HEART FAILURE

KEEPING YOUR PATIENT

AT HOME

SUZANNE FRAZIER MS, CRNP, NP-C, CHFN HEART FAILURE DISEASE MANAGEMENT COORDINATOR

PENN STATE HERSHEY HEART & VASCULAR INSTITUTE

IMPACT OF HEART FAILURE

• In 2010, 6.6 million US adults ≥18 years of age (2.8%) had HF

• It is estimated that by 2030, an additional 3 million people will have HF, a 25.0% increase in prevalence from 2010

• In 2010, estimated heart failure costs the United States…

34.4 BILLION dollarsHeart Disease and Stroke Statistics-2012 Update January 2012

Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association2011

YOU will treat patients with heart failure….

• As our population ages, this epidemic of heart failure will only continue to grow. The cost of providing heart failure ranks among the leading U.S. healthcare expenditures.

• Additionally, the toll of heart failure on life, both in quality and longevity, is sobering.

©2010, American Heart Association

Healthcare Reimbursement:A Changing Paradigm

Center for Medicare & Medicaid• Shift from pay-for –service

• Now based on outcomes with possible penalties

Pay-For Performance• Private insurers monitor quality benchmarks

• Apply incentives and penalties

CMS Bundled Care Payments2013 Bundled Payments for Care Improvement initiative:

• Organizations enter into payment arrangements that include financial and performance accountability for episodes of care (90 days).

• These models, it is speculated, lead to higher quality, more coordinated care at a lower cost to

Medicare.

What can you do?

• Apply evidence based care

• Support self care management

• Treat volume overload

• Use community resources

• Recognize advanced HF and palliate

HF Evidence–Based Therapies & Medications

• Classifications of Recommendations

• Levels of Evidence

Types of Heart FailureHF with Reduced EF (HFrEF) ≤ 40%

SystolicHF with Preserved EF (HFpEF) >50%

Diastolic

Approach to Treatment of HFrEF

ICDCRT-P/CRT-D

Cardiac Resynchronization Therapy

NYHA Class II-IV, EF<35%

NYHA Class III-IV, EF<35%, QRS>120 ms

EF still 35%

Diuretic

Assessment of fluidvolume status

Signs and symptoms offluid retention

Titrate ACEI/ARB/ARNI &Beta-blocker Therapy

EF 40%

Assessment of EF

In selected patients: aldosterone antagonists, digoxin

Apply evidence-based medications

Stop aggravating meds• Select anti-arrhythmics• Calcium channel blockers• NSAIDS

TransplantLVADPalliative Care

Beta Blockers

**Metoprolol Succinate(Toprol XL): Start 12.5 mg daily

Titration Schedule: Double the dose every 2 weeks as tolerated until reach target dose 200 mg daily (Target)

Carvedilol (Coreg): Start 3.125 mg BID

Titration Schedule: Double the dose every 2 weeks until at target dose25 mg BID (Target) for patients <187 lbs or 50 mg BID (Target) for patients >187 lbs

**Bisoprolol (Zebeta): Start 1.25 mg daily

Titration Scheduled: Double the dose every 2 weeks as tolerated until reach target dose 10 mg daily (Target)

**cardio selective

Angiotensin Converting Enzyme Inhibitors (ACE-i)

• Lisinopril: ( Prinivil, Zestril): Start 2.5 mg – 5 mg daily

– Titration Schedule:5 mg daily for 1 week10 mg daily for 2 weeks

– 20 mg daily for 2 weeks(Target)

– 40 mg daily if needed for BP control (Max dose)

• Enalapril (Vasotec): Start 2.5mg Bid

– Titration Schedule:2.5 mg BID for 2 weeks

– 5 mg BID for 2 weeks10 mg BID for 2 weeks

– (Target)20 mg BID if needed for BP control (Max dose)

• Captopril (Capoten):Start 6.25 mg TID

– Titration Schedule:6.25 mg TID for 2 weeks12.5 mg TID for 2 weeks25 mg TID for 2 weeks (Target)50 mg TID if needed for BP control (Max dose)

– *BMP and BP check before initiation and with each med adjustment*________________________________________________________________________________________________________________

• Use cautiously in patients with chronic renal insufficiency (Creatinine > 2.5) or K+ > 5.0)

• If cough occurs, consider 3-5 day trial off med or try ARB• Avoid taking NSAID’s

Angiotensin Receptor Blockers (ARB)

• Valsartan (Diovan): Start 20-40 mg BID

– Titration Schedule:80 mg BID (Target)160 mg BID if needed for BP control (Max dose)Losartan

• Losartan(Cozaar): Start 25-50 mg daily

– Titration Schedule:50 mg daily (Target)100 mg daily if needed for BP control (Max dose)

*Used for those who are intolerant to ACE-I, typically due to cough

*BMP and BP check before initiation and with each med adjustment

*Used cautiously in patients with chronic renal insufficiency (Creatinine > 2.5)or K+ > 5.0

Angiotensin Receptor-Neprilysin Inhibitor (ARNI)

sacubitril/valsartan(Entresto)Dosages: 24/26 mg tab 49/51 mg 97/103 tab

Titration:lisinopril or enalapril ≤10 mg daily or No ACE - start 24/26 mg BID

valsartan or losartan ≤ 160 mg daily - start 24/26 mg BID

lisinopril or enalapril ≥ 10 mg daily – start 49/51 mg BID

valsartan or losartan ≤ 160 mg daily - start 49/51 mg BID

Double dose every 2-4 weeks; monitor for renal dysfunction & hyperkalemia

Severe renal impairment (gfr<30) or moderate liver impairment (Child –Pugh B) start at lowest dose

MUST stop ACEi 36 hours before starting ARNI - need washout period to avoid chance for angioedema

ARNI

Mechanism of Action:1) Inhibits overactive RAAS

2) Inhibits breakdown of vasoactive peptides which in return promotes

• Vasodilation

• Natriuresis

• Renin/aldosterone suppression

Monitor:• Hypotension

• Angioedema

• Hyperkalemia

• Impaired renal function

Aldosterone Antagonists

• Spironolactone/ eplerenone: Start 12.5-25 mg daily

Titration Schedule:25 mg daily (Target) 25 mg BID (Max dose)

Cautions: **Contraindicated in patients with serum K+ > 5.0 or

creatinine > 2.5

**BMP weekly x 3 and following any dose adjustment

**If gynecomastia – switch to epleronone

**K+ supplements should be discontinued or reduced

** NSAID’s, lithium, or digoxin should be avoided

**Side effects: hyperkalemia, worsening renal function,

hypotension, hypovolemia

Approach to Treatment of HFpEF

Diuretic

Assessment of fluidvolume status

Signs and symptoms offluid retention

Control DBP and SBPCan use BB,CCB,ACE,ARB

EF > 40%

Assessment of EF

Control HRTachy-arrhythmias such as atrial fibrillation or atrial tachycardia

(decrease diastolic filling)

Optimize treatment of co-morbidities• Diabetes• CAD• Sleep apnea• COPD• Obesity• Smoking cessation

Use cautiously• NSAIDS• Steroids

(cause fluid retention)

HF Self Care Management

DAILY WEIGHTS

weight everyday after AM voiding; in the same amount of clothing. Place scale on a hard surface, not on carpeting.

Record weights and compare day-to-day. Look for weight gains of 2-3 pounds overnight or a 4-5 pound weight gain in one week. Also look for quick weight loss.

Every HF patient needs an Action Plan

2000 mg SODIUM DIET

FLUID GUIDELINE: No more than two (2) quarts daily / 64 ounces

ENERGY-CONSERVING ACTIVITIES: Progressive walking program

CARDIAC REHABILTATION PROGRAM: Start 6 weeks after discharge

Fluid Retention….Why?

• Diet indiscretion

• Medication non-adherence

• Use of NSAIDS

• Prednisone

• TZDs

• Diuretic resistance

• Advancing disease

Diuretic Action Plan

• Double daily oral diuretic

• Transition to different loop diuretic

• Add a thiazide PRN

• Office IV diuretics

Fluid retention in abdomen can affect choice of diuretic

Need BMP and magnesium monitoring

Overuse of thiazides can result in hyponatremia and hypomagnesia

BNP level can act as marker for treatment

Diuretics furosemide (Lasix):PO: Start at 20-40 mg daily or BID; 400 mg daily (Max dose )

bumetanide (Bumex):PO: Start at 0.5 to 1.0 mg daily or BID; 5 mg BID / 10 mg daily(Max dose)

torsemide (Demadex):PO: Start at 10-20 mg daily; 200 mg daily (Max dose)

metolazone (Zaroxolyn):PO: Start at 2.5 mg daily; 20 mg daily (Max dose)

hydrochlorothiazide (Microzide):PO: Start at 25 mg daily or BID; 200 mg daily (Max dose)

*Titrate quickly: Goal 0.5-1.0 kg/day (3-4 lb/day) weight loss*Monitor K+, Mg, & Creatinine until goal weight achieved*Torsemide: greater bio-availability and longer half-life

Diuretic Pharmacokinetics

Product Bioavailability of oral tablets

Duration of effect after single dose

Furosemide(Lasix)

47-64% PO: 6-8 hrsIV: 2 hrs

Bumetanide (Bumex) 59-89% PO: 4-6 hrsIV: 4-6 hrs

Torsemide (Demadex) 80-90% PO: 6-12 hrsIV: 6 hrs

Ethacrynic Acid (Edecrin)* For sulfa allergy *

100% Po: 4-8 hrsIV: 15 min-3 hrs

Conversion Equation:Lasix 40 mg = Bumex 1 mg = Demadex 20 mg

Coming Soon………………….

Subcutaneous furosemide

From Hospital to Home…Transitioning requires good hand-off communication to PCP and 7 day follow-up.

Use outpatient resourcesMedical Home Care Managers

Hospital-based programs

Home health services- tele health

Medical Home Model -Case managers

Remote monitoring resources

Remote Monitoring

Resources

Patient:AHA online support group for HF patients/families

Low salt cookbooks / website recipes

Phone apps

Pharmacy dietary/medication free counseling services

Grocery Store- 1:1 grocery shopping counseling

Healthcare Providers:www.heart.org

www.aahfn.org

www.hfsa.org

Time for Palliation?

Identifying Patients with Advanced HF

• Two or more hospitalizations / ED visits for HF in the past year

• Progressive deterioration in renal function

• Weight loss without other cause (cardiac cachexia)

• Intolerance to ACE inhibitors due to hypotension and/or worsening renal function

• Intolerance to beta blockers due to worsening HF or hypotension

• Frequent systolic blood pressure <90 mm Hg

• Persistent dyspnea with dressing or bathing requiring rest

• Inability to walk 1 block on the level ground due to dyspnea or fatigue

• Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapy

• Progressive decline in serum sodium, usually to <133 mEq/L

• Frequent ICD shocks

Adapted from Russell et al. Congest Heart Fail. 2008;14:316-21. Yancy, CW et al.

2013 ACCF/AHA Heart Failure Guideline.

http://circ.ahajournals.org/content/early/2013/06/03/CIR.0b013e31829e8776.citation

It takes a village to treat HF….

OK…maybe not this village!

Help your patients be….. “Heart Strong”!