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Module 1: Evidence-based Education for Health
Care Professionals
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1
Heart Failure is a HUGE Problem
Prevalence Incidence Mortality Hospital
Discharges Cost
5,300,000 660,000 284,965 1,084,000 $34.8 billion
1American Heart Association. 2008 Heart and Stroke Statistical Update. Dallas, TX: American Heart Association; 2008.
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Major Cause of Hospital Readmissions 1 in 5 Medicare patients are readmitted to
the hospital within 30 days of discharge Heart failure is the most common reason
for readmission Many of these readmissions may be
preventable with: Better understanding of disease by patients Closer follow-up after discharge
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What is Heart Failure? Impaired ability of the
left ventricle to pumpblood
Classic symptoms:1. Shortness of breath2. Edema3. Fatigue
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Heart Failure Classes New York Heart Association
Developed in 1963 NYHA I – Asymptomatic NYHA II – HF symptoms with significant
exertion NYHA III – HF symptoms with minimal
exertion NYHA IV – Symptoms at rest
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Two Types of Heart Failure
Systolic Heart Failure
Heart is weak Ejection fraction is
reduced (<50%)
Diastolic Heart Failure
Heart is stiff Ejection fraction is
normal (55-65%)
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Two Phases of Heart Failure Phases
Acute Heart Failure
Chronic Heart Failure
Systolic Heart Failure
Diastolic Heart Failure
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Heart Failure Therapy Acute
Therapy aimed atreducing fluidcongestion on thelungs Diuretics (e.g. Furosemide,
Lasix) Nitroglycerine Ultrafiltration Inotropes (e.g. Milrinone;
Dobutamine)
Chronic Therapy aimed at
maintaining fluidlevels and lowering therisk of recurrent heartfailure or death Beta blockers ACE-inhibitors Aldosterone Antagonist (e.g.
Spironolactone) Diuretics (e.g. Furosemide, Lasix)
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Acute Heart Failure Therapy In general, same therapies for both diastolic and systolic
Sy stolic Heart Failure 1. Diuretics2. Nitroglycerine3. Ultrafiltration4. Inotropes
Diastolic Heart Failure 1. Diuretics2. Nitroglycerine3. Ultrafiltration
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Chronic Heart Failure Therapy Diastolic Heart Failure
1. Control fluid levelswith oral diuretics
Systolic Heart Failure 1. ACE Inhibitors or
Angiotensin receptoblockers (ARBs)
2. Beta-blockers3. Aldosterone
antagonists4. Implantable cardiac
defibrillators (ICDs)5. Others drugs and
therapies
r
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Medications Chronic Systolic Heart Failure
ACE inhibitors: Angiotensin Receptor Captopril (Capoten) Blockers (ARBs): Enalapril (Vasotec) Candesartan (Atacand) Lisinopril (Zestril, Prinivil) Irbesartan (Avapro) Ramipril (Altace) Valsartan (Diovan)
Beta Blockers: Nitroglycerine Carvedilol (Coreg) Digoxin Metoprolol (Toprol,
Lopressor) Spironolactone Hydralazine (Aldactone)
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Beta Blocker Evidence
N = 3,991 patients
Class II-IV HF
Average EF=28%
Used with permission The Lancet, Volume 353, Issue 9169, 2001 - 07, 12 June 1999
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ACE Inhibitor Evidence All Cause Mortality
01020304050
0 6 12 18 24 30 36 42 48
Mor
talit
y%
Months
Placebo Enalapril
16% Risk Reduction p = 0.0036
Used with permission N Engl J Med 1991;325:293-302
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ACE Inhibitor Evidence Symptomatic HF Patients with EF < 35% NYHA Class II-III
0100200300400500600700800900
1000
Placebo + Conv TX
Enalapril + Conv TX
# Hospitalizations Due to Heart Failure
971 683
30% Reduction p<0.001
Used with permission N Engl J Med 1991;325:293-302
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Medications Chronic Diastolic Heart Failure
Control fluid levels with diuretics Treat blood pressure Treat arrhythmias (i.e. atrial fibrillation)
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Preventing Sudden Death General
population
Any previous coronary event
Low ejection fraction
Cardiac arrest VT/VF survivors
0LOW INTERMED HIGH HIGHEST
Incidence of Sudden Death
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Other Treatment Options Implantable Cardiac Defibrillators (ICDs)
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Indications for ICDs 2009 AHA Guidelines
Any EF < 35% with class II or class IIIsymptoms
On optimal medical therapy Reasonable expectation of survival with
a good functional status for more thanone year
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Other Therapy Options Systolic Heart Failure
Bi-ventricular pacemakers Chronic IV therapy with inotropes Ventricular assist devices (VADs) Heart transplant
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Summary Two types of heart failure: diastolic and
systolic Two phases of heart failure: acute and
chronic Patient self-management: Patients who
understand their disease live longer andspend less time in the hospital
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For information on the Heart Talk videos,
please visit us on our website: www.qualidigm.org
or email us at: [email protected]
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Credits The Hospital of Central Connecticut
Shelley Dietz RN, MBAQualidigm
Anne Elwell, RN, MPH Michelle Pandolfi, MSW, LNHA
University of Connecticut Heath Center Wendy Martinson RN, BSN Jason Ryan, MD, MPH
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Special Thanks to:
University of Connecticut Health Center
Dr. Jason Ryan for his dedication to teaching us all how to live well with heart failure
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�
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This-material was prepared in collaboration with Qualidigm, the Medicare Quality Improvement Organization for Connecticut1 under
contract with the Centers for Medicare & Medicaid Services (CMS)1 an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Pub #CT-
800100-2011052
The views and opinions expressed here do not reflect the policy or position of the Centers for Medicare and Medicaid Services1 nor of
Qualidigm. Examples and information provided are for educational purposes only and should not be construed as medical advice. Any
person with questions or concerns relating to any medical condition or treatment should consult with a qualified health care professional.