar, regardless of underlying cause. Loss of cardiac output results in activation, and ultimately, over-activation, of the sympathetic nervous system and the renin-angiotensin-aldosterone axes. These compensatory systems are physiologic attempts to overcome the loss of cardiac output, but their over-activation contributes to excess edema, increased preload and increased afterload that further reduce myocardial performance. Drug therapy for heart failure is designed to interrupt the over activation of these compensatory systems, thereby improving patients symptoms and decreasing mortality.9Pumping and Filling Problems and Heart Failure

The enlarged ventricles fill with bloodThe ventricles fill normally with bloodThe stiff ventricles fill with less blood than normalThe ventricles pump out ~60% of the bloodThe ventricles pump out less than 40-50% of the bloodThe ventricles pump out ~60% of the blood, but the amount may be lower than normalNORMALSYSTOLIC DYSFUNCTIONDIASTOLIC DYSFUNCTIONDiastole(Filling)Systole(Pumping) Omnicare, Inc. 20139To understand how HF presents, it is helpful to understand how the heart normally functions in comparison to how the heart functions in either systolic or diastolic heart failure. Normally, the heart stretches as it fills with blood (during diastole), then contracts to pump out the blood (during systole). Heart failure due to systolic dysfunction usually develops because the heart cannot contract normally. It may fill with blood, but it cannot pump out as much of the blood it contains because the muscle is weaker. As a result, the amount of blood is pumped to the body and to the lungs is reduced, and the heart, particularly the left ventricle, usually enlarges.Heart failure due to diastolic dysfunction develops because the hearts walls stiffen and may thicken so that the heart cannot fill normally with blood. The epidemic of diastolic dysfunction is secondary to that of type 2 diabetes and obesity. Consequently, blood backs up in the left atrium and lung (pulmonary) blood vessels and causes congestion. Nonetheless, the heart may be able to pump out a normal percentage of the blood it receives.Because the heart contracts to enclose the amount of blood that it contains, there is never any empty space in its chambers. The different amounts of blood entering or leaving the chambers is indicated by the thickness of the arrows.10Facts About Heart Failure (HF) (continued)Prevalence of HF in nursing homes (NHs) is ~20%HF is the 2nd most preventable cause of emergency department (ED) visits (19%)668,000 ED visits and 1,094,000 hospital discharges in 2009Discharges to someplace other than home have tripled in the past decade50% of Medicare patients discharged to NHs are rehospitalized within 6 monthsCharacteristics associated with a high risk for rehospitalization with HFHigher NYHA stageGreater functional limitations (ADLs)Concomitant psychosis Concomitant renal failure10Roger VL et al. Heart disease and stroke statistics2012 update: a report from the AmericanHeart Association. Circulation. 2012;125:e2e220.Hutt E et al. J Am Med Dir Assoc 2011; 12:595-601 Omnicare, Inc. 2013This slide represents many facts about heart failure that are discussed in the American Heart Associations 2012 statistical report. In 2008, 1 in every 9 death certificates in the U.S. mentioned the diagnosis of heart failure. And overall an estimated 6.6 million US adults have HF with the incidence of HF increasing with age. An important fact on this slide is that 75% of patients with heart failure had hypertension prior to their being diagnosed with heart failure, so as we will discuss again later in this presentation, controlling a patients blood pressure is very important. Overall HF is more common among African Americans and among men. It is also important to realize that heart failure is considered the 2nd most preventable cause of emergency department visits, accounting for 19% of all visits. This also means that there are a lot of discharges associated with heart failure. Facts About Heart Failure (HF)In 2008, 1 in 9 death certificates in the U.S. mentioned HFAn estimated 6.6 million US adults have HF60-79 years-old: 9% of men and 5.4% of women80+ years-old: 11.5% of men and 11.6% of women 75% of HF cases had HTN prior to their HFLifetime risk for HF is double for those with BP >160/90 mmHg compared to MEtiologyCoronary artery diseaseHypertensionLVEFReducedNormalComorbiditiesFewMultipleRCTsManyFewTherapyEvidence-basedEmpiricPhysicianCardiologistPrimary careM=male; F=female; LVEF=left ventricular ejection fraction; RCT=randomized clinical trialFeatures Distinguishing Heart Failure in the Elderly from Heart Failure Occurring During Middle AgeAdapted from Rich RW. Drug therapy for heart failure in the elderly. Am J Ger Cardiol 2003;12:235-42.13The incidence and prevalence of heart failure (HF) increases progressively with age, and HF is currently the leading indication for hospitalization among older adults, as well as the most costly cardiovascular disorder in the Medicare population. In the United States, the prevalence of HF increases from 10% in persons over age 80. As HF has emerged as a major public health concern during the past 20 years, HF research has intensified. Indeed, there have now been hundreds of clinical trials evaluating the safety and efficacy of a broad range of pharmacologic therapies for the treatment of HF, and the results of these trials have led to the development of authoritative, evidence-based guidelines for HF management. Unfortunately, most of these studies have focused primarily on middle-aged HF patients, who may differ in many important respects from older HF patients. As a result, the generalizability of HF trials to older HF patients has been questioned, and it has been estimated that a minority of older HF patients would have been suitable candidates for the HF trials, even if older age had not been an exclusion. Despite limited data from clinical trials, clinicians must still provide appropriate care for the large number of elderly HF patients. Pharmacokinetic and Pharmacodynamic Variants in Older Persons with Heart FailureAbsorptionIncreased gastric pH, delayed gastric emptying, reduced GI blood flow and slowed intestinal transitDecreased bioavailabili