maximizing treatment options with congestive heart failure david wolinsky facc prime care physicians...
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Maximizing Treatment Options with Congestive Heart failure
David Wolinsky FACC
Prime Care Physicians
Jan 31, 2009
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CHF Magnitude in the US
5 million have CHF (prevalence)1
550,000 new cases annually (incidence)1
• HF most common cardiovascular discharge in elderly patients2
• 25% probability of dying over 2.5 years3
– 50% of these deaths occur suddenly1 American Heart Association. Heart Disease and Stroke Statistics – 2005 Update.2 NHLBI, CHF Data Fact Sheet, September 1996.3 Sweeney MO. PACE. 2001;24:871-888.
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Classification of Heart Failure: ACC/AHA Stage vs NYHA Class
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Heart Failure Treatment Algorithm
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1 Framingham Heart Study (1948-1988) in Atlas of Heart Diseases.2 American Heart Association. Heart Disease and Stroke Statistics—2005 Update.
CHF Patients Survival Results1
100
90
80
70
60
50
40
30
20
10
0
Pro
bab
ilit
y o
f S
urv
ival
(%
)
Men (N = 237)
Time After CHF Diagnosis (Years)0 2 4 6 8 10
80% of men and 70% of women who have CHF will die within 8 years.2
Women (N = 230)
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Hospitalization for Congestive Heart Failure is
a Sentinel Event
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Paradigms of CHF Management
• Patient Based management
• ADHF• Chronic Heart Failure• Patient Based
approach• CORE Measures• ACC/AHA/HFSA
Guidelines
• Systems Based Approach
• Inpatient Therapy• Outpatient Therapy• Transitional Care• Measured by
Readmission and Mortality Rates
• Benchmarks?
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*Adjusted for baseline age, sex, race, HF etiology, LVEF, systolic blood pressure, smoking, signs of congestion, laboratory values, discharge medications, in-hospital invasive procedures, and history of diabetes and cardiovascular, neurological, pulmonary, and renal diseases
End point LV systolic dysfunction, n=3001
Preserved LV systolic function, n=4153
Mortality 0.77 (0.68–0.87) 0.94 (0.84–1.07)
Readmission 0.89 (0.80–0.99) 0.98 (0.90–1.06)
Mortality or readmission
0.87 (0.79–0.96) 0.98 (0.91–1.06)
Hernandez AF et al. J Am Coll Cardiol 2009; 53:184-192.
Adjusted* hazard ratios (95% CI) for one-year outcomes, beta blocker therapy vs no beta blocker therapy, by LV functional status
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Beyond CORE Measures
• Reduce readmission rate at 30 days• Reduce 30 day and 180 day mortality• Improve documentation• Incorporation of transitional care i.e.
redefine ‘home care”• Identlify endstage patients early on and
enroll into appropriate care algorithms• Implications of outcomes to patients,
physicians, and hospitals
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RAS, renin-angiotensin system; SNS, sympathetic nervous system.
Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease)
Morbidity and mortalityArrhythmiasPump failure
Peripheral vasoconstrictionHemodynamic alterations
Heart failure symptoms
Remodeling and progressiveworsening of LV function
Initial fall in LV performance, wall stress
Activation of RAAS and SNS
Fibrosis, apoptosis,hypertrophy,
cellular/molecular
alterations,myotoxicity
FatigueActivity altered Chest congestionEdemaShortness of breath
Neurohormonal Activation in Heart Failure
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JCAHO: Quality-of-Care Indicators for HF
HF-1: Discharge Instructions
HF-2: Assessment of LV Function
HF-3: ACEI or ARB at Discharge in AppropriatePatients
HF-4: Smoking Cessation Advice/Counseling
www.jcaho.org
1. Daily weights 4. What to do if Sx worsen 2. 2 gram sodium diet 5. Follow-up appointment3. Activity Rx 6. List of medications
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Heart Failure Core Measure Outcomes 2006-1st Q 2008
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Written D/C instructions (activitylevel, diet, d/c medications, f/u apt.,
wt. monitoring, worseningsymptoms)
LVF assessment ACEI/ARB Smoking cessationadvice/counseling
Quality Indicator
Pe
rce
nta
ge
1st Q 06 2nd Q 06 3rd Q 06 4th Q 06 1st Q 07 2nd Q 07 3rd Q 07 4th Q 07 1st Q 08
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Heart Failure Appropriate Care Measure 2006 - 1st Q 2008
97.6%
90.8%
94.4%
90.1%
81.7%
71.8%68.0%
85.1%82.4%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
1st Q 06 2nd Q 06 3rd Q 06 4th Q 06 1st Q 07 2nd Q 07 3rd Q 07 4th Q 07 1st Q 08
Time Period
Perc
enta
ge
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Health Grades CHF
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Goals for Patients Hospitalized With HFGoals for Patients Hospitalized With HF
Relieve symptoms rapidly Reverse hemodynamic abnormalities Prevent end-organ dysfunction Initiate patient education and survival-
enhancing medications before discharge Optimize survival-enhancing oral medications
(ACE inhibitor, beta blocker, aldosterone receptor antagonist)
Optimize patient education and HF disease management
Relieve symptoms rapidly Reverse hemodynamic abnormalities Prevent end-organ dysfunction Initiate patient education and survival-
enhancing medications before discharge Optimize survival-enhancing oral medications
(ACE inhibitor, beta blocker, aldosterone receptor antagonist)
Optimize patient education and HF disease management
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Case History
• 73 yo moved up from Fla and presented to SPH via car in acute CHF
• Past HX remote MI, remote CABG,Hx ICD, Hx chronic CHF, AFib EF less than 30
• COPD, OSA, DM, Hx carotid stent
• Non compliance felt to be component
• Initial BP 130/70 BUN 58 CR1.9
• ECG : Afib LBBB
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Hospital Course
• Diuresed with bolus IV Bumex 2mg IV BID• Seen by cardiology for CHF x3 days• Seen by EP for evaluation of rhythm- active GI
bleed precludes TEE cardioversion. Later consider upgrade to Bivent device. Maintain rate control
• Discharged with BUN 34 and Cr 1.7• Meds Bumex 2 PO BID , Imdur 30QD, Coreg 25
BID, Hydralazine 25 TID
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Readmitted 8 days later with sob
• “I told them I didn’t have enough diuretics”• Placed on hosp service boarded in PCU• Seen by cardiology 3 days later• Moved to CCU started on Nesiritide and Lasix
gtts• Diuresed 30 #, BUN 24 CR 1.4• Repeat EP evaluation BiV IVD already in place• MEDS: Lasix 80 BID, Coreg 25 BID, Coumadin,
Accupril 20,
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Hospitalizations forAcute Decompensated Heart Failure
• Congestion is the primary reason for heart failure admissions
• This may be associated with systolic or diastolic dysfunction
• Low cardiac output and associated signs/ symptoms are uncommon.
• Sub-optimal weight reduction during hospitalization.
• Although appear improved clinically, many patients are discharged with persistent fluid overload (related to pulmonary congestion that is not being identified clinically).
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Can we Risk Stratify Patients
• Early determination of level of care needed
• Determination of short term risk and needs
• Predict long term risk to guide adjunct therapy- ICD, CRT, Transplant , Hospice
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Therapeutic Challenges
• Decongest organs • Diurese• Win the Battle with
the Kidneys
• Cardiac Decompensation urges the kidneys to play unfairly
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Cardiorenal Syndrome• Worsening renal function in CHF patient who
remains congested despite increasing doses of diuretics
• Increased venous pressure with ”choked kidneys” and decreased cardiac output
• Neurohormonal activation • Decreased renal perfusion• Fluid retention• Worsening cardiac performance• POOR PROGNOSIS
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Prognostic /Therapeutic Targets
• Blood Pressure
• Body Weight
• Serum Na
• Renal Function
• QRS Duration
• CAD
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Fonarow GC et al. Circulation 1994; 90: I-488
High PCWP at Hospital Discharge is Associated with Higher Long-Term Mortality
Time (months)
N=199
N=257
PCWP > 16 mmHg
PCWP < 16 mmHg
Mortality (%)
0 6 12 18 240
10
20
30
40
50
60
P = 0.001
CI > 2.6 L/min/m2
CI < 2.6 L/min/m2
Mortality (%)
0 6 12 18 240
10
20
30
40
50
60
P = NS
N=236
N=220
Time (months)
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Predictors of Mortality Based on Analysis of ADHERE Database
Classification and Regression Tree (CART) analysis of ADHERE data shows:
Three variables are the strongest predictors of mortality in hospitalized ADHF patients:
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dL
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dL
Fonarow GC et al. JAMA 2005;293:572-80.
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ADHERE® CART: Predictors of Mortality
SYS BP 115SYS BP 115n=24,933n=24,933
SYS BP 115SYS BP 115n=24,933n=24,933
SYS BP 115SYS BP 115n=7,150n=7,150
SYS BP 115SYS BP 115n=7,150n=7,150
6.41%6.41%n=5,102n=5,1026.41%6.41%
n=5,102n=5,10215.28%15.28%N=2,048N=2,04815.28%15.28%N=2,048N=2,048
21.94%21.94%n=620n=620
21.94%21.94%n=620n=620
12.42%12.42%n=1,425n=1,42512.42%12.42%n=1,425n=1,425
5.49%5.49%n=4,099n=4,0995.49%5.49%
n=4,099n=4,0992.14%2.14%
n=20,834n=20,8342.14%2.14%
n=20,834n=20,834
BUN 43BUN 43N=33,324N=33,324
BUN 43BUN 43N=33,324N=33,324
Greater thanLess than
2.68%2.68%n=25,122n=25,122
2.68%2.68%n=25,122n=25,122
8.98%8.98%n=7,202n=7,2028.98%8.98%
n=7,202n=7,202
Cr 2.75Cr 2.752,0452,045
Cr 2.75Cr 2.752,0452,045
Highest to Lowest Risk CohortOR 12.9 (95% CI 10.4-15.9)
Reference: Fonarow GC, et al. Risk stratification for in-hospital mortality in heart failure using classification and regression tree(CART) methodology. JAMA. 2005;293:572-580.
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Primary Prevention of Sudden Cardiac Arrest in
Heart Failure Patients with LV
Dysfunction
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SCD in Heart Failure• Despite improvements in medical therapy,
symptomatic HF still confers a 20-25% risk of premature death in the first 2.5 years after diagnosis1-4
50% of these premature deaths are SCD (VT/VF)1-4
1 SOLVD Investigators. N Engl J Med 1992;327:685-691.2 SOLVD Investigators. N Engl J Med 1991;325:293-302.3 Goldman S. Circulation 1993;87:V124-V131.4 Sweeney MO. PACE. 2001;24:871-888.
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Severity of Heart FailureModes of Death
1 MERIT-HF Study Group. LANCET. 1999;353:2001-2007.
12%
24%64%
CHF
Other
SuddenDeath(N = 103)
NYHA II
26%
15%
59%
CHF
Other
SuddenDeath(N = 103)
NYHA III
56%
11%
33%
CHF
Other
SuddenDeath(N = 27)
NYHA IV
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14
11.6
8.47.89
8.2
4.9
7.2
0
2
4
6
8
10
12
14
16
1-17 mo 18 - 59 mo 60 - 119 mo > 120 mo
ConvICD
(n = 300) (n = 283) (n = 284) (n = 292)
Hazard Ratio .98
(p = 0.92)
0.52
(p = 0.07)
0.50
(p = 0.02)
0.62
(p = 0.09)
Wilber, D. Circulation. 2004;109:1082-1084.
Relation of Time from MI to ICD Benefit
in the MADIT-II Trial
Time from MI
% M
ort
alit
y fo
r E
ach
T
ime
Per
iod
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HFSA 2006 Practice Guideline (9.1, 9.4)
Device Therapy:Prophylactic ICD Placement
In patients on optimal medical therapy (ideally 3-6 months) with or without concomitant coronary artery disease (including a prior MI > 1 month ago):
Prophylactic ICD placement should be considered in those with NYHA II-III HF (LVEF 30%)
Prophylactic ICD placement may be considered in those with NYHA II-III HF (LVEF 31-35%)
Strength of Evidence = A
Concomitant placement should be considered in NYHA III-IV patients undergoing implantation of a biventricular pacing device. Strength of Evidence = B
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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Disease Management Program for Congestive
Heart Failure
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HFSA 2006 Practice Guideline (8.7)
Heart Failure Disease Management
Patients recently hospitalized for HF and other patients at high risk should be considered for referral to a comprehensive HF disease management program that delivers individualized care.
Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
1 of 2
HFSA 2006 Practice GuidelinePatient Education
Recommendation 8.1 (1 of 2)
It is recommended that patients with HF and their family members or caregivers receive individualized education and counseling that emphasizes self-care.
This education and counseling should be delivered by providers using a team approach in which nurses with expertise in HF management provide the majority of education and counseling, supplemented by physician input and, when available and needed, input from dietitians, pharmacists and other health care providers.
Strength of Evidence = B
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Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice GuidelinePatient Education
Recommendation 8.6
During acute care hospitalization, only essential education is recommended, with the goal of assisting patients to understand:
Heart failure
The goals of its treatment
Post-hospitalization medication and follow up regimen.
Education begun during hospitalization should be:
Supplemented and reinforced within 1-2 weeks after discharge
Continued for 3-6 months
Reassessed periodically Strength of Evidence = B
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HF Disease Management and the Risk of Readmission
Cline
J aarsma
Rich
Naylor
Stewart
Rauh
Lasater
Ekman
Venner
Fonarow0.5
0.6
0.7
0.8
0.9
1
1.1
RiskRatio
Summary RR = 0.76 (95% CI .68-.87)Summary RR for randomized only = 0.75 (CI = .60-.95)
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Transitional Care for Heart Failure
• May assist in device guided monitoring of volume status
• May determine needs for supplemental oxygen therapy Involve Palliative care/ Hospice
• Effective reporting to all appropriate physicians • Goal is to reduce rehospitalization and mortality• If patient is readmitted maintain transparency of
care allocation
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CHF Education and Rehab
• Cardiac Rehab not approved by CMS for CHF
• Recovery from AHDF is slower than from acute coronary event
• More likely to have repeat setbacks over first 180 days than from CAD
• Heart Failure Monitoring can be accomplished how?
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Post Discharge Vulnerable Period
• Two period of neurohormonal modification which are crucial to prognosis and survival
• Changes in renal and hepatic function worsening signs and symptoms were predicitive of early events
• BEST PREDICTORS : rising BUN and rising body weight cTHESE PEOPLE NEED CLOSE
COMPETENT FOLLOWUP
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MONITORING OUTPATIENT THERAPYMONITORING OUTPATIENT THERAPYTIME-CHFTIME-CHF
1.1. To compare To compare intensified BNP-guidedintensified BNP-guided therapy therapy to to standard symptom-guidedstandard symptom-guided therapy on 18-therapy on 18-month outcome.month outcome.
2.2. To assess if there is a difference in response to To assess if there is a difference in response to such therapy in patientssuch therapy in patients ≥75years of age ≥75years of age compared to those compared to those <75years of age<75years of age, , previously included in large heart failure trials.previously included in large heart failure trials.
3.3. Can monitoring of BNP reduce hospitalization Can monitoring of BNP reduce hospitalization in high risk patients?in high risk patients?
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TIME-CHFTIME-CHF
Intensified, BNP-guided therapy did not improve the primary Intensified, BNP-guided therapy did not improve the primary endpoint of all-cause hospitalisation free survival overallendpoint of all-cause hospitalisation free survival overall
However, it improved the more disease-specific endpoint of However, it improved the more disease-specific endpoint of heart failure hospitalisation free survivalheart failure hospitalisation free survival
Response to therapy differed significantly between age groupsResponse to therapy differed significantly between age groups
Patients age 60-74 yearsPatients age 60-74 years Reduced mortalityReduced mortality Improved HF Improved HF
hospitalisation free hospitalisation free survivalsurvival
Patients aged ≥75 yearsPatients aged ≥75 years No benefit on outcomeNo benefit on outcome Less improvement in Less improvement in
quality of lifequality of life
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Sleep Related Breathing Disorder
• Affects 40-50% of pts with systolic HF• Central sleep apnea Cheyne Stokes
respiration• Does not correlate with ejection fraction• Overnight oximetry- easy diagnostic test• Treatment with supplemental oxygen• May also need mild sleeping pills,
acetazolamide• May need Full sleep study -BiPap• Nocturnal 02 lowers BNP and catecholamine
levels
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Central Sleep Apnea and CHF
• Withdrawal of central respiratory drive to respiratory muscles during sleep
• Usually more than five events per hour of more than 10 seconds of apnea
• Disrupted sleep
• Hypersomnia during the day
• CHF- often associated with hyperventilatory events- hypocapnia
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Relationship of Sleep Apnea to CHF
• Epiphenomenon vs Risk predictor• Lanfranchi Apnea index of nonsurvivors
twice that of survivors • AHI> 30 worst prognosis• Treatment includes• -treat underling decompensated HF• -Positive airway pressure• -nocturnal oxygen
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Impedance
Pulmonary Congestion
Impedance Monitoring Bi-V devices
As fluid accumulates in the lungs, intrathoracic impedance decreases
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OptiVol Fluid Trends
OptiVol Threshold
OptiVol Fluid Index: Accumulation of the difference between the Daily and Reference Impedance
Reference Impedance adapts slowly to daily impedance changes
Daily impedance is the average of each day’s multiple impedance measurements
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Types of Chronic Heart Failure
The use of the term “Diastolic Heart Failure” is controversial
Some experts prefer the terms “Heart Failure with Preserved Ejection Fraction” or “Heart Failure with Preserved Systolic Function”
The term diastolic heart failure is used to describe patients with the signs and symptoms of heart failure, a normal EF, and LV diastolic dysfunction
It is not simply LVH
Aurigemma N Engl J Med 355 (2006) 308-310
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Treatment Options for Diastolic Heart Failure
• Diuretics
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End point HR (95% CI) p
Primary end point* 0.95 (0.86–1.05) 0.35
CV mortality 1.02 (0.87–1.19) 0.85
HF death or hospitalization 1.01 (0.88–1.16) 0.89
Massie BM, Carson PE. American Heart Association 2008 Scientific Sessions; November 11, 2008; New Orleans, LA.
Hazard ratios (95% CI) for outcomes in I-PRESERVE, irbesartan vs placebo, over a mean of 50 months
*Composite of death from any cause or hospitalization for heart failure, MI, unstable angina, arrhythmia, or stroke
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Advanced Glycation End-products (AGEs) in Heart Failure
Hartog et al. European Journal of Heart Failure 9 (2007) 1146–1155
Advanced Glycation End-products (AGEs) have been proposed as a novel factor involved in the development and progression of chronic heart failure Pathways involved include cross-linking of extra cellular matrix as well as enhanced stimulation of AGE receptors leading to (prolonged) cellular activation and release of inflammatory cytokines
The clinical and prognostic value of AGEs in patients with CHF remains largely unproven.
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Alagebrium: Effects in Reversing Cardiac Pathology
arterial stiffness
left ventricular stiffness
end diastolic volume
diastolic compliance
stroke volume
fractional shortening
pulse wave velocity
Prevents increase in cardiac
A.G.E.s, BNP, CTGF, collagen III
Restoration of collagen solubility
Optimized ventriculo-vascular coupling
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HFSA 2006 Practice Guideline (8.13)
End-of-Life Care in Heart Failure
End-of-life care should be considered in patients who have advanced, persistent HF with symptoms at rest despite repeated attempts to optimize pharmacologic and nonpharmacologic therapy, as evidenced by one or more of the following:
Frequent hospitalizations (3 or more per year)
Chronic poor quality of life with inability to accomplish activities of daily living
Need for intermittent or continuous intravenous support
Consideration of assist devices as destination therapy
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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The Clinician Perspective
What the palliative careteam can do for clinicians:
Save time by helping to handle repeated, intensive patient-family communications, coordination of care across settings,
comprehensive discharge planning.
Bedside management of pain and distress of highly symptomatic and complex cases, 24/7, thus supporting the treatment plan of
the primary physician.
Promote patient and family satisfaction with the clinician’s quality of care.
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The Hospital Perspective
For hospitals, a palliative care team can help -
Effectively treat the growing number of people with complex advanced illness.
Provide service excellence, patient-centered care.Increase patient and family satisfaction.
Improve staff satisfaction and retention. Meet JCAHO quality standards.
Rationalize the use of hospital resources.Increase capacity, reduce costs.
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30 Day Mortality Tracking
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