HEART FAILURE: A FAILED ORGAN OR A FAILED SYSTEM?
Educational Objectives
| The goal of this program is to improve the quality of care of patients with heart failure (HF). After hearing and assimilating
this program, the clinician will be better able to:
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 | 1. List treatment goals for hospitalized patients with decompensated HF.
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| 2. Implement practice guidelines for managing decompensated HF.
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| 3. Discuss the effect of HF-related hospitalization on patient outcomes and identify strategies to prevent rehospitalization.
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| 4. Assess adherence to quality-of-care indicators and implement protocols that improve adherence.
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| 5. Educate patients and families about HF and its management.
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Acknowledgments
Drs. Piña, Yancy, Albert, Tang, and Mehra were recorded at 7th Annual Primary Care Conference—What to Do and When:
Managing Heart Failure in 2008, presented by Heart Failure Society of America, and held February 9, 2008, in New Orleans,
LA. The Audio-Digest Foundation thanks the speakers and the Heart Failure Society of America for their cooperation
in the production of this program.
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the following has been
disclosed: Dr. Piña is a lecturer for AstraZeneca, NitroMed, and Novartis and is on the scientific advisory board for
Merck/NovaCardia; Dr. Yancy is a consultant for AstraZeneca, GlaxoSmithKline, Medtronic, NitroMed, Otsuka, and
Scios, is on the scientific advisory board for GlaxoSmithKline and Scios, receives research support from Medtronic,
NitroMed, and Scios, and is a lecturer for GlaxoSmithKline and Novartis; Dr. Albert is a consultant for GlaxoSmithKline,
and Medtronic, receives research support from Medtronic, and is a lecturer for GlaxoSmithKline; Dr. Tang is a
consultant for Medtronic and Boston Scientific; Dr. Mehra is a consultant for Roche, Astellas, Scios, Johnson &
Johnson, and Novartis. The planning committee reported nothing to disclose.
| MANAGEMENT OF DECOMPENSATED HEART FAILURE —Ileana L. Piña, MD, Cleveland, OH
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| Case: black man, 49 yr of age, with nonischemic, class III heart failure (HF), has acute exacerbation of symptoms despite
compliance with medical therapy (10 mg lisinopril; 6.25 mg carvedilol, bid; 40 mg furosemide; 20 mg isosorbide plus 50 mg
hydralazine, tid); examination—respiratory rate, 28 bpm; elevated blood pressure (BP); cool moist skin; clear lungs; third
heart sound (S3 ) present; jugular venous pressure (JVP), 12 cm H2 O; palpable liver edge; pretibial edema; brain-type natriuretic
peptide (BNP) level, 921 pg/mL; elevated creatinine; chest x-ray reveals cardiomegaly; ejection fraction (EF), 20%
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| Patients presenting to emergency department (ED): HF—most patients who present with decompensated HF
have preexisting diagnosis; ≈20% of patients have acute de novo HF; systolic BP—\>150 mm Hg in ≈35% of patients; 90 to
150 mm Hg in ≈50% of patients; few patients present with very low BP or cardiogenic shock; demographics—older patients;
women constitute 50% of cases; clinical characteristics—50% of patients have EF \>45%; 60% of patients have
some coronary disease; most patients have hypertension; other common comorbidities include diabetes, atrial fibrillation,
and chronic renal dysfunction; congestion occurs in 80% of patients
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| Hospitalization: mean length of stay, 5.4 to 6.2 days; 20% of patients readmitted within 30 days of discharge; 50% readmitted
within 6 mo; mortality—12% by 30 days after discharge, 33% by 1 yr; patients with stable class III HF have
annual mortality rate of 12%; predictors of mortality—serum urea nitrogen (BUN) \>43 mg/dL; systolic BP ≤115 mm
Hg; serum creatinine ≥2.75 mg/dL
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| Treatment goals for hospitalized patients: improve symptoms (eg, congestion, cardiac output); optimize volume status;
identify etiology and precipitating factors (eg, diet, medication noncompliance); optimize long-term oral therapy; identify
candidates for revascularization; educate patients; consider referral to disease management program; treatment
options—fluid and sodium restriction; diuretics; ultrafiltration in selected patients; vasodilators; inotropic agents in
selected patients
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| Admission guidelines: recommended—patients with decompensated HF and hypotension, worsening renal failure, or altered
mentation; patients with dyspnea at rest, arrhythmia that results in hemodynamic compromise, or acute coronary syndrome;
consider hospitalization for patients with—worsened congestion, even without dyspnea (eg, weight gain ≥5 kg); pulmonary
or systemic congestion, even without weight gain; major electrolyte disturbance (eg, severe hypokalemia or hyperkalemia);
associated comorbid conditions (eg, pneumonia); repeated firings of implantable cardioverter defibrillator (ICD); fluid
overload—intravenous (IV) administration of loop diuretics
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| Diuretics: goal—relieve symptoms of congestion; normalize JVP; relieve edema; supplement primary therapy for HF;
diuretic resistance—often occurs in setting of insufficient restriction of sodium; may require intermittent use of diuretics;
other problems—diuretics stimulate renin-angiotensin system; loop diuretics can cause hypertrophy of distal
tubule cells; unknown impact on mortality; renal dysfunction—common among patients with HF; clinician may hesitate
to add or increase dose of angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker
(ARB) in patients with elevated creatinine levels; renal dysfunction increases length of stay and mortality rate and enhances
sensitivity to vasoconstriction; efficacy of diuresis—data from large registry of patients with decompensated
HF show 30% of patients lose 0 to 5 lb (wide variation; some patients gain even gain weight)
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| Diuretic resistance: response to diuretic diminishes or disappears before therapeutic goal attained; edema persists; euvolemia
difficult to achieve; morbidity—associated with prolonged hospital stays; iatrogenic cardiorenal syndrome—
diuretic therapy causes neurohormonal activation; blood flow and renal perfusion decrease; impaired renal function
and diuretic resistance increase morbidity and mortality; loop diuretics—associated with decreased glomerular filtration
rate; aldosterone—because diuretics stimulate renin-angiotensin-aldosterone system, sodium resorption occurs;
this dynamic likely accounts for repeated hospitalizations after diuretic monotherapy; clinical trials show higher doses
of diuretic associated with worse outcomes
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| Guidelines: administer diuretics at doses that achieve optimal volume status (assess edema, congestion, and JVP) without
reducing intravascular volume too quickly; repeatedly assess signs and symptoms of congestion; record weight daily
(patient weighed at same time each day); patients with persistent symptoms—restrict daily intake of sodium (2 g) and
fluid (2 L)
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| Continuous vs pulsed dosing: continuous infusion of furosemide results in better diuresis and sodium excretion over 24
hr; IV dosage—loading dose 20 to 40 mg; begin infusion at 5 mg/hr
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| Indications for vasoactive agents: hypertension—few patients require IV therapy; nitroprusside or nitroglycerin
commonly used; nesiritide useful for patients with volume overload and high filling pressures; hypotension—in patients
with signs and symptoms of hypoperfusion, consider using inotropic agent (eg, dobutamine, dopamine, phenylephrine,
milrinone); worsening renal function—try dobutamine or milrinone in patients unresponsive to diuretics
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| Clinical trials: milrinone treatment did not decrease 60-day rate of readmission or death and was associated with serious
adverse events (eg, arrhythmias, hypotension); important to assess risk; nesiritide better than nitroglycerin at reducing
filling pressures over 3 hr and improving shortness of breath
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| Guidelines: monitor BP frequently; decrease dosage or discontinue agents if hypotension develops (may reintroduce
agents after hypotension resolves)
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| IV inotropic agents: guidelines—consider in patients with left ventricular (LV) dilation, reduced LVEF, and end-organ
dysfunction or diminished peripheral perfusion; especially recommended for patients with low BP or symptomatic hypotension
despite adequate filling pressure; consider milrinone or dobutamine in patients with poor response to vasodilator
therapy; outcomes—tolvaptan (vasopressin antagonist) improves weight reduction and urine volume (compared to
placebo) but does not affect outcomes; improving filling pressure and normalizing venous pressure associated with improved
outcomes
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| Discharge criteria: address factors that exacerbate HF; approach optimum fluid status; transition from IV to oral diuretics;
adjust other pharmacologic therapy as needed; schedule follow-up (patient should return in 7-10 days)
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| Return to case: admit patient; check lungs (chest x-ray); begin gentle diuresis; add vasodilators as necessary to lower
BP; increase daily dose of lisinopril (10 mg bid, then titrate up); evaluate functional capacity; follow up in 7 to 10 days;
refer patient to disease management program with home care if symptoms do not sufficiently improve
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| Education and instructions: educate patient and family about dietary restrictions and importance of daily weights;
provide specific instructions about what to do if symptoms worsen; facilitate transition from inpatient to outpatient care
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| DEFINING QUALITY OF CARE IN HEART FAILURE —Clyde W. Yancy, MD, Dallas, TX
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| Background: increasing pressure on institutions (and physicians) to meet defined measures of quality of care
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| HF hospitalizations: \>1 million annually in United States; outcomes—survival decreases with number of hospitalizations,
presence of chronic renal disease, and advanced age; patients with multiple risk factors have high rates of mortality;
30-day mortality—Medicare database shows rates did not improve between 1992 and 1999
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| Primary prevention strategies: risk factor modification; early diagnosis; patient education; dietary and medication
compliance; causes for readmission—\>80% preventable; include failure to seek care, inappropriate treatment, treatment
noncompliance (including inability to afford medications), and dietary noncompliance
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| Acute decompensation: guideline-recommended therapies initially target decongestion; options—parenteral diuretics;
add vasodilative therapy for patients with symptoms at rest; add inotropic therapy for hypotensive patients (with
symptoms at rest) and those with compromised end-organ perfusion; individualize O2 therapy for patients with low O2
saturation at rest; management of refractory disease—more aggressive restriction of fluid and sodium; increasing dose
of loop diuretics; continuous infusion of loop diuretics; addition of second type of diuretic; ultrafiltration, as appropriate
(eg, patients with diuretic resistance or cardiorenal syndrome)
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| Secondary prevention: guidelines provide template for management; adherence to guidelines—Acute Decompensated
HF National Registry (ADHERE) contains data from \>200 hospitals in United States, including \>200,000 cases of decompensated
HF; of patients with known HF with reduced EF and without contraindications to evidence-based therapies, 51% received
ACE inhibitors, 13% received ARBs, and 57% received β blocker; more recent data show slight improvements in some
areas
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| Enforcing guidelines: program at University of California, Los Angeles, resulted in substantial improvements in use of
ACE inhibitors and enrollment in disease management programs; interventions improved efficiency of patient care; implementation
of similar program at Intermountain Health Care increased adherence to recommendations for ACE inhibitors
from 65% to 95%; rates of readmission and 1-yr mortality decreased; core measures of quality of care—patient education;
assessment of ventricular function; use of ACE inhibitors; directions for smoking cessation; structured processes focusing on
core measure improve adherence; program increased use of β blockers, ACE inhibitors, warfarin (for patients with atrial fibrillation),
statins (in appropriate patients), and aldosterone antagonists
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| Critical practices: study assessed impact of various measures of quality of care (eg, discharge instructions, evaluation
of systolic performance, use of evidence-based medical therapy) on 60- to 90-day mortality rates; initiation of ACE inhibitor
or ARB during hospitalization (and continued after discharge) and initiation of β blocker at discharge have greatest
effect; implementing entire strategy for process-of-care improvement (including patient education and discharge instructions)
results in statistically significant decreases in rates of in-hospital mortality and rehospitalization or death within 60
to 90 days
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| Disease management programs: outpatient programs with similar concept as process-of-care improvement programs
in hospitals; multidisciplinary programs associated with greatest benefits, including reductions in mortality and readmission
rates; team members include physicians, nurses, dietitians, social workers, exercise therapists, and others
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| Public access to quality-of-care data: grading—Centers for Medicare and Medicaid Services (CMS) began publicly
reporting data about 30-day mortality after hospitalization for HF (Medicare data; July 2005 to June 2006); average
rate, 11.1% (ie, virtually unchanged from rate published ≈15 yr ago); poor adherence to evidence-based treatment strategies
likely responsible; variation in quality—30-day mortality rates ranged from 6.7% to 17.3%; hospitals with rates 2
SD below mean named “high-quality hospitals” and received public commendation; those with rates 2 SD above mean
named “poor-quality hospitals” and received public condemnation; as criteria become more strict, more hospitals at risk
for designation as poor performance; eventually, criteria and grading will extend to individual providers
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| Best practices: following practice guidelines improves patient care by appropriately using life-saving therapies and devices;
recommendations change as evidence base grows; collaboration encouraged; cumulative impact on survival—
patients treated with only digoxin and diuretics have 2-yr mortality rate of 35%; adding ACE inhibitor reduces mortality
rate to 27%; appropriate addition of aldosterone antagonist reduces risk to 19%; adding β blocker reduces risk to 12%; device
therapy in appropriate patients further reduces risk; appropriate use of evidence-based therapies reduces 2-yr mortality
by ≥50%
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| COORDINATION OF CARE— Dr. Yancy; Nancy M. Albert, RN, PhD, Cleveland, OH; W.H. Wilson Tang, MD, Cleveland,
OH; Mandeep R. Mehra, MD, Baltimore, MD
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| Coordinator of care: “captain of ship” (eg, primary care phyician, nurse, cardiologist) directs patient to department or
clinician who can best address current symptoms or issues; familiarization with patient and HF-associated issues (eg, psychosocial
issues, sleep disordered breathing, anemia) helps ensure adequate treatment
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| Roles of nurses: facilitate continuity of care by providing frequent contact with patient and following case longitudinally;
cardiac monitoring—nurses may assess internal cardiac monitoring devices (eg, to identify recent episodes of
atrial fibrillation); patient education—dietary counseling (eg, sodium restriction); meaning of symptomology; rationale
for dietary restrictions; chronic nature of HF
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| Patient education: critical to empower patients and families; patients should have active role in HF management; longitudinal
education key (repeat educational message often; assess comprehension and retention of educational message;
follow up as needed); physical activity—example of important educational message that often is incomplete; although
patients may understand importance of physical activity, fear of symptom exacerbation often limits willingness to exercise;
educating patients about what to expect (eg, shortness of breath) and what to do in different circumstances provides
reassurance and motivation; low-sodium diet—clinicians should become familiar with sodium content of food; typical
American diet high in sodium (daily intake, 6-7 g); helpful to have examples of food packaging to teach patients how to
read nutritional labels; even with significant education, most patients consume \>2 g sodium daily
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Suggested Reading
Ahmed A et al: Effects of digoxin on morbidity and mortality in diastolic heart failure: the ancillary digitalis investigation
group trial. Circulation 114:397, 2006; Chung ES et al: Relationship of a quality measure composite to clinical outcomes
for patients with heart failure. Am J Med Qual 23:168, 2008; Fonarow GC et al: Factors identified as precipitating hospital
admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF. Arch Intern Med 168:847, 2008; Fonarow
GC et al: Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart
failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF).
Arch Intern Med 167:1493, 2007; Heart Failure Society of America: Evaluation and management of patients
with acute decompensated heart failure. J Card Fail 12:e86, 2006; Heart Failure Society of America: HFSA
2006 Comprehensive Heart Failure Practice Guideline. J Card Fail 12:e1, 2006; Konstam MA et al: Effects of oral tolvaptan
in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA 297:1319, 2007; Lennie TA:
Relationship of heart failure patients' knowledge, perceived barriers, and attitudes regarding low-sodium diet recommendations
to adherence. Prog Cardiovasc Nurs 23:6, 2008; Mullins W et al: Sodium nitroprusside for advanced low-output heart
failure. J Am Coll Cardiol 52:200, 2008; Paul S: Hospital discharge education for patients with heart failure: what really
works and what is the evidence? Crit Care Nurse 28:66, 2008; Popescu I et al: Do specialty cardiac hospitals have greater
adherence to acute myocardial infarction and heart failure process measures? An empirical assessment using Medicare quality
measures. Am Heart J 156:155, 2008; Setoguchi S et al: Repeated hospitalizations predict mortality in the community
population with heart failure. Am Heart J 154:260, 2007; Yancy CW: Vasodilator therapy for decompensated heart failure. J
Am Coll Cardiol 52:208, 2008; Yancy CW et al: Clinical presentation, management, and in-hospital outcomes of patients
admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated
Heart Failure National Registry (ADHERE) Database. J Am Coll Cardiol 47:76, 2006.
Internet Resources
HFSA guidelines: www.hfsa.org/hf_guidelines.asp
Faculty
Ileana L. Piña, MD, Professor of Medicine, Case Western Reserve University, School of Medicine, and Director, Section
of Heart Failure and Cardiac Transplantation, University Hospitals of Cleveland, Cleveland, OH; Clyde W. Yancy,
MD, Medical Director, Baylor Heart and Vascular Institute, and Chief of Cardiothoracic Transplantation, Baylor University
Medical Center, Dallas, TX; W.H. Wilson Tang, MD, Assistant Professor, Department of Cardiovascular Medicine,
Lerner College of Medicine, Cleveland Clinic, Cleveland, OH; Nancy M. Albert, RN, PhD, Director of Nursing
Research and Innovation, and Clinical Nurse Specialist, George M. and Linda H. Kaufman Center for Heart Failure, Cleveland
Clinic; Mandeep R. Mehra, MD, Herbert Berger Professor of Medicine, and Chief, Division of Cardiology, University
of Maryland, School of Medicine, Baltimore.
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