2012 CCU Competency2012 CCU Competency Heart Failure Module 1:

Medical Management Issues

Heart Failure Focus for 2012 Heart Failure Focus for 2012

Heart failure is our disease specific focus area for 2012 competency.

There will be 2 modules, each with a specific focus.◦Medical Management Issues ◦Nursing Driven Care ◦Quality Outcome Assessment

Purpose Purpose

The purpose of this module is to review key medical management areas where there is opportunity for improvement.

As part of the interdisciplinary team a thorough understanding of medical treatment goals will allow you to optimally contribute to the treatment plan and advocate for your patients with heart failure.

Stages of Heart Failure Stages of Heart Failure ACC / AHA ACC / AHA Stage A Stage B Stage C Stage D At high risk for HF but without structural heart disease or symptoms of HF.

HTN

CAD

DM

Obesity

Metabolic syndrome

Family HX CM

Structural heart disease but without signs or symptoms of HF

Previous MI

LV Remodeling including LVH and low EF

Asymptomatic valvular disease

Structural heart disease with prior or current symptoms of HF.

Known structural disease and SOB, fatigue, reduced exercise tolerance.

Refractory HF requiring specialized interventions.

Marked symptoms of HF at rest despite maximal medical therapy.

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Classification of Heart Failure: Classification of Heart Failure:

New York Heart Association New York Heart AssociationClass I Class II Class III Class IV

Cardiac disease no resulting limitation in physical activity.

Ordinary activity free of fatigue, palpitation, dyspnea or anginal pain.

Cardiac disease with slight limitation of physical activity.

Comfortable at rest but ordinary activity results in fatigue, palpitations, dyspnea, or anginal pain.

Cardiac disease with marked limitation on physical activity.

Comfortable at rest but less than ordinary activity results in fatigue, palpitations, dyspnea, or anginal pain.

Cardiac disease resulting in inability to carry out any physical activity without discomfort.

May have symptoms of cardiac insufficiency at rest.

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Systolic Dysfunction (Reduced EF)

Diastolic Dysfunction (Preserved EF)

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Heart failure with preserved or Heart failure with preserved or reduced left ventricular function. reduced left ventricular function.

Although the commonly used terms are systolic and diastolic heart failure, the current recommended terms are heart failure with preserved left ventricular function and heart failure with reduced left ventricular function.

The reason for the clarification is because most patients with “systolic heart failure” also have some abnormalities during diastole, and patients with “diastolic heart failure”, although their overall EF is normal do not have completely normal systolic function.

Evidence Based Guidelines for Evidence Based Guidelines for Heart Failure with Heart Failure with ReducedReduced LV LV Function Function

There are evidence based guidelines for the management of patients with heart failure with reduced LV function. ◦ACE-I (or ARB) ◦Beta blocker ◦Aldosterone antagonists (NYHA Class III or IV HF) ◦Hydralazine / Nitrate combination (for African Americans

- in addition to standard therapy)

◦Cardiac resynchronization therapy if BBB (especially LBBB) and EF < 35%

◦Referral for ICD therapy if EF < 35%

More on Beta-Blockers More on Beta-Blockers

There are only three beta-blockers that are recommended for use in patients with reduced LVEF (<40%)

These are considered evidence based beta blockers ◦ Carvedilol (Coreg) ◦ Metoprolol succinate (long acting metoprolol) (ToprolXL) ◦ Bisprolol (Zebeta)

This is the reason you may see patient’s switched from Lopressor, which is metoprolol tartrate (short acting metoprolol)

Quality Indicator: In 2011 evidence based beta blockers were only prescribed 84.7% of the time.

Note: There are no clear evidence based guidelines for patients with preserved LVEF.

In HF patients with preserved LVEF (diastolic dysfunction) the focus is on managing the patient’s

comorbid conditions. This means rate control in atrial fibrillation, treatment of hypertension, and

diagnosis and treatment of obstructive sleep apnea.

Focus areas to improve outcomes. Focus areas to improve outcomes.

Our quality data indicates that only 60-65% of potentially eligible patients have documentation regarding counseling or referral for cardiac resynchronization therapy and / or ICD.

When caring for a heart failure patient with an EF < 35% ask / discuss during rounds if this patient is a candidate for CRT and / or ICD therapy.

Cardiac Resynchronization Cardiac Resynchronization Therapy (CRT)Therapy (CRT)Treatment modality for heart failure not just pacing

◦ Used in patients with dysynchrony (QRS > 120 msec) Used in conjunction with optimal drug therapyIn addition to the atrial lead there are two

ventricular leads ◦ RV Apex ◦ LV lateral wall

Goal: Force biventricular pacingGoal: Ventricular Pacing 90% of time or greaterAnticipated Outcomes:

◦ Improve hemodynamics by restoring synchrony of ventricular contraction

◦ Improve quality of life◦ Decrease mortality and morbidity

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Implantable Cardiovertor Implantable Cardiovertor Defibrillator - Indications Defibrillator - Indications Secondary Prevention (Class IA Recommendation)

◦ Symptoms of HF◦ History of cardiac arrest, VF, or hemodynamically

destabilizing VT

Primary Prevention (Class IA Recommendation)◦ Non-ischemic dilated myopathy or ischemic heart disease >

40 days post-MI or > 90 days post intervention◦ EF < 35%◦ NYHA class II or III in optimal medical therapy◦ Not recommended in Stage D

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Recognizing Potential Obstructive Sleep Apnea Another Important Opportunity for Improvement

Obstructive Sleep Apnea Obstructive Sleep Apnea

Approximately 1 in 5 adults: mild Approximately 1 in 15 adults: moderate /

severe 15 million Americans > 85% have not been diagnosed Adverse consequences may be greater

in those < 50 years. High prevalence of pathological daytime

sleepiness in OSA Almost all with OSA snore but not all

snorers have OSA

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During Sleep During Sleep 16

Physiological Impact of Obstruction Physiological Impact of Obstruction 17

Source: Source: Javaheri, et al. (2011). American Javaheri, et al. (2011). American Journal of Respiratory Critical Care Medicine, Journal of Respiratory Critical Care Medicine, 183, 539-546. 183, 539-546.

The prevalence of sleep apnea in heart failure has been reported to be approximately 50%. ◦This includes both obstructive and central sleep

apnea. In this study of 30,719 Medicare HF patients

only 2% were tested for sleep apnea. Those who were tested, diagnosed and

treated had improved survival compared to those who were not.

The STOP-BANG Screening Tool The STOP-BANG Screening Tool for Obstructive Sleep Apnea. for Obstructive Sleep Apnea.

Answer each of the following yes or no: 1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?2. Do you often feel TIRED, fatigued, or sleepy during daytime?3. Has anyone OBSERVED you stop breathing during your sleep?4. Do you have or are you being treated for high blood PRESSURE?5. BMI more than 35?6. AGE over 50 years old?7. NECK circumference > 15.75 inches?8. Male GENDER? ≥3 yes answers: High-risk for OSA<3 yes answers: Low-risk for OSA

To Complete this Module: Document the answers to To Complete this Module: Document the answers to the above patient questions in QUIA. Put the date, the above patient questions in QUIA. Put the date, room number and initials of the patient you assessed. room number and initials of the patient you assessed.

Our focus is linking knowledge to practice and practice to patient outcomes. For this module we want to increase awareness of our practice patterns in the care of HF patients.

Find one patient in CCU admitted with HF with a reduced LVEF: ◦ Does the patient have a LVEF of < 35%

If yes - does the patient have an ICD? If not – is there a notation regarding contraindication?

◦ Does the patient have a LBBB and a LVEF of < 35% If yes – does the patient have a CRT device? If not is

there a notation regarding contraindication? ◦ What is the patient’s STOP BANG Score?

Is the patient being treated for sleep apnea? If not has the patient ever had a sleep study?

For your Portfolio.For your Portfolio.Please include any examples of your input into rounding

or collaborative discussion where you have identified potential candidates for ICD/CRT or sleep apnea testing.

Thank you. Your commitment to excellence makes a difference!