chronic heart failure / chronic obstructive pulmonary ... · acute heart failure (ahf) •rapid...

Investigating (unwarranted) clinical variation in the inpatient setting

Chronic Heart Failure / Chronic Obstructive Pulmonary Disease

Professor Peter Macdonald

Conjoint Professor of Medicine in the University of New South Wales,

Medical Director Heart Transplant Unit, St Vincent’s Hospital, Sydney

LEADING BETTER VALUE CARE

1

Quality Improvement Collaboration –

QuIC February Webinar

A QuIC Update on Initial Clinical Assessment &

Diagnostic Investigations for an Acute Exacerbation of CHF

Acute Decompensated Heart Failure Assessment & Treatment

Peter Macdonald Medical Director

Heart Transplant Unit St Vincent’s Hospital, Sydney

Take home messages: Acute Heart Failure (AHF)

• Rapid onset of or increasing severity of symptoms and signs of heart failure – New onset of AHF – Acute decompensation of chronic heart failure

• Key Questions – Is this heart failure? – What is the trigger? – What is the underlying cause?

• Life-threatening condition – Initial triage – Is the patient hypoxaemic? – Is the patient hypotensive ? – Usually require admission to hospital

Newton P, et al. Med J Aust 2016:Feb 15;204(3):113.e1-8

13

25 hospitals


Recruitment

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10

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50

60

70

80

90

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Nu

mb

er

recr

uit

ed

n = 811


Baseline demographics All n = 811

Demographic Profile

Male 465 (58%)

Age (mean ± SD) 77 ± 13

Caucasian 699 (86%)

Residential aged care facility 80 (11%)

Clinical Profile

CHF 540 (68%)

IHD 445 (56%)

Chronic pulmonary disease 251 (32%)

Diabetes 204 (38%)

Charlson Co-morbidity Index 3.6 + 2.6


LV Dysfunction (n = 751)

0

5

10

15

20

25

30

35

40

45

50

> 50% 40-49% 30-39% < 30%

318 125 139 169

Pe

rce

nta

ge o

f p

atie

nts

(%

)

LV Ejection Fraction


LV Dysfunction (n = 751)

0

5

10

15

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25

30

35

40

45

50

> 50% 40-49% 30-39% < 30%

318 125 139 169

Pe

rce

nta

ge o

f p

atie

nts

(%

)

LV Ejection Fraction

HFPEF (LVEF > 50%) 42% HFREF (LVEF < 50%) 58%

HFPEF (LVEF > 40%) 59% HFREF (LVEF < 40%) 41%


HFPEF vs HFREF (LVEF – 40%)

HFPEF (n = 443)

HFREF (n = 307)

p value

Age (mean + SD)

78 + 12

74 + 14

<0.001

Sex (M:F%)

48:52

76:24

<0.001

De novo: Decomp (%)

36:64

27:73

0.01

Admisson Rhythm Sinus Afl/Fib Paced

41 46 9

43 35 17

0.001

Admission BP (mmHg)

Systolic Diastolic

139 + 34 75 + 21

131 + 30 80 + 52

0.002 0.08


HFPEF vs HFREF (LVEF – 40%)

HFPEF (n = 443)

HFREF (n = 307)

p value

Cause of HF (%) IHD Hypertension Cardiomyopathy Other

36 32 10 38

53 15 24 17

<0.001

Charlson Co-morbidity Index (mean + SD) Chronic Lung Mod/Severe Kidney Diabetes

3.7 + 2.8

35 36 40

3.5 + 2.4

28 34 38

ns

Frailty Category (%) Non-frail Pre-frail Frail

7

20 73

9

22 69

ns


Frailty

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10

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60

70

80

Not frail Pre-frail Frail

Pe

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%)


Section 6


Jamar

Dynamometer

Clinical Criteria for Congestive Heart Failure

Major Criteria

• Orthopnoea +/- PND

• Bilateral lung crepitations

• Cardiomegaly

• Third heart sound

• Elevated JVP

Minor Criteria

• Dyspnoea on exertion

• Nocturnal cough

• Pleural effusion

• Bilateral ankle oedema

• Hepatomegaly

• Tachycardia (HR > 120/min)

Precipitants AHF

Rapid triggers (mins – hrs)

• Arrhythmias – VT, Severe Bc

• Acute Coronary Syn (ACS)

• Mech complication of ACS – Pap muscle rupture

– Post-MI VSD

• Acute pulmonary embolism

• Acute valve pathology

• Hypertensive crisis

Less rapid triggers (days - weeks)

• Arrhythmias

– Afl/Afib

• Non-adherence to diet/drug Rx

• Iatrogenic eg NSAIDs, BB

• Alcohol or drug abuse

• Infection

• Anaemia/Fe Deficiency

• Thyroid

– is the pt on amiodarone?

• Renal impairment

McMurray et al. Eur J Heart Fail 2012;14:803-869

Suspected Acute Heart Failure

• History/examination – incl BP & Respiratory Rate

• O2 saturation • ECG (Rhythm, ACS) • Chest X Ray • Echocardiogram

– HFREF vs HFPEF – Structural Abnormalities

• Bloods – UEC/LFTs/hs TnT – TFTs/Fe Studies – Full blood count

Cardiomegaly Pulmonary Oedema

AF & LVH

HFREF HFPEF

McMurray et al. Eur J Heart Fail 2012;14:803-869

Acute pulmonary oedema/congestion

IV bolus frusemide

O2 Sat < 94% Oxygen

Severe anxiety distress

Consider IV morphine

Measure Systolic BP

SBP < 90 mm Hg or shock SBP > 110 mmHg SBP 90 -110 mmHg

Add inotrope Consider IV GTN Observe response

Yes

Yes

No

No

Adapted from McMurray et al. Eur J Heart Fail 2012;14:803-869

Re-evaluation of patient’s clinical status

SBP < 90 mmHg

O2 sat < 94% Urine output < 20 ml/hr

Stop vasodilator Stop BB, ACEI (if on them)

Consider inotrope then mechanical support

Increase frusemide dose Consider diuretic

combination Consider ultrafiltration

Oxygen CPAP or NIPPV

Invasive Ventilation

No No

Yes Yes Yes

Adapted from McMurray et al. Eur J Heart Fail 2012;14:803-869

Acute Precipitant

Trigger Total HFREF HFPEF

Ischaemia 13% 16% 9%

Infection 22% 21% 25%

Arrhythmia 15% 14% 16%

Non-adherence Rx 5% 5% 7%

Diet/fluid 16% 18% 14%

Other 28% 28% 29%


Acute Precipitant – What investigations should I do?

Trigger Total Investigations

Ischaemia 13% ECG, hsTnT

Infection 22% CXR +/- MSU, Viral Swabs etc (depending on Hx & Ex)

Arrhythmia 15% ECG

Non-adherence Rx 5% History

Diet/fluid 16% History

Other 28% FBC (Anaemia/Infection) Fe Studies

UEC/LFTs (Kidney/Liver) TFTS (Thyroid)

BNP or nt-proBNP?*

* If there is doubt re cause of dyspnea – Cardiac versus Respiratory

Acute Precipitant – What other investigations should I do?

New Onset HF

• Echo – HFREF vs HFREF

– LV Hypertrophy

– RWMA/VSD

– Valvular Dis

– Pericardial Disease

• +/- Cardiac MRI

• +/- Coronary Imaging – CT

– Invasive

ADHF in person with CHF

• Echo and more invasive investigations likely to have been performed previously – If no , Echo is essential

– If yes, Consider repeat Echo

• ACS

• ? Mechanical complication

• ? Valvular pathology

– Repeat coronary angio if ACS

Rx- To admit or not to admit?

Rapid trigger

• Does the patient have an advanced care directive (ACD)?

– Immediate transfer to

hospital ED

– Vs

– Palliative/Symptom Management at home

Less rapid trigger

• Home-based Rx vs ED – Re-institution of drug Rx, diet

& fluid management

– Cessation of iatrogenic cause

– Increased oral vs IV diuretic (may depend on Community Heart Failure Service availability)

– Further Rx dept on ACD.

Non-pharmacological Rx

• Monitoring – ECG – Vital signs including HR, BP, RR & O2 satn – Fluid balance – Daily Weight

• Ventilatory support – Oxygen (I/N or by mask) if O2 satn < 94% – Target O2 satn 94-98% – Non-invasive ventilation if inadequate response – ETT & invasive ventilation (ICU)

• Diet – salt & fluid restriction

Aliti et al. JAMA Intern Med. 2013;173(12):1058-1064.

Salt & fluid restriction in acute decompensated heart failure: a word of caution

From: Aggressive Fluid and Sodium Restriction in Acute Decompensated

Heart Failure: A Randomized Clinical Trial

Figure 2. Change in body weight from baseline to 3-day reassessment and from baseline to the end of the study period in the

intervention and control groups. Significance was determined using the Mann-Whitney test. Data points indicate the mean values;

whiskers indicate SD.

Alti et al. JAMA Intern Med. 2013;173(12):1058-1064. doi:10.1001/jamainternmed.2013.552

Increased Thirst in

Intervention Group

From: Aggressive Fluid and Sodium Restriction in Acute Decompensated

Heart Failure: A Randomized Clinical Trial

Alti et al. JAMA Intern Med. 2013;173(12):1058-1064. doi:10.1001/jamainternmed.2013.552

Treatment during admission All n = 811

Oxygen 673 (87%)

CPAP / BiPAP 133 (17%)

Mechanical ventilation 29 (4%)

IV Diuretics 643 (81%)

IV GTN 53 (7%)

IV Inotrope 63 (8%)

Dialysis 16 (2%)

IABP / ECMO 8 (1%)

CPR 21 (3%)

Referred - Heart Tx / LVAD 17 (2%)


Treatment of ADHF – ALARM HF

Follath et al Intensive Care Medicine 2011: 37(4); 619-629

Adjusted outcomes for various Rx

Mebazaa et al Intensive Care Medicine 2011: 37(2); 290-301

Baseline demographics The Real

World (Snapshot)

SURVIVE (2007)

REVIVE I & II (2013)

ATOMIC-AHF (2016)

No. of patients

811 1327 600 606

IV Drug frusemide Dobutamine vs levosimendan

Levosimendan Vs placebo

Omecantiv mecarbil vs plac

Male 58% 72% 73% 77%

Age (years) 77 67 64 66

HFREF (LVEF < 40%)

42% 100% (LVEF < 30%)

100% (LVEF < 35%)

100% (LVEF < 40%)

Comorbidities Multiple

Few Few Few

Primary Endpoint

Clinical outcome

Dyspnoea Dyspnoea Dyspnoea

Baseline demographics The Real

World (Snapshot)

ASCEND – HF (2011)

Relax (2013)

No. of patients

811 7141 1161

IV Drug frusemide Nesiritide Vs placebo

Serelaxin Vs placebo

Male 58% 66% 73%

Age (years) 77 67 72

HFREF (LVEF < 40%)

42% 80% 55%

Comorbidities Multiple

Few Few

Comment Mean sBP 136 mmHg

sBP > 100 mmHg sBP > 125 mmHg

CHF Medications (All patients)

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Admission

Discharge

Percentage (%)


Medications in HFREF (using LVEF 40% as cut-point

de novo cases excluded at admission)

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50

60

70

80

90

100

Admission

Discharge

Percentage (%)

**

** p = 0.01

Digoxin


Other CVS Medications (All patients)

0102030405060708090

100

Admission

Discharge

Percentage (%)


Medications in HFREF (using LVEF 40% as the cut-point

de novo cases excluded)

0

10

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60

70

80

90

100

ACEI/ARB + BB ACEI/ARB + BB + MCA

Admission

Discharge


Median Length of Stay (Days)

0

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4

6

8

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12

14

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

LOS


Post-discharge Follow-Up • Prospective studies and registry data have shown

that the most vulnerable period for readmission is within the first 2 weeks post-discharge.

• Ideally AHF patients should be reviewed within the first 7-14 days of discharge from hospital, regardless of the type of appointment.

• The frequency of their appointments thereafter should be guided by their clinical stability.

Discharge Planning

• Multidisciplinary Heart Failure Service

– Nurse

– Pharmacist

• GP

• Palliative Care

Discharge Medications & Management

• 10 + 4 prescribed medications

• 13 + 7 pills

• 59% referred to HF multi-disciplinary care program


Discharge status

0

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80

Home RACF Transferred toanother facility

Died

Pe

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%)


Conclusions

• Patients admitted with ADHF

– Elderly

– Frail

– Multiple co-morbidities

– Limited use of evidence-based HF medications

– Complex medical Rx with high pill burden

– High consumption of complementary medicines


Take home messages: Acute Heart Failure (AHF)

• Rapid onset of or increasing severity of symptoms and signs of heart failure – New onset of AHF – Acute decompensation of chronic heart failure

• Key Questions – Is this heart failure? – What is the trigger? – What is the underlying cause?

• Life-threatening condition – Initial triage – Is the patient hypoxaemic? – Is the patient hypotensive ? – Usually require admission to hospital

chronic heart failure / chronic obstructive pulmonary ... · acute heart failure (ahf) •rapid...

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