dr. walid hassan

HEART FAILURE Family Centered Approach

International Medical CenterJeddah, Saudi Arabia

Walid Hassan, MD, FACC, FAHA, FCCP, FACP

Professor of Medicine

IMANA/IMC December 28-29, 2014

الرحيم الرحمن الله بسمالعالمين رب لله الحمد

4

Walid Hassan, MD

NO DISCLOSURE

Key points Introduction

Heart Failure Internationally and in Saudi Arabia.

Evidence supporting HF Pathophysiology and Management.

Role of the HF Family.

Future plans of the HF management at IMC-JEDDAH

All Heart Talks The heart is most frequent organ

mentioned in:

The Glorious Qura’n Hadith “Prophet sayings” Poetry and literature by all

languages Relation to emotions

IBN EL NAFIS (1210-1288 A.D.)

Abu Al Hassan Ala Addin Abu Al Hasm

He said that heart has only two ventricles and explained the coronary circulation.

He discovered pulmonary circulation well before Harvey.

Referred to as

Avicenna the Second.

IN THE HISTORY OF MEDICINE

William Harvey in 1628IN THE HISTORY OF MEDICINE

The heart is a Unique Organ !

وآدآئه النسيجى تركيبه و خلقه فى فريد عضو

الوظيفى

فى معجزة ظواهرالقلب

و األمراض لمقاومة األورام

Preconditioning

Stunning

Hibernation

Rarity of Oncogenesis

Unique in Resistance to Ischemia, Diseases

and Tumors

Blood Emotions

?Hormones

ElectricalActivity

ElectroMagnetic

Neurological Activity

Cardiac Functions

القلب وظائف

HEART FAILURE EFFECT ON ORGANS

Heart Failure is a complex clinical syndrome that can result from any structural or functional cardiac or non-cardiac disorder that impairs the ability of the heart to respond to physiological demands for increased cardiac output. (European Society of Cardiology 2012)

HF EpidemiologyPrevalence: 22 millions HF patients in the world.

Incidence: 2 millions new HF cases diagnosed / year.

WHO, 2005

AHA, Heart & Stroke statistical update 2006

Mortality of HF

USA EUROPE0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

IncidenceMortality

WHO, 2005 AHA, Heart & Stroke statistical update 2006

Saudi Arabia64% of the Acute HF patients enrolled in the

registry have Chronic HF and are 10 years

younger than other patients enrolled in

international registries.

HEARTS Registry

European Journal of Heart Failure (2014)

IMC-JEDDAH

2012520 patients with BNP >400 pg/ml

2014

Surviving Patients: 360 Dead Patients: 160

The Prevalence, Clinical Characteristics, and Prognosis of 519 Elderly Patients with Heart Failure and Preserved Systolic Function. A Clinical Study with a 5 years Follow-up period

F.El Shaer , W.Hassan, et al.KFSH&RC Saudi Arabia.

ESC, WCC 2006 CHFJ 2009

61%

39%

0%

10%

20%

30%

40%

50%

60%

70%

Prevalence of DHF

PR

Risk factors for HF in all patients81.30%

46.10%

34.50% 33.00%

5.40%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Patients equal to or >65 yrs old

HTNDMHyperlipidIHDSmoker

Cause of death?

Mainly Multi-organ failure & Septic shock

The process of failing of the human heart:review of the current knowledge of the mechanisms of heart failure.

Epidemiology of Heart FailureClinical criteria – Prevalence 2 %

Males Females; in 65+ Prevalence 7%

50% of LVSD is asymptomatic

HFREFHFPEF

Maggioni et all. Eur J Heart Fail 2013;15:808-17

Pathophysiology of HF Decreased cardiac output results in

End Diastolic Pressure (LVEDP), LVH, LVD Pulmonary Capillary Wedge Pressure (PCWP) The development of pulmonary edema

Activation of Neurohormonal Mechanism Renin-Angiotensin-Aldosterone- System (RAAS) Sympathetic Nervous System (SNS) Other circulating and paracrine effects

Counter-regulatory systems Natriuretic Peptide System (BNP, pro BNP)

Models of HF

1 •Hemodynamic

2 •Neuro hormonal

3 •Autonomic

4 •Microenvironmental

Cardiac RemodelingNa and H2O retention, PerformanceMyocyte hypertrophy, death, fibrosisDilated and spherical ventricle, thinned

Hemodynamic Model and targets

Factor Mechanism Therapeutic Strategy 1. Preload (work or stress the heart faces at the end of diastole)

increased blood volume and increased venous tone--->atrial filling pressure

-salt restriction-diuretic therapy-venodilator drugs

2. Afterload (resistance against which the heart must pump)

increased sympathetic stimulation & activation of renin-angiotensin system ---> vascular resistance ---> increased BP

- arteriolar vasodilatorsNTG, ACEI, Hydralazine

3. Contractility decreased myocardial contractility ---> decreased CO

-inotropic drugs (cardiac glycosides)

4. Heart Rate decreased contractility and decreased stroke volume ---> increased HR (via activation of b adrenoceptors)

Heart rate lowering (BB, Dig)

V-HEFT ICumulative Mortality from the Time of Randomization in the Three Treatment Groups

0

0.1

0.2

0.3

0.4

0.5

0.6

0 6 12 18 24 30 36 42Interval (months)

Cum

ulat

ive

Mor

talit

y R

ate

PlaceboPrazosinHyd-Iso

N Engl J Med 1986;314:1547-52

DIG Trial 6800 chronic

HFREF patients were randomized to digoxin and placebo

New Engl J Med 1997;336:525-33

Pathological Effects of RAAS

RAAS Axis and its Blockade

RAAS Blockade

AGTNG• Renin• Aliskire

n

AT-I• ACE• ACE-i

AT-II

• AT1R• ARB

ALDO• Renal• MRA

Bradykinin AT2 AT4 as

Vasoprotection

Sympathetic Nervous System

CO activates baroreceptors - SNSEffects of Circulating Epinephrine & NE

Increased Heart Rate Increased Blood Pressure Increased myocardial oxygen

demand Toxic effects on myocardium – cell

death Down regulation of 1 receptors in

heart Decrease in parasympathetic

activity

Effect of Norepinephrine in HF

Natriuretic Peptides in HF

HF Joint Neurohormonal ModelRAAS

Sympathetic System

BNP

Medical Therapy for HF: Magnitude of Benefit Demonstrated in RCTs

GDMT RR Reduction in Mortality

NNT for Mortality Reduction

(Standardized to 36 mo)

RR Reductionin HF

Hospitalizations

ACE inhibitor or ARB 17% 26 31%

Beta blocker 34% 9 41%

MRA 30% 6 35%

Hydralazine/nitrate 43% 7 33%

Levy W C et al. Circulation. 2006;113:1424-1433

+ CRT

Multidisciplinary Programs

Identified 3 crucial elements to success of multidisciplinary programs:

1. Specially trained nurses/MDs should be key components of any intervention

2. Importance of education provision to patients and family members.

3. Provision of available access to HF clinicians when needed.

McAlister and colleagues (2004)

Heart Failure Nurse

Cardiologists

Family

Laboratory

PharmacistsCardiac

Rehabilitation

Dieticians

ECG & Echo techs.

Information

technology

Primary health care

centers

Patients and

Caregivers

Role of the Heart Failure Nurse

Systematic review of 29 RCTs of HF multidisciplinary management programs:

43% REDUCTION in HF admissions

McAlister and colleagues (2004)

Heart Failure Nurse

Cardiologists

Family

Laboratory

PharmacistsCardiac

Rehabilitation

Dieticians

ECG & Echo techs.

Information

technology

Primary health care

centers

Patients and

Caregivers

Engaging family

In-patient assessment• Identify cognitive level• Determine the acuteness of their

disease

Assessment of learning

needs• To match a teaching strategy• Identify patient’s literacy

Assessment of learning

style• To fill missing information• Assess the home situation• Assess family member support and

participation

Family interview

Multidisciplinary ProgramFamily

Knowledge Empowerment Confidence

Self-manage

ment

Heart Failure NurseFamily

Education

Discharge planning

Education

Phone follow up within 3-7 days from discharge

Education

Heart Failure clinic

Assessment of knowledge about Heart Failure, and readiness to learnSelf-management education

Encourage diet and medication compliance, promote exercise, regular symptoms monitoring, and daily weight.

ConclusionsPatients seeking ED care for decompensated HF had inaccurate HF beliefs and poor self-care adherence. Lack of association between HF beliefs and self care (and trend of an inverse relationship) reflects a need for pre-discharge HF education, including an explanation of what HF means and how it can be better controlled through self-care behaviors Journal of Emergency

Medicine, 2014

Self-Family Management Education

Medication

compliance

Daily weighing

Salt and fluid

restriction

Activity and

exercise

Smoking cessation

Signs and symptoms of Heart Failure

Patient will assume

responsibilitychoose

healthier life style

Increase satisfaction

Promote patient active

involvement Improve

medication adherence

Ensures continuity

of care

Reduces disease related

complication

Maximizes individual’s

independence

Goals of the Heart Failure TT

Empowerment

Improve Quality of Life

Reduce mortality

Symptom management

Improve exercise tolerance

Prevent progression of disease

Reduce health care

cost

Reduce ER visits and

re-admission

rates

Schematic depiction of comprehensive heart failure care

Goodlin, S. J. J.A.C.C. 2009;54:386-396Copyright ©2009

Func

tion

Death

High

LowBegin to use hospital more often, self-care more difficult

Time ~ 2-5 years. Death usually seems “sudden”

Modified from Lunney JR et al. JAMA 2003: 289: 2387.

TerminalPhase

Heart failure

Transitions in life-limiting illness

Transitions

EarlyDisease

containmentMaintaining

function

DecompensationExperiencing life limiting illness

Decline and terminal

Transitions Transitions

Dependency and symptoms increase

Transitions Transitions

Death and bereavement

Time

Time of Diagnosis

McGregor and Porterfield 2009

Assess: Patient and their Illness experience

DISEASE

DIAGNOSIS

SPREAD

TREATMENT

BENEFITS

BURDENS

OTHERPROGNOSTICFACTORS

PATIENTEXPERIENCE (SUFFERING)

CULTUREBACKGROUND

NEEDS and PREFERENCES

GOALS of CAREVALUES,

BELIEFS

Assess: Goals of careGoals of care change over time and may include: Maintaining and improving function. Staying in control. Relief of suffering. Prolonging life for as long as possible or until a specific

event (time limited trials of care). Quality of life/ living well.

Assess: Goals of care (continued) Pain and symptom management. Strengthening relationships. Preferences for location of care.

1. Psychosocial care for person.

2. Psychosocial care for family.

3. Spiritual care. Preferences for location of death. Life closure/ dying well.

Communication: Vital for EOL care

Patient experiences Being seen. Being heard. Being met.

Family and caregivers’ experience Support in transitions.

Establish partnership with clear goals of care and a plan for the future.

Who supports HF End of Life care? Primary care physicians and HF Specialists Home and Community Care palliative teams Patients and families/caregivers Linking with...

Acute care hospitals and tertiary ambulatory services End of Life Care programs and services Local Hospice Societies and other community services

Produces patient- family centred interdisciplinary practice

Ambiguous dying

“There will not be a distinct terminal phase. The week we die will start out like any other and

some unpredictable calamity will occur. Amongst those of us with advanced heart failure,

we will have had a 50-50 chance to live for six months on the day before we died”

Joanne Lynn: Sick to Death and Not Going to Take it Anymore (2004)

Integrating the palliative approach

Improved survival

Needs of the family/caregivers

CONCLUSIONS

Integrated care: Shifting the focus in HFMeeting the majority of people’s health care needs by providing high quality, accessible, community based health care and support services Built around attachment to a family physician and an integrated health care team (HF nurse). Stronger voice for the patient, family and local community in the design and delivery of healthcare services. More focus on proactive management of chronic HF Pt to remain independent.

IMC Team players Patient and Family Family physician Community pharmacist Home Health / Community Care –

Nurses/rehab/home support Nurse practitioners, community RT Disease specific specialists / services Hospice palliative care consult teams

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Walid Hassan, MD

NO DISCLOSURE

Thanks " .. نبأه لتعلمن و للعالمين ذكر اال هو ان

حين "بعد