Transitioning Patients Out of theHospital and Keeping Them Out:

Keeping Patients Out of the Hospital

Lisa Rathman, MSN, CRNP, CHFN Lead HF Nurse PractitionerHF Program Coordinator

Objectives

1. Discuss the importance of recognizing congestion in our HF patient and the associated signs/symptoms

2. Review guideline recommendations for the transition of care(post-hospital)

Worsening Chronic Heart Failure: The Major Reason for

Heart Failure Hospitalizations

Worsening chronic heart failure (75%)

De novo heart failure (23%)

Advanced/ end-

stageheart failure 2%

Fonarow GC. Rev Cardiovasc Med. 2003; 4 (Suppl. 7): 21

Cleland JG et al. Eur Heart J. 2003; 24: 442

• 90% of HF hospitalizations present with symptoms of pulmonary congestion.1,2

• Post-hoc analysis of 463 acute decompensated HF patients from DOSE-HF and CARRESS-HF trials showed:

– 40% of patients are discharged with moderate to severe congestion.3

– Of patients decongested at discharge, 41% had severe or partial re-congestion by 60 days.3

Current HF Management Is Inadequate For Identifying and Managing Congestion Leading to

Decompensation

1. Adams KF, et al. Am Heart J. 2005

2. Krum H and Abraham WT. Lancet 2009

3. Lala A, et al. JCF 2013

Importance of Recognizing Congestion

PCWP Predicts Subsequent Mortality

Time (months)

Hemodynamic measurement in 456 heart failure patients after tailored vasodilator therapy.

Fonarow GC, et al. Circulation. 1994;90(4 pt 2):I-488.

n=199

n=257 P = 0.001

0 6 12 18 24 0 6 12 18 24

PCWP > 16 mm Hg

PCWP < 16 mm Hg n=236

n=220

CI > 2.6 L/min-m2

CI < 2.6 L/min-m2

Mortality Risk (%)Mortality Risk (%)

0

10

20

30

40

50

60

0

10

20

30

40

50

60

P = NS

Early response of PCWP but not CI predicts subsequent mortality in advanced heart failure

Congestion in Heart Failure* – Potential deleteriouseffects

LV Remodeling:increased afterload (wall stress) worsening mitral regurgitation

Increased PA/RA pressure with systemic congestion

Neurohormonal activation

Subendocardial ischemia/cell death by necrosis/apoptosis1

Changes in extra cellular matrix structure and function1

Progression of LV dysfunction

Impaired cardiac drainage from coronary veins (diastolic dysfunction)

Lower threshold for arrhythmias

The number of patients with congestion will probably increase due to a decrease in the rate

of sudden death (beta blockers, ICD

Filippatos GS et al. Am J Physiol. 1999; 277: H445

Reduction in Filling Pressures

• Symptom relief

• Decreased mitral regurgitation

• Decreased neurohormonal activation

• Better exercise tolerance

• Longer survival

Pathophysiologic Differentiation ofSymptoms and Progression

• What produces symptoms?

Hemodynamic abnormalities, such as changes in cardiac function and peripheral hemodynamics

• What contributes to progression?

Neurohormonal abnormalities, such as activation of the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS)

HF Hospitalizations are a Strong Predictor of Mortality

Setoguchi S, et al. Am Heart J, 2007

Worsening Heart Failure Leading to HFHospitalizations Contributes to Disease

Progression

Graph adapted from: Gheorghiade MD, et al. Am J. Cardiol. 2005

What do the Guidelines Say about Transition of Care and Keeping Patients Out of the Hospital?

COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; and LOE, Level of Evidence

Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2013;62(16):e147-e239.

Telemonitoring: Weights

1 Chaudhry SI, N Engl J Med 2010;363:2301–23092 Koehler F. Eur J Heart Fail 2010;12:1354–1362.3AngermannCE. Circ Heart Fail 2012;5:25–35.

4 Lyng PEur J Heart Fail 2012;14: 438–444.5 Boyne JJ. JEur J Heart Fail 2012;14:791–801.6 Ong MK. JAMA Intern Med. 2016;176(3):310-318.

Trials Description Results

Tele-HF (2010)1 RCT 1653 pts; telephone-based interactive voice response system

No difference in readmission or death from any cause within 180 days.

TIM-HF (2011)2 RCT 710 pts; device measured ECG, BP and weight to monitoring center

No reduction in mortality. No effect on CV death or HF hospitalization

INH (2012)3 RCT 715 pts; telephone based monitoring and education

No reduction in death or rehospitalization.

WISH (2012)4 RCT 344 pts; weight monitoring No reduction in all cause hospitalization, death or composite of cardiac hospitalization or death

TEHAF (2012)5 RCT 382 pts; BP, peak flow, weight, and glucose test

No reduction in HF hospitalization

BEAT-HF (2016)6 RCT 1427 pts; telephone calls andtelemonitoring (wt, BP, HR)

No reduction in readmission for anycause within 6 months

Weight Changes

Before

HF

Hospitalization

> 10 lbs

3-5 lbs

6-10 lbs

< 2 lbs

Chaudhry et al, Circulation 2007;116:1549-54

Weight Changes are Not Sensitive for Predicting

Heart Failure Hospitalization

Time Course of Decompensation

Physiologic Markers of Acute Decompensation

* Graph adapted from Adamson PB, et al. Curr Heart Fail Reports, 2009.

PA Pressure Sensor on Catheter

Delivery System

PA Pressure DatabasePatient

Home Electronics Unit

Physician Access Via Secure

Website

120c

m

4.5c

m

Ambulatory Hemodynamic Monitoring System

Received FDA approval on May 28, 2014

Daily Weight is Still Recommended

• Daily weight- still gold standard for monitoring

– Notify weight gain 2-3 pounds overnight or 5 pounds in 1 week especially if patient has worsening symptoms (orthopnea, bloating, SOB, edema etc.)

– Should weigh in am before breakfast with the same type of clothes

– Write it down

Key Goals for HF Visit

• Focus on the following:– Assessment of patient volume status and clinical

stability with adjustment of HF therapy as needed

– Identify causes of HF, barriers to care and limitations insupport

– Renal function and electrolytes

– Stability of co-morbid conditions

– HF education and self-care

– Emergency plans

– Medication reconciliation/discharge orders

Congestion at RestNo Yes

Low

perfusion

at rest

No

Yes

Signs/symptoms of congestion

Orthopnea/PND

JV distention Ascites

Edema

Rales (rare in HF)

Possible evidence of low perfusionNarrow pulse pressure

Sleepy/obtunded Low serum sodium

Cool extremities

Hypotension with ACE inhibitor Renal dysfunction (1 cause)

Adapted from Stevenson LW. Eur J Heart Fail. 1999;1:251

Heart Failure Clinical Assessment

Warm & Dry PCWP normal CI

normal

Warm & Wet PCWP elevated CI

normal

Cold & Dry PCWP low/nmL CI decreased

Cold & WetPCWP elevated CI

decreased

Physical Exam: What should you focus on?

What I am focused on?

Overall distress

Appearance

Cyanosis

Breathing/sleep pattern

Diaphragm motion

Neck Veins

Abdominal Distention

Edema

Heart Failure Assessment: Symptoms

• Shortness of breath

• Dyspnea on exertion

• ORTHOPNEA…# pillows or elevation HOB

• PND

• COUGH (NON-PRODUCTIVE)

• Edema

• Nocturia

• Chest pain

• Early satiety

• Fatigue

• Activity level

Heart Failure: Physical Exam

• Neuro: – LEVEL OF CONSCIOUSNESS

• Respiratory:

• SaO2

• RESPIRATORY RATE, DEPTH & EFFORT• BREATH SOUNDS (ANTERIOR & POSTERIOR) – CRACKLES AT THE BASES

(TRANSUDATION OF FLUID INTO ALVEOLI)

• EXPIRATORY WHEEZES (SECONDARY TO FLUID BACKED UP INTO THE LUNGS)

• BIBASILAR DULLNESS TO PERCUSSION (PLEURAL EFFUSIONS)

• Don’t Be Fooled

• YOUR PATIENT HAS CLEAR BREATH SOUNDS, THEYCAN STILL BE IN HF

Jugular Venous Distension

Jugular Venous Distension

Jugular Venous Distension

Sensitive Indicators of Volume Overload

• Jugular venous distension

• Orthopnea

• S3

• Dr Tom Heywood You Tube video

Heart Failure: Physical Exam

PERIPHERAL VASCULAR•PULSES: UPPER AND LOWER EXTREMITIES - BILATERALLY EQUAL: STRONG, WEAK, THREADY

•CAPILLARY REFILL (< 3 SECONDS)•PRESENCE OF PRETIBIAL EDEMA (PERIPHERAL EDEMA…DEPENDENT EDEMA)

•CYANOTIC NAILBEDS(Integument)

•COLD EXTREMITIES (VASOCONSTRICTION)

GI

• ASCITES

• ASSESS THE LIVER:

• Hepatomegaly (PASSIVE CONGESTION)

• MAY OR MAY NOT HAVE ABDOMINAL TENDERNESS

• HEPATOJUGULAR REFLUX (>1 CM INCREASE IN JVD WITH A SUSTAINED PRESSURE OVER THE LIVER)

Communicate the Plan: Home Diuretic Rescue Plan

• Home diuretic rescue plan

included in discharge summary

or office visit

• Estimated patient’s dry weight

• Adjustment in oral diuretic and

IV based on criteria

• CHF diuretic kit/Protocols

• Ensure follow-up labs and

appointment

What Do Patients Need to Know?

ACC/AHA Heart Failure Guidelines 2013

Why is HF Education Important for Patients

• 25% (1 in every 4 patients) will be readmittedto the hospital within 30 days

• The more you know and understand about your heart failure the more likely you will stay out of the hospital and feel well

What is Heart Failure?

There are many possible causes of heart failure.Whatever the cause, the heart is less efficient.

When fluid begins to build up in your body, this often is referred to as Congestive Heart Failure.

Systolic versus Diastolic Heart Failure

How do we treat HF in the hospital?

1. Treat symptoms – remove extra fluid♥ We do this with water pills or “diuretics” through your IV♥ We need to be careful of kidney function and adjustments in these

medications require blood tests to check kidney numbers and potassium levels

2. Figure out why you developed HF

3. Treat the disease- slow the progression of disease• Medications

• Lifestyle

• Devices

How do we treat HF at Home?

1. Maintain euvolemia

2. Identify causes of HF, barriers to care and limitations in support

3. Optimization of chronic oral HF therapy(GDMT)

4. Management of comorbid conditions

5. HF education, self-care and emergency plans

How do we slow the progression of disease?

♥ A combination of medications have been shown to slow down the disease, improve symptoms and help you live longer

– You will receive written instructions about your medicines.

– Most of these are available as inexpensive, generic forms.

– It is important that you take your medications as prescribed!!

Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease)

Initial fall in LV performance, wall stress

Morbidity and mortality

Arrhythmias

Pump failure

Peripheral vasoconstriction

Hemodynamic alterations

Remodeling and progressive

worsening of LV function

Activation of RAS and SNS

Fibrosis, apoptosis,

hypertrophy, cellular/

molecular alterations,

myotoxicity

Fatigue Activity

altered

Chest congestion

Edema

Shortness of breath

Neurohormonal Activation in

Heart Failure

ΘANP, BNP

What can I do to help myself?Know the symptoms of worsening heart failure

Worsening shortness of breath

Fatigue/decrease tolerance to usual activity

Sudden weight gain

Trouble Sleeping due to breathing difficulties

Using more pillows/having to sit up at night

Chest congestion

Edema or ankle swelling

Bloating/decreased appetite

What can I do to help myself?

• Weigh yourself daily

– First thing in morning (before dressing and eating)

– Write it down

– Call with weight gain 2-3 lb overnight or 5lb in 1 week. We will provide you with phone number to call at discharge

What can I do to help myself?

• Recognize signs and symptoms of heart failure and CALL right away

Discharge Instructions

Take your medicines

Weigh yourself daily and write down

Call with weight gain or worsening symptoms

Limit your salt intake

Be active—use common sense

Avoid alcohol and smoking

Avoid advil, motril, aleve, ibuprofen.

Follow up appointments

• VERY IMPORTANT TO KEEP ALL APPOINTMENTS!

• Bring your binder to all appointments

• This is the best way for us to manage your medications, evaluate your fluid status, and help keep you OUT OF THE HOSPITAL.

Teach Back: What have I learned?

• What is a diuretic?

• Name one heart failure symptom

• Why do I weight myself everyday?

• How much weight do I gain before I call?

• Who do I call with symptoms or weight gain?

What can I do to help myself?• Eat a low salt diet

– You should not eat more than 2000mg of salt per day

Avoid adding salt to food at the table (remove the salt shaker!)

Do not cook with salts or salt substitutes, sea salt is salt!

Avoid canned, processed or convenience foods

Eat fresh or frozen vegetables

Limit restaurant foods

Read all labels for salt content

Be sure to read the

“serving size” and the

sodium content on the food

label.

Use a guide of less than

150 mg per serving

What can I do to help myself?

• Fluid Restriction

– We will tell you if we want you to restrict yourfluid intake

– Limit fluid intake to less than 64 ounces per day

Why Teach-Back?

• Patients recall 50% of what they are told

• 40 to 80% of the medical information patients receiveis forgotten immediately

• 49% of patients experience at least 1 medical error after hospital discharge

• Most common errors involve medications

• 20% of patients adverse drug occurs after discharge

• Health literacy poses an increased problem

• All guidelines reinforce the importance of patienteducation

Cu

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lati

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ent-

free

surv

ival

.30

.4

.5

.6

.8

1.0

HF Discharge Education: Time to 1st

Hospitalization or Death

Koelling et al. Circulation 2005;111:179-185

P = 0.012

N = 223

60 120 180Days

.7

.9

Control group

1:1 one-hour education session

Endorsement of Teach-back

• Institute of Healthcare Improvement

• Agency for Healthcare Research and Quality

• National Quality Forum

What is Teach-Back?• Health literacy sensitive tool to ensure patientunderstanding

• Asks patients to repeat in their own wordswhat they understood was taught to them

• Teach-Back is unique because it teaches and assesses patient comprehension

• Confirms that you have explained– What patients need to know

– In a manner that patients understand

What does the literature say?

• What we know – Low literacy is associated with lower teach back scores. Teach back is effective in improving knowledge, improves acute event rate

• Gaps – What is the optimal teaching methodfor HF patients?

Teach-Back Closing the Loop

The interactive communication loop in clinician-patient education. Only by assessing recall and comprehension can the clinician ensure that a key concept has been understood and remembered. Not uncommonly, a patient responds to an initial assessment by demonstrating poor recall, lack of understanding, or health beliefs that may interfere with integration of the concept. The clinician should then repeat, clarify, or tailor subsequent information. To ensure recall and comprehension of this tailored explanation, the clinician should reassess the patient's recall and comprehension until a common understanding has been achieved.Recall and comprehension have been shown to be predictive of subsequent adherence.

Arch Intern Med. 2003;163(1):83-90.

Keep in Mind

• This is not a test of the patient’s knowledge but a test of how well you explained the concept

Step 1: The Clinician explains newconcept/information

• Use simple lay language to deliver the teaching point/explain the concept/demonstrate the process

• For more than one concept:– Chunk and Check (IHI)

– Example – teach the 2-3 main points for the first concept & check for their understanding using teach back….then go to the next concept.

Step 2: Clinician assesses patient recalland comprehension

• Ask the patient to repeat in his/her own words how he/she understands the information. If a process was demonstrated, ask the patient to demonstrate without assistance.

– Tell me what you would tell your wife about……

Step 3: Clinician clarifies and tailorsexplanation

• Identify and correct misunderstandings/incorrect procedures by patient

• Step 4 Clinician reassesses recall andcomprehension/demonstration

– Ask patient to demonstrate his/her understanding or procedural ability to ensure misunderstandings are corrected

• If they still do not understand consider other strategies/supplemental material

Examples of Teach Back in Heart Failure

5 Key teaching points:

1. What is the name of your diuretic (water pill)?

2. What symptoms should you report and towhom?

3. What food should you avoid?

4. What weight gain should you report to yourhealth care provider?

5. When will you follow-up after discharge andwhy?

Step 5: Patient recalls &comprehends/demonstrates mastery

• Repeat steps 4 and 5 until the clinician is convinced the comprehension of the patient about the concept or ability to perform the procedure accurately and safely is ensured

• This may require multiple interactions toensure mastery.

Examples of Teach-Back Questions

• “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?”

• “What will you tell your daughter about the changes we made today in your water pill?”

• “We’ve gone over a lot of information, a lot of things you can do to get more exercise in your day. In your own words, please review what we have talked about. How will you make it work?”

Talking with Patients and Families

ALWAYS:

• Slow down

• Use plain language

• Break information into short statements

• Focus on the 2 or 3 most important concepts

• Check for understanding using teach-back

Use Language the Patient and FamilyUnderstands

Avoid Acronyms•Instead of “HDL,” explain “good cholesterol”

Avoid Abbreviations & Technical Terms•Instead of “anti-hypertensive,” explain “drugsthat help to lower blood pressure”

Be Specific & Clear•Instead of “don’t go crazy with salt,” explain “keep your salt intake to _mg a day”

Teach Back – Elements of Competence

• Responsibility is on the provider• Use plain language; avoid jargon (TAVR)• Ask patient to explain using their own words• Avoid yes/no (closed ended questions)• Used for all important patient education,specific to their condition• Not meant to be scripted (we will develop

talking points)• Practice• Document use & response to teach back

Keep your message clear

and simple

Key Messages

• Evidence that teach back can improve knowledge and may impact outcomes

• Valuable tool to focus on most important teaching points

• Meaningful time spent – teach back created an opportunity to confirm comprehension or skill acquisition in the moment.

Key Items to include in Report to HF clinic

1. Why you are calling? Concern?

2. Symptoms

3. Physical Exam findings – focus on volume status and perfusion

4. Vital signs – discharge weight; weight trends; BP, HR, Resp rate, pulsox, ortho BPs

5. Identify causes of HF, barriers to care and limitations in support

6. Labs

7. Other pertinent issues

Final Thoughts

• HF patients remain at risk for worsening HF beyond the early post-discharge period. Early post-discharge follow-up is key.

• Fluid management is a common focus after ahospitalization

• Important to recognize signs and symptoms of worsening congestion

The Heart

CV System: Function

• Heart

• Receives blood from lungs + body

• Pumps blood to lungs + body

• Influences location & amount of body fluids

• Influences blood pressure

• Helps maintain homeostasis• Blood vessels

• Provide pathway for blood to get to cells

• Include capillary beds

•Exchange!! transfer of gases, nutrients & wastes

•4 chambers made of

muscle (myocardium)

•Powerful pump(s)

•Size of fist

•Tilted in mediastinum

•Upside down pyramid

• Upper portion = base

• Lower portion = apex

•Made of several layers

The Heart

Coronary Vessels

Blood Supply to the Heart

Coronary Circulation

Fit over heart like a crown

•Supply heart w/blood

• Gas exchange

• Blood supplied on diastole

• Penetrate myocardium to feed

heart tissue

•Pattern varies b/w people

•L Coronary Artery• AKA LCA or LM (left main)

• Immediate branch off aortic root

•L Anterior Descending artery (LAD)

•L Circumflex Artery (LCX)

•R Coronary Artery • AKA RCA

• Marginal Branch (OM)

• Posterior Descending Artery (PDA)

2 Main Coronary

Arteries

Heart Chambers

•Atria – Superior chambers

• RA = site of SA node

• Low-pressure

• Thin walled

• Receiving chambers

•Ventricles – lower chambers

• LV = thickest, strongest

• Hi-pressure

• Thick walled

• Ejecting chambers

•R-ATRIUM

• SVA or IVC

•TRICUSPID VALVE (atrioventricular) AV

•R-VENTRICLE

•PULMONARY VALVE

Flow of Blood Thru Right Heart

•Pulmonary veins (4) from lungs

•L-ATRIUM

•Mitral Valve (AV or Bicuspid)

•L-VENTRICLE

•Aortic Valve

•Aorta

•Systemic circulation

Flow of Blood Thru Left Heart

venules

arterioles

Cardiac

Conduction

Cardiac Conduction

•Begins at the sinoatrial node (SA node)• AKA the heart’s “pacemaker”

• Located in R-atrium

• 60–100 bpm Normal sinus rhythm

•Electrical pulse travels thru other nodes to ventricles & then thru intercalated discs so entire heart is synchronized

Cardiac Conduction

•Sinoatrial (SA Node)

•Atrioventricular (AV Node)

•Bundle of His (AV Bundle)

•R&L Bundle Branches

•Purkinje fibers

Cardiac Cycle

•Systole

• Contraction (atria then ventricles)

• Ejects blood

•Diastole

• Relaxation (atria then ventricles)

• Fills with blood (coronaries fed)

Heart Sounds

•S1 = “lub”• AKA systole

• Closing of AV valves as ventricles contract

• Heard loudest at apex

•S2 = “dup”• AKA diastole

• Closing of SL valves as ventricles relax

• Heard best at base

Apical pulse (PMI)

Loudest heartbeatLMC @ 5th ICS

Cardiac Output

•Refers to the amount of blood the heart

pumps in one minute

•Stroke volume (SV) x Heart rate (HR)= CO

Cardiac Output

•Cardiac Output (CO)

• measured by SV X HR

• volume of blood ejected in 1 min (~5-6 L)

• affected by:

autonomic NS (SNS: vagus; PNS: NE, epi)

muscle strength of heart

preload / afterload

•Stroke volume (SV)

•volume of blood ejected w/ beat

• ~ 60–80ml/beat

HF Defined

“Heart failure is a complex

clinical syndrome that can

result from any structural

or functional cardiac

disorder that impairs

the ability of the ventricle to

fill with

or eject blood.”

Hunt SA et al. Circulation. 2001;104:2996

Heart Failure in the US

Current State• 5.1 million people

• 825,000 new diagnoses yearly

• > 1 million hospitalizations for HF as a primary diagnosis (>6 million hospital days per year)

• > 3 million hospitalizations as a secondary diagnosis

• 1 in 9 deaths has HF mentioned on the death certificate

• Total cost for HF 31 billion

Projected 2030

• >8 million people

• 2 million over 80 years old

• Prevalence of HF growing faster

than any other CV disease

• Total cost of HF 70 billion

Page RL et al, Circulation 2007;116:2707 Heidenreich, L. Cirulation. 2013

Right and/ or Left Ventricular

failure:•R-sided: increased

workload of the right

ventricle• Increased the amount of

contractile force needed or

required of pumping excess

blood vol. (preload)

• What diseases do you think

contribute to R-sided HF?

• R ventricle cannot empty

normally and you see a back-up

of blood in the systemic blood

vessels.

•Typically the L -side

weakens first• Greatest workload to eject blood

against the resistance in the aorta

(afterload) peripheral vascular

resistance (PVR) the pressure

within the aorta and the arteries

• What diseases do you think cause

L- sided HF?

• Increases pulmonary pressure

(congestion)

Classification of HF: Comparison Between ACC/AHA

HF Stage and NYHA Functional Class

Carvedilol is indicated for use in patients with mild to severe chronic HF and in patients with HTN.1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.2New York Heart Association/Little Brown and Company, 1964.

Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.

ACC/AHA HF StageNYHA Functional Class

A At high risk for heart failure but withoutstructural heart disease or symptomsof heart failure (eg, patients withhypertension or coronary artery disease)

B Structural heart disease but withoutsymptoms of heart failure

C Structural heart disease with prior orcurrent symptoms of heart failure

D Refractory heart failure requiringspecialized interventions

I Asymptomatic

II Symptomatic with moderate exertion

IV Symptomatic at rest

III Symptomatic with minimal exertion

None

At Risk for Heart

Failure

Heart Failure

Stage A

High risk no

disease

Asymptomatic

HTN

DM

Obesity

CAD

Prior MI

LVH

Low EF

Valve dx

Stage D

Refractory HF

Structural

Heart dx

SOB,

fatigue

Refractory

symptoms

at rest

Stage B

Structural

disease

Asymptomatic

Stage C

Structural

disease

Symptomatic

Hunt SA, et al. Circulation 2009; 119:e391-e479

From Risk Factors to Heart Failure: The

Cardiovascular Continuum

Coronary Thrombosis

Myocardial Ischemia

CAD

Atherosclerosis

LVH

Risk Factors

•HTN

•Hyperlipidemia

•Diabetes

•Insulin Resistance

Adapted from Dzau and Braunwald. Am Heart J. 1991; 131: 1244-1263

Myocardial

Infarction Arrhythmia

Loss of muscleSudden

death

Remodeling

Ventricular

Dilatation

Heart Failure

Death

AB

C

D

Myocardial Ischemia

Definition of Heart FailureClassification Ejection

Fraction

Description

I. Heart Failure with

Reduced Ejection

Fraction (HFrEF)

≤40% Also referred to as systolic HF. Randomized clinical trials have

mainly enrolled patients with HFrEF and it is only in these patients

that efficacious therapies have been demonstrated to date.

II. Heart Failure with

Preserved Ejection

Fraction (HFpEF)

≥50% Also referred to as diastolic HF. Several different criteria have been

used to further define HFpEF. The diagnosis of HFpEF is

challenging because it is largely one of excluding other potential

noncardiac causes of symptoms suggestive of HF. To date,

efficacious therapies have not been identified.

a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their

characteristics, treatment patterns, and outcomes appear similar to

those of patient with HFpEF.

b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF

previously had HFrEF. These patients with improvement or recovery

in EF may be clinically distinct from those with persistently

preserved or reduced EF. Further research is needed to better

characterize these patients.

2013 AHA/ACC HF Guidelines

Pathophysiologic Differentiation

of Symptoms and Progression

•What produces symptoms?

Hemodynamic abnormalities, such as changes in cardiac function

and peripheral hemodynamics

•What contributes to progression?

Neurohormonal abnormalities, such as activation of the renin-

angiotensin-aldosterone system (RAAS) and the sympathetic

nervous system (SNS)

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult.

J Am Coll Cardiol. 2001;38:2101-2113.

Comparison HFrEF Versus HFpEF

Signs and Symptoms

Right-Sided Heart Failure

•Jugular veins become distended

•Edema in peripheral tissue

•Edema in the abdominal organs

•Fluid congestion in GI tract

Left-sided Heart Failure

•Dyspnea on exertion or at rest

•Fatigue

•Dry hacking cough

•Crackles, wheezing

•Orthopnea

•Paroxysmal nocturnal dyspnea

•Cheynes Stokes respiration

•Cyanosis

•Tachypnea, tachycardia

Cardiac Output R/T HF

Compensatory Mechanisms

•SNS detects a low CO, it

tries to speed it up HR

• Epinephrine and

norepinephrine

• Increased HR, increased

demand for O2

•Low circulating blood vol.

• Kidneys: activate Renin-

angiotension-aldosterone

system

• Pituitary Gland secretes:

ADH cause the body to retain

water , causing decreased

u/o

Increased workload

•Causes dilatation of the heart chambers (heart fibers stretch- to increase

force Starling law)

• Increase the muscle mass, hypertrophy (remodeling)

Temporarily these compensatory changes help but

over time lead to increased O2 demands and

increased HF, additionally the heart wall stiffens,

decreased ability to pump

Pathophysiology of Heart Failure: Left

Ventricular Remodeling

Left-ventricular (LV) remodeling is defined as a change in LV geometry, mass and volume that

occurs over a period of time

RAS, renin-angiotensin system; SNS, sympathetic nervous system.

Myocardial injury to the heart (CAD, HTN, CMP, Valvular

disease)

Morbidity and mortality

Arrhythmias

Pump failure

Peripheral vasoconstriction

Hemodynamic alterations

Heart failure symptoms

Remodeling and progressive

worsening of LV function

Initial fall in LV performance, wall stress

Activation of RAS and SNS

Fibrosis, apoptosis,

hypertrophy, cellular/

molecular alterations,

myotoxicity

Fatigue

Activity altered

Chest congestion

Edema

Shortness of breath

Neurohormonal Activation in

Heart Failure

ΘANP, BNP

•Reduced left ventricular ejection fraction remains the

single most important risk factor for overall mortality and

sudden cardiac death1

•Increased risk is measurable at ejection fractions above

30%, but an ejection fraction ≤ 30% is the single most

powerful independent predictor for SCD2

1 Task Force on Sudden Cardiac Death of the European Society of Cardiology. Eur Heart J, 2001;22:1374-14502 Myerburg RJ, In Braunwald E, Zipes DP, Libby P, Heart

Disease, A textbook of Cardiovascular Medicine. 6th ed. Philadelphia: W.B. Saunders, Co. 2001: 895.

Relationship of SCD and

Left Ventricular Dysfunction

References:

Hopper, P. & Williams, L. Understanding Medical Surgical Nursing 5th ed.,

(2015) Davis: Philadelphia: PA.

Hunt SA et al. Circulation. 2001;104:2996

Rathman, Lisa MSN, CRNP, CCRN Nurse Practitioner, Heart Failure

Clinic, The Heart Group

Nurse Practitioner, Heart Failure Program, Lancaster General Hospital

Rhoads, Janet MSN, RN Nursing Instructor LCCTC

Rosdahl, C. & Kowaiski, Textbook of Basic Nursing 9th ed., (2008) Davis:

Philadelphia: PA.

LGH Post–Acute Care

CHF Clinical Plan Overview

Phyllis Wojtusik 12.12.2016

What is a Clinical Plan? •A clinical pathway is a task-oriented care plan that details essential

steps in the care of patients with a specific clinical problem and

describes the patients expected clinical course. The goal of clinical

pathways is to standardize care, improve outcomes and reduce cost.

www.chop.edu/pathways

•Clinical Pathways: multidisciplinary plans of best clinical practice

OpenClinical.org

•Multidisciplinary management tool based on evidence-based practice for

a specific group of patients with a predictable clinical course, in which

the different tasks (interventions) by the professionals involved in the

patient care are defined, optimized and sequenced either by hour (ED),

day (acute care) or visit (homecare). Outcomes are tied to specific

interventions. Wikipedia

Why is the PAC PPN using a

Clinical Plan for CHF in Skilled

Nursing Stays?

•Standardize Care

•Structure Care Process

•Focus on education across the continuum

•Reduce re-admissions

• Improve patient clinical outcomes

• Improve Transitions of Care

•Develop quality clinical measurements across the continuum

Key Concepts to Achieving Goals

•Standardization of care

•Transparency

• Data

• Outcomes

•Ability to change and transform care

•We are all in this together for the patient

CHF Clinical Pathway

Clinical Pathway

• Approval from THG

• Approval from Medical Directors of PPN members

• Approval from PPN Members

Key Clinical Components of the

Plan•VS BID

•Daily weights, same time same scale – encourage patient to write them

on their clinical plan

•48 hour onboarding process

•Assessment of key clinical indicators

•Education – Heart Failure Passport and Heart Failure Zones

•Clinical Quality Measures

• 2 minute walk test – 2MWT

• MOCA

• CAMs – delirium protocol

•Early identification of home health needs and consult

How does my staff use this?

•Review with Staff

•Keep laminated copy at desk on unit

•Review with patients when they arrive at “48” hour on

boarding process

•Use patient Clinical Plan for education

•Document in EMR like you normally do

•Complete tasks on a daily basis

•Discuss where patients are in standup

•Root Cause analysis if not meeting Goals

•Work with Case Manager to help get patients back on

track

What do I do After the Pathway is

completed?•Monthly PPN meeting to review results – via clinical Management Group

• How many patients on pathway?

• LOS

• Complications

• Delays in discharge

• Trends in care

Patient and Family Clinical Plan

http://www.ihi.org/topics/CMSPartnershipForPatients/Documents/IHI_Transitions

HowtoGuides_Summary_Aug11.pdf

Patient Engagement

"Patient engagement" is a broader concept that combines

patient activation with interventions designed to increase

activation and promote positive patient behavior, such as

obtaining preventive care or exercising regularly.

Patient Engagement - Health Policy Briefs Feb 14, 2013

www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=86

Patient and Family Clinical Plan

•Review with patient and family during on boarding process

•Keep at patient’s bedside

•Engage patient to record daily weights

•Track progress with patient – highlight improvement

Heart Failure Zones

•Based on Red Yellow Green Concept

•Easy way for patients/caregivers to identify current status as onset of

CHF is very insidious at times

•Gives instructions as to what to do; continue as is, contact physician or

in an emergency call 911

•Standardized way to

Heart Failure Passport

•Provide consistent education across all settings

•Easy for patients to refer for personalized information

• Includes heart Failure zones

•Repeat Repeat Repeat

Questions?