comprehensive approach to managing heart failure patient

Comprehensive Approach

to Managing HF patients

: Experience from Korea Seok-Min Kang, MD, Ph D.

(smkang@yuhs.ac)

Director, Heart Failure Center,

Professor, Division of Cardiology,

Severance Cardiovascular Hospital,

Yonsei University College of Medicine,

Seoul, Korea

Contents

• Prevalence of HF in Korea

• Current status of

- Device therapy (ICD, CRT, ECMO, LVAD) in HF

- Heart transplantation

- Cardiac Rehabilitation in HF

• Comprehensive and multidisciplinary team

approach in HF management

Increasing HF prevalence in Korea

(Data from National Health Insurance Service, Korea)

0

100

200

300

400

500

600

700

20032004200520062007200820092010201120122013

ICD

CRT

Number of ICD & CRT in Korea Cases

Year

Number of ECMO Cases in Korea

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2006 2007 2008 2009 2010 2011 2012

Cases

Year

Number of Heart Transplantation in Korea

1992-2014 : total 1,021 cases

12 21

11 15 23 26 29

50

84

65 73

98 107

127 118

0

20

40

60

80

100

120

1402000년

2001년

2002년

2003년

2004년

2005년

2006년

2007년

2008년

2009년

2010년

2011년

2012년

2013년

2014년

Cases

Year

Ready for LVAD in Severance

Comprehensive Management

Integrated Inter-

disciplinary Patient-centered

Transitions of Care in Heart Failure

Comprehensive HF management Program

Optimization

of

Drug Therapy

Intensive

Patient

Education

Vigilant f/u

and

Early recognition

of problem

Identification

and

Management

of comorbidities

Monthly HF-HR Joint Meeting

in Severance Cardiovascular Hospital

Heart Failure Team

Heart Rhythm Team

Monthly Heart Transplantation Committee

in Severance

Heart Failure Team

Cardiac Surgeon Team

: Severance Cardiac Wellness Center

(2011.7.4 Open)

(2012.7.4. 1st anniversary)

Cardiac Rehabilitation in Severance

Patients and Family Education

Evaluation and Reduction of CV risks

Physical Training, Psychosocial Counseling

Clinical Evaluation

Counseling on appropriate use of prescribed medications

• CR Nurse (n=2) • Clinical Exercise Specialist (n=1)

• Nurse practitioner (n=3)

Severance Cardiac Wellness Center

Symptom-limited CPET

• Assessment of symptom and

prognosis of HF patients

• Risk stratification

• Exercise prescription

심장재활 운동 프로그램

Exercise Training Program in HF

Item Study 1 month 2 month 3 month Follow up

Lower Extremity Muscle Power

Lower Extremity

Muscle - Quadriceps - Hamstring

Lower Extremity Muscle Power

Exercise (Leg press)

Low Intensity Interval

Reset exercise duration and intensity q

2 wks

Lower Extremity

Muscle - Quadriceps - Hamstring

Aerobic Exercise Capacity

Body Composition

(every 1 month) - Muscle - Body Fat - Visceral Fat

CPET - VO2peak - LT - HR, BP

Bicycle

Low Intensity Interval

Reset exercise duration and intensity q

2 wks

Body Composition (every 1 month)

- Muscle - Body Fat - Visceral Fat

CPET - VO2peak - LT - HR, BP

TMT

Walking

5~20 min

Walking slope 20~40 min

Reset walking slope q 2 wks

Enhanced External Counter

Pulsation (EECP) in Severance

Effect:

Systolic Unloading

Reduce Cardiac Workload

Increase Cardiac Output

Diastolic Augmentation

Increase Coronary Perfusion

Increase Cardiac Output

Effects:

Increase Venous Return

Hospitalization is the key moment

to optimize treatment

2013 ACCF/ AHA guidelines for HF

Recommendations for hospital discharge1

Nurse-led Follow-Up Program Schedule OPD F/U schedule, 30-50 minutes

Method HF Guidebook

Subjects HF patients and their families

Contents • Importance of medication adherence and regular follow up

• Self-Care

Aggravation of HF symptom monitoring

Monitoring BW everyday

Restricted sodium diet

Non-smoking, Alcohol Moderation

• Flu vaccination periodically

• Comorbidity management

• Emotional support

• Telephone counseling

P = 0.010

Patients in usual care (n=98)

(After adjusting age, gender, etiology of HF, BMI, comorbidities, LVEF, use of RAS blockers, beta blockers, and digoxin)

P = 0.014 Patients in usual care (n=98)

(After adjusting age, gender, etiology of HF, BMI, comorbidities, LVEF, use of RAS blockers, beta blockers, and digoxin)

C Rhou, SM Kang, et al. 2012 AHA abstract

Heart Failure Clinic

Diet Education in HF

Sodium Intake in Korea

Source : Korea Food and Drug Administration 2010

Daily sodium

Intake (grams)

South Korea

Japan

UK

USA

Recommended

Allowance

by WHO

4.878

4.28

3.44

3.436

2

Annual Low Salt Cooking Class

CVD(in-patients) HF (out-patients)

HF Clinic Cardiac Wellness Center

• Pre-discharge education for performance measure

• Heart Rhythm Team

• Heart Failure Team

• Cardiac Imaging Team

• Heart Failure Team

• Cardiac Surgeon Team

• Pathology Team

Improve Clinical Outcomes

Nurse-led Follow-Up Program Cardiac Rehabilitation Program

Multidisciplinary Team Approach in HF Management

HF specialists (MD)

CR co

ord

inato

rs (N

urse

) D

ietitians

Certificated Clinical Exercise Specialist

HR specialists (MD)

Cardiac surgeons (MD)

Cardiac Imaging Specialists (MD)

Pediatrician (MD)

LifeTag Service in Emergency Situation

Korean Society of Heart Failure

(www.khfs.or.kr)

Appreciate your attention