![Page 1: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/1.jpg)
FINISHING WELL: WHEN TO
DISCHARGE THE ADHF PATIENT
BART COX, M.D., FACC
DIRECTOR, ADVANCED HEART FAILURE PROGRAM
ASSOCIATE PROFESSOR OF MEDICINE
UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE
![Page 2: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/2.jpg)
DISCLOSURES
NONE
![Page 3: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/3.jpg)
2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES
Journal of Cardiac Failure 2010; 16:e1-e194
![Page 4: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/4.jpg)
AHA STATISTICS 2010
> 1 million ADHF admissions /year HF complicates the admission diagnosis
in another 2 million admissions / year In- hospital mortality for ADHF 4% 90 day readmission rate for ADHF:
>50% Admission LVEF > 40%: 40- 50% Cost of HF: $37 billion/year (most of
cost is hospitalization)
![Page 5: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/5.jpg)
WHAT’S WRONG WITH READMISSION? If readmitted within 30 days: no
reimbursement Readmission increases the chances of
readmission Readmission increases mortality
![Page 6: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/6.jpg)
MARKERS OF RISK OF READMISSION FROM ESCAPE, ADHERE, AND EFFECT
BNP BUN AND CREATININE CARDIAC ARREST OR MECHANICAL
INTUBATION SERUM Na AGE SBP RESPIRATORY RATE COMORBID CONDITIONS HEART RATE
![Page 7: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/7.jpg)
MARKERS OF 6 MONTH READMISSION RISK: ESCAPE
BNP > 500 (HIGH) AND > 1300 (HIGHER BUN > 40 (HIGH) AND >90 (HIGHER) DIURETIC DOSE > 240 mg/day
FUROSEMIDE SERUM Na < 130 INABILITY TO TOLERATE BETA
BLOCKERS AGE >70 6 MINUTE WALK < 300 FEET
![Page 8: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/8.jpg)
2010 HFSA GUIDELINES: HOSPITAL DISCHARGE
It is recommended that criteria in the following table be met before a patient with Heart Failure is discharged from the hospital. (Strength of Evidence = C)
![Page 9: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/9.jpg)
DISCHARGE CRITERIA FOR ALL HEART FAILURE PATIENTS
Exacerbating factors addressed Near optimal volume status observed Transition from IV to PO diuretic
successfully completed Patient and family education completed,
including clear discharge instructions LVEF documentation
![Page 10: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/10.jpg)
DISCHARGE CRITERIA FOR ALL HEART FAILURE PATIENTS
Smoking cessation counseling initiated Near optimal pharmacologic therapy
achieved, including ACEI and beta blocker (for patients with reduced LVEF) or intolerance documented
Follow up clinic visit scheduled, usually for 7-10 days
![Page 11: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/11.jpg)
HOSPITAL DISCHARGE
In patients with advanced Heart Failure or recurrent admissions for Heart Failure, additional criteria listed in the following table should be considered. (Strength of Evidence = C)
![Page 12: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/12.jpg)
CRITERIA SHOULD BE CONSIDERED FOR PATIENTS WITH ADVANCED HF OR RECURRENT HF ADMISSIONS
Oral medication regimen stable for 24 hours No IV vasodilator or inotropic agent for 24 hours Ambulation before discharge to assess
functional capacity after therapy Plans for post discharge management (scale
present in home, visiting RN or telephone follow up within 3 days after discharge)
Referral for disease management, if available
![Page 13: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/13.jpg)
2010 HFSA GUIDELINES: PRECIPITATING FACTORS It is recommended that patients admitted
with ADHF undergo evaluation for the following precipitating factors:Atrial fibrillation or other arrhythmiasExacerbation of hypertensionMyocardial ischemia/infarctionExacerbation of pulmonary congestionAnemiaThyroid diseaseSignificant drug interactionOther less common factors
![Page 14: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/14.jpg)
COMMON AND UNCOMMON PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION Dietary and medication related causes Progressive cardiac dysfunction Cardiac causes not primarily myocardial in
origin Non-cardiac causes Adverse cardiovascular effects of
medications
![Page 15: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/15.jpg)
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: DIETARY AND MEDICATION RELATED CAUSES
Dietary indiscretion - excessive salt or water intake
Nonadherence to medications Iatrogenic volume expansion
![Page 16: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/16.jpg)
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: PROGRESSIVE CARDIAC DYSFUNCTION Progression of underlying cardiac
dysfunction Physical, emotional, and environmental
stress Cardiac toxins: alcohol, cocaine,
chemotherapy Right ventricular pacing
![Page 17: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/17.jpg)
PRECIPITATING FACORS ASSOCIATED WITH ADHF HOSPITALIZATION: CARDIAC CAUSES NOT PRIMARILY MYOCARDIAL IN ORIGIN
Cardiac arrhythmiasAtrial fibrillation with RVRVTMarked bradycardiaConduction abnormalities
Uncontrolled hypertension Myocardial ischemia or infarction Valvular disease: progressive MR
![Page 18: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/18.jpg)
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: NONCARDIAC CAUSES
Pulmonary disease - PE, COPD Anemia - bleeding, BM suppression, relative
lack of erythropoietin Systemic infection - especially pulmonary
infection, UTI, viral illness Thyroid disorders
![Page 19: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/19.jpg)
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION- ADVERSE CV EFFECTS OF MEDICATION Cardiac depressant medications Nondihydropyridine calcium antagonists Type Ia and Ic antiarrhythmic agents Sodium retaining medications Steroids NSAID, COX-2 inhibitors, pregabalin,
thiazolidinediones
![Page 20: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/20.jpg)
PRECIPITATING FACTORS: MY HEARTS DIE MYOCARDIAL DISEASE PROGRESSION HIGH OUTPUT CAUSES/ HYPERTENSION EMBOLISM (PE) ARRHYTHMIAS REDUCTION OF THERAPY THE DEVELOPMENT OF A SYSTEMIC ILLNESS
/TOXINS SECOND HEART DISEASE DRUGS, DEPRESSANTS, DOC INFECTION, INFLAMMATION, ISCHEMIA, INFARCT EXCESS IN ENVIRONMENTAL, EMOTIONAL, OR
PHYSICAL EXTREME
![Page 21: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/21.jpg)
2010 HFSA GUIDELINES: EVALUATION OF HEART FAILURE
HISTORY AND PHYSICAL PA AND LATERAL CHEST X-RAY EKG ECHOCARDIOGRAM LABS ISCHEMIA EVALUATION
![Page 22: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/22.jpg)
2010 HFSA GUIDELINES: LAB EVALUATION OF HEART FAILURE LABS
CBCELECTROLYTES, BUN, CREATININE,
GLUCOSEFASTING LIPID PANELLIVER FUNCTION TESTCa AND MgTHYROID FUNCTIONURINALYSISURIC ACIDBNP
![Page 23: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/23.jpg)
2009 ACCF/AHA OR 2010 HFSA GUIDELINES: ISCHEMIA EVALUATION
ANGINA + HF: CATH HF + OBJECTIVE EVIDENCE OF
ISCHEMIA: CATH HF + HIGH PROBABILITY OF CAD: CATH HF + KNOWN CAD: CATH HF + LOW PROBABILITY OF CAD:
STRESS OR CATH HF + YOUNG PATIENT: CATH TO R/O
CONGENITAL CORONARY ANOMALY
![Page 24: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/24.jpg)
DISCHARGE PLANNING
Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues:Details regarding medications, dietary
sodium restriction, and recommended activity level
Follow up by phone or clinic visit early after discharge to reassess volume status
Medication and dietary adherence
![Page 25: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/25.jpg)
DISCHARGE PLANNING
Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues: (Strength of Evidence=C)Alcohol moderation and smoking cessationMonitoring of body weight, electrolytes, and
renal functionConsideration of referral for formal disease
management
![Page 26: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/26.jpg)
UNM SOLUTION HEART FAILURE EDUCATOR: LORENA BEEMAN, RN
PAGER: 951-3113 PHONE: 307-1242 ALL INPATIENT EDUCATION GOALS MET
CARDIAC REHABILITATION CONSULT PHONE: 272-2396 EXERCISE AND OUTPATIENT EDUCATION GOALS MET
CORE MEASURES ORDERED ON EVERY PATIENT SMOKING CESSATION IF SMOKED WITHIN THE PAST YEAR LVEF ASSESSED IF NOT WITHIN THE PAST 6 MONTHS ACEI/ARB OR CONTRAINDICATION DOCUMENTED FOR
LVEF <40% MEDICATION RECONCILIATION
![Page 27: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/27.jpg)
UNM SOLUTION HEART FAILURE CONSULT SERVICE 24-7
PAGER: 951-0049 HEART FAILURE CLINIC REFERRAL
BEFORE DISCHARGECALL THE CLINIC 24-7 AT 925-6002 AND LEAVE
MESSAGE NAME, TELEPHONE NUMBER, DATE OF DISCHARGE,
MRN
72 HOUR TELEPHONE CALL DOCUMENTEDCLINIC VISIT WITHIN 7 CALENDAR DAYS OF
DISCHARGE HEART FAILURE POWER PLAN
![Page 28: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/28.jpg)
IF DR. STEVENSON WERE TO DISCHARGE A PATIENT:
MANN’S HEART FAILURE: A COMPANION TO BRAUNWALD’S HEART DISEASE, SECOND EDITION (2011)EDITED BY DOUGLAS MANN, M.D. CHAPTER 48: “MANAGEMENT OF ACUTE
DECOMPENSATED HEART FAILURE” BY LYNNE WARNER STEVENSON, M.D.
![Page 29: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/29.jpg)
TEXTBOOK DISCHARGE: CLINICAL STATUS GOALS No discharge until dry weight achieved
Bring the home scale to the hospital before discharge ○ This facilitates immediate disclosure of lack of
home scale
Blood pressure range is defined Walking without dyspnea or dizziness
![Page 30: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/30.jpg)
TEXTBOOK DISCHARGE : STABILITY GOALS 24 hours without changes in oral
regimen for heart failure > 48 hours off IV inotropic agents, if
used Even fluid balance on oral diuretics Renal function stable or improving
![Page 31: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/31.jpg)
TEXTBOOK DISCHARGE : DISCHARGE REGIMEN Estimated diuretic dose, with plan for
first escalation if needed ACEI/ARB or documented
contraindication Beta blocker discharge dose, plans for
outpatient initiation, or documented contraindication
Anticoagulation for atrial fibrillation unless contraindicated
![Page 32: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/32.jpg)
TEXTBOOK DISCHARGE: PATIENT/FAMILY EDUCATION
Sodium restriction Fluid limitation if indicated Medication schedule Medication effects Exercise prescription
![Page 33: BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE](https://reader036.vdocuments.mx/reader036/viewer/2022062511/55170c9f55034603568b5378/html5/thumbnails/33.jpg)
TEXTBOOK DISCHARGE : HOME INSTRUCTIONS Monitoring of symptoms and weights Instructions regarding when and whom
to call Scheduled call to patient within 3 days Clinic appointment within 7 calendar
days of discharge and information handed off to monitoring physician