Leadership. Knowledge. Community. Canadian Cardiovascular Society Recommendations on Heart Failure: Focus on the Elderly Symposium on Changes and Challenges

Leadership. Knowledge. Community.

Canadian Cardiovascular SocietyRecommendations on Heart Failure:Focus on the ElderlySymposium on Changes and Challenges in Geriatric Care

Waterloo, May 7, 2008

George Heckman MD MSc FRCPC

Leadership. Knowledge. Community.2

Disclosures

• Consultant and speaker fees from Janssen-Ortho, Novartis, and Pfizer

• Research support from the Canadian Institutes of Health Research, Novartis


The Demographic Imperative


The Elderly HF patient

• Generally excluded from clinical trials– treatment by “extrapolation”

• Multiple co-morbidities• Concurrent geriatric syndromes common

– frailty– functional impairment– cognitive impairment– depression


Objectives

• Using illustrative case, review– therapies– assessment and management of frail elderly HF

patient– transitional care


A typical “atypical” presentation

• 83 year old woman: confusion and falls for 3 days– ischemic cardiomyopathy (EF 25%)– diabetes, hypertension, gout, mild chronic renal failure– meds

• furosemide 80 mg bid• ramipril 2.5 mg od• amlodipine 10 mg od• ibuprofen 200 mg prn• lorazepam 1 mg qhs prn, gravol (for sleep)


Assessment: salient features • Physical exam

– O2 sat 78% on room air, RR 40– atrial fibrillation with rate 100-110– high JVP, leg edema– bibasilar crackles– S3

• Neurological exam– delirious, no focal deficits


Investigations

• hemoglobin 105, normocytic, mild neutrophilia• glucose 22.1• creatinine 130, electrolytes normal• TSH, calcium, urine normal• ECG: LBBB• chest x-ray: cardiomegaly, pulmonary oedema


Course in hospital• Diagnoses: delirium and heart failure• Oxygen and diuresis• Medications optimized

– ramipril 10 mg od– bisoprolol 2.5 mg od initiated– metformin initiated– warfarin– amlodipine, gravol, NSAID discontinued,

lorazepam reduced


Recommendation (2006)

• Heart failure therapies in elderly heart failure patients should be similar to those in younger patients, although their use may depend primarily on concomitant conditions (level 1, class B)



• Beta-blockers should be initiated as soon as possible after diagnosis of heart failure, including during the index hospitalization, provided that the patient is clinically stable. Clinicians should not wait until hospital discharge to start a beta-blocker in stabilized patients (class I, level B)


ACE-I and HF in elderly: Observational data

• Fewer deaths, hospitalizations–including with chronic renal insufficiency

• Administrative database, LTC age 85 yrs–slower functional decline vs. digoxin

• Retrospective cohort,1220 hospital pts, 79 years–greater cognitive improvement in hospital, dose-response observed

Philbin Am J Cardiol 96; Arling Ann Long Term Care 98; Ahmed J Am Geriatr Soc 02; Hutcheon Heart 02; Gambassi Arch Intern Med 00; Zuccala Eur Heart J 05


ACE-I in frail older HF patients

• RCT 60 geriatric day hospital pts with HF– aged 81+/- 6 years yrs– NYHA II-III, LV systolic dysfunction– perindopril 2 to 4 mg daily vs. placebo

• Improved 6 minute walk at 10 weeks– perindopril +37.1 m vs. –0.3 m in placebo (p<0.001)

Hutcheon Heart 02


ACE inhibitors and depression

• Cross-sectional survey 1223 LTC pts, 245 with HF• 85.9 ± 7.5 years• Antidepressants prescribed to 101 of HF pts• HF pts with history of depression less likely to

receive antidepressants if appropriate ACE inhibitor doses– OR 0.11 (0.02-0.76)

Heckman et al J Am Geriatr Soc 2006


ACE inhibitors and insomnia

• Cross-sectional Irish primary care survey• 353 pts with HF, 72 yrs

– 18% getting ACE inhibitors, most low dose– HF pts more likely to get

• hypnotics : 14.7% vs. 8.3% (p<0.001)• insomnia : 11.8% vs. 6.9% (p<0.001)

Connolly Pharmacoepi Drug Safety 1998


Beta-blockers

• Cardiovascular Health Study

– 950 pts, incident HF, 80+/-6 yrs

– lower mortality: HR 0.74 (0.56-0.98)

• SENIORS: RCT (Nebivolol)

– 2128 pts 70 yrs and over, f/u 2 years

– Systolic AND Diastolic failure

– lower death/CV hospitalization: HR 0.86 (0.74-0.99)

• Geriatric outcomes??

Chan Am Heart J 2005; Flather Eur Heart J 2005


Other heart failure therapies

• Exercise may improve cognition• Digoxin: high normal levels associated with

benzodiazepine use in LTC• Angiotensin blockers, aldosterone antagonists,

nitrates and hydralazine: no geriatric data• Rehab: cardiac and / or geriatric

Heckman J Am Geriatr Soc 2006; Arnold Liu Can J Cardiol 06; Tanne Int J Cardiol 05


Practical tips

• HF medications: start low and titrate slowly• Monitor orthostatic vitals (supine and standing)• As ACE-I and Beta-blocker optimized

– consider reducing diuretic dose if patient stable– reassess need and dose of other vasodilators, such as

long-acting nitrates, if no longer clinically needed


Course in hospital

• Slow to mobilize– significant deconditioning

• Geriatric consultation: GRU admission– function, strength, endurance improve– medications optimized further

• bisoprolol titrated to 10 mg od• spironolactone 25 mg• metformin 1000 mg bid


Discharge planning

• cognition: MoCA: 16/30• home care referral

– home assessment– personal support worker

• children / spouse given HF education• medication dosette



• Frail elderly HF patients should be referred to a geriatrician for comprehensive geriatric assessment (level 1, class B)

• Elderly or frail heart failure patients who present with acute illness should be assessed for evidence of delirium and, before discharge, cognitive impairment (class IIa, class C)


The post-discharge chasm 86 yo male hospitalized mid-August 2007 with

abdominal pain and distension Past history:

Previous MI, CABG x 2 (1998), EF 40% (2006)Type II diabetes, hyperlipidemiaAtrial fibrillationChronic renal failure (baseline creatinine ~115)Previous hernia repair, cholecystectomy


The Case

Ascites from right-sided heart failure1.5 litres drained, no malignant cells

LVEF 25%, regional wall motion abnormalities

In retrospect, patient had been getting more dyspneic over the past year (which was attributed to ‘age’?)


In hospital medications Metoprolol 37.5 mg bid Ramipril 5 mg od Atorvastatin 20 mg Digoxin 0.0625 mg od Metolazone 2.5 mg od Furosemide 120 mg bid ECASA 81 mg od

Discharged on these …

Repaglinide 0.5 mg Slow-K 8 mg tabs bid Septra 1 od (SBP

prophylaxis) Warfarin 2 mg od Prevacid 30 mg bid


Course in hospital

Diuresed slowly but steadily Able to walk up 24 steps, laps around the ward Discharged Sept. 3, 2007 with home care (PSW),

bedside commode, shower bench and walker Referred to heart function clinic (earliest

appointment October 3, 2007)


Heart function visit

Significant decline since discharge Seen by internist in interim

reduces Metolazone to Monday/ Wednesday/ Friday

Wife reports patient had increasing fatigue, weakness (6 steps with difficulty) in bed most of the time since dischargeanorexic, weight loss of 5-6 kgno chest pain or dyspnea


Clinical assessment Looks tired

BP 90/45 sitting, radial pulse barely palpable standingHR 55, atrial fibrillationHeart sounds and chest unremarkableJVP flat, mucous membranes dry, no ascites

Labs- Creatinine 385, urea 61.3, Sodium 131, Cl 90, K 5.1- Digoxin 2.6 mmol/L- CBC, calcium, albumin normal, CXR: nothing acute


Caregiving situation Wife frail finding it difficult to help him dress

not enough time to look after daily household issues

Live in a side-split, 6 steps up and down Patient has had

memory loss for past 3-5 months recent low mood, passive death wishes

Couple isolated, daughter 1.5 hours away


Could this have been prevented?


Transitional Care• Processes to facilitate safe / timely transfer of patients

from one level of care to another– Multidisciplinary: APN, MD, others– Focus on enhanced “self-care”– Multiple f/u methods, including home visits– Cost-effective

• Targets high risk HF patients– previous hospitalizations, multiple comorbidities or medications– frail elderly– depression, limited social support

Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008;24(1):21-40.


Self Care components

• Maintenance: adherence to treatment and positive health practices– diet, medications, exercise, daily weights

• Management: more active process– recognize subtle changes in status– evaluate their significance– take appropriate action– evaluate effects of action


Recommendation

• Patients and caregivers should be educated while in hospital and soon after discharge on

– Signs and symptoms of worsening HF

– Self management skills

– Factors that may aggravate heart failure

– Reasons for and appropriate use of medications

(Class I, Level C)

• Effective means of communication and collaboration between patient, caregiver and health care providers should be identified

(Class I, Level B)


• A written summary should be provided to the patient at the time of discharge and to the primary care physician within 48 hours of discharge, covering

– Diagnoses

– Significant interventions in hospital

– In-hospital complications

– Medications at discharge (including prescriptions and explicit instructions for adjustment)

– Plans for follow-up, including delineation of the roles of each caregiver

(Class IIa, Level B)


Recommendation


• RN/APNs with training and expertise in enhancing patient and caregiver HF management skills may assess the patient in hospital and then follow them at home

• The goals and directions of care should be shared and openly discussed among the patient’s health care professionals; any differences in perspective/opinion should be identified and a best solution agreed upon

• Personal contact with the referring or primary care physician should be considered at or before discharge


Practical tips


• Health care institutions serving HF patients should provide resources for or access to appropriate disease management care for patients recently discharged from hospital with a primary diagnosis of HF

(Class I, Level C)

• These have been shown to improve adherence to therapy, reduce readmission/resource use rates and may improve mortality and quality of life


Recommendations


Case resolution Patient re-hospitalized from October 3-13, 2007

cardiac medications adjusted treated for depression MMSE 24/30, abnormal clock (cognitive impairment)

At discharge: enhanced home care for bathing and dressing wife and daughter taught about fluid management and how to

seek medical help if deterioration seen in HF clinic within 2 weeks of discharge, followed since referred to geriatric day hospital for outpatient rehabilitation close follow-ups = no re-hospitalization


Lessons to be learned Classic patient: ‘fits the bill’ of ‘at risk’ senior

Multiple functional deficits Polypharmacy Limited social support system 2+ total number of chronic health conditions

Transitional care is imperative This patient fell through a 4 week ‘crack’/black hole avoidable 11 day hospital readmission (at about $1000/day,

for a grand total of $11,000.00)


Final thoughts• Frail elderly are growing segment of HF population

– multiple health issues require multidisciplinary approach– usual treatments apply, benefits on geriatric outcomes

• Health care institutions (hospitals, LIHNs, CCAC) must collaborate to provide adequate HF management capacity to support primary care– multidisciplinary– heart function clinics– transitional care programs

Documents

Leadership. Knowledge. Community. Canadian Cardiovascular Society Recommendations on Heart Failure: Focus on the Elderly Symposium on Changes and Challenges