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  • Heart Failure / Transplantation

  • Heart Failure / Transplantation

    Congestive Heart Failure: The Challenges of Transitioning from

    Hospital to Community

    Stuart J. Smith MD FRCP©

    Director, Heart Failure Services

    Medical Director, Cardiac Transplantation & Mechanical Circulatory Support

    Western University

  • Faculty/Presenter Disclosure

    •Faculty: Stuart J Smith MD FRCP©

    •Relationships with commercial interests: –Grants/Research Support:

    –Aztra-Zeneca , Novartis ,

    –Speakers Bureau/Honoraria:

    –Novartis, Servier, Abbott , Medtronics, Bayer

    –Consulting Fees: Novartis ,

    –Other: N/A

  • Objectives:

    • Review our current understanding of congestive heart failure from epidemiology to management

    • Introduce the concept of “transition of care “ as it applies to CHF

    • Discuss possible approaches that may help improve transition of care from hospital to community.

    • Explore the potential roles of family physicians in the transition of care.

  • 275,000 people living in Ontario with HF

    83% of people with HF are 65+ years of age

    66,000 hospitalizations that included HF (with Avg LOS 12 days)

    25,000 hospitalizations with main diagnosis of HF (with Avg LOS 9 days)

    50,000 Outpatient/ER visits

    770,000 days in hospital / year

    In-hospital mortality rate: 12.5%

    30-day readmission rate: 16.0%

    The Burden of Heart Failure in Ontario

    Quick Facts

    6

    Data source: CIHI DAD/NACRS FY 2015/16

    Note- data represents Ontario residents with valid HCN, age 20+ years using acute care services

    Wodchis et al., CMAJ 2016

    Case: Any diagnostic code is : "I255*" "I500*" "I501*" "I509*"

  • Heart failure is a major health threat in Canada and worldwide

    About 600,0003 and 26 million1 adults have HF in Canada and worldwide respectively.

    The prevalence rising to ≥10% among persons >70 years of age.2

    Prevalenc e

    About 50,0003 and 960,0003 new cases of HF are diagnosed annually in Canada and in USA respectively.

    Incidence

    1). Ponikowski et al. ESC Heart Fail 2014;1:4-25; 2.) Ponikowski et al. Eur Heart J 2016;37:2129–2200; 3.) Mamas et al. Eur J Heart Fail. 2017;19(9):1095-1104

    MED/ENT/0374

  • Heart Failure (Ontario Context )

    (Source: HQO, 2017)

    • The prevalence of HF varies significantly across regions in Ontario

    • There is a two-fold difference in prevalence from the lowest at 134 per 10,000 people in Mississauga Halton LHIN, to the highest at 253 per 10,000 people in the North East LHIN

  • Mortality rate is higher for heart failure than many cancers

    1.) Mamas et al. Eur J Heart Fail. 2017;19(9):1095-1104; 2.) Benjamin et al. Circulation 2017;135(10):e146-e603; 3.) Roger et al. JAMA 2004;292:344–50

    Survival rates in men

    0.0

    0.2

    0.4

    0.6

    0.8

    1.0

    0 2 4 6 8

    Years since diagnosis

    Su rv

    iv al

    Prostate cancer

    Lung cancer

    Colorectal cancer

    Bladder cancer

    Heart failure

    Breast cancer

    Colorectal cancer

    Lung cancer

    Ovarian cancer

    Heart failure

    0.0

    0.2

    0.4

    0.6

    0.8

    1.0

    0 2 4 6 8

    Years since diagnosis

    Su rv

    iv alWhy are heart failure patients not managed with

    the same urgency as patients diagnosed with cancer?

    The mortality rate for patients with chronic HF is as high as 50% at 5 years post-diagnosis1,2,3

    Survival rates in women

    MED/ENT/0374

  • HF is one of the most common causes of hospitalization for patients aged >65 years in developed countries1

    Nearly 44% of all HF patients are readmitted within 1 year after discharge2

    Length of stay for HF hospitalization ranges between 5–10

    days3

    In the USA, 30-day re-admission rates are >25%4

    In Europe, re-admission rates are ~24% at 12 weeks5

    Heart failure leads to frequent hospitalizations

    1. Bui et al. Nat Rev Cardiol 2011;8:30–41; 2. Maggioni et al. Eur J Heart Fail 2013;15:808–17; 3. Ponikowski et al. ESC Heart Fail 2014;1:4-25; 4. Kociol et al. Am Heart J 2013;165:987–94; 5. Cleland et al. Eur Heart J 2003;24:442–63

    MED/ENT/0374

  • The risk of rehospitalization is very high after an acute event, especially in the first 30 days

    1. A.P. Maggioni et al. Eur J Heart Fail. 2013 Jul;15(7):808-17. 2. Yancy et al. Circulation. 2013;128:e240-e327, originally published October 14, 2013.

    • Patients were readmitted at least once for any cause during the 1-year follow-up in 43.9% of the cases1

    • Hospitalizations due to HF accounted for 56.4% of the total hospitalizations1

    1-year rehospitalization

    rate

    30-day rehospitalization

    rate

    30-day readmission rate for all- cause rehospitalization is approximately 25%2

    Total1

    Hospitalized patients (n = 1,892) n = 1,892

    All-cause death, % 17.4

    CV death, % 66.4

    Non-CV death, % 9.7

    Unknown, % 23.9

    All-cause hospitalization, % 43.9

    HF hospitalization, % 24.8

    All-cause death or HF hospitalization, %

    35.8

    Ambulatory patients (n = 3,226) n = 3,226

    All-cause death, % 7.2

    CV death, % 54.5

    Non-CV death, % 16.3

    Unknown, % 29.2

    All-cause hospitalization, % 31.9

    HF hospitalization, % 13.3

    All-cause death or HF hospitalization, %

    17.6

    MED/ENT/0374

  • Heart Failure (Ontario Context )

    (Source: HQO, 2017)

    • Heart Failure Hospitalization rates also vary significantly across regions in Ontario

    • From a high of 306 per 100,000 in the NW LHIN, to a low of 123 per 100,000 in the MH LHIN

  • • 6200 hospitalizations that included HF

    • 2100 hospitalizations with main diagnosis of HF

    • 4200 Outpatient/ER visits

    • 69,000 days in hospital

    • 85% of people with HF are 65+ years of age

    • In hospital mortality rate: 13.6%

    • 30 day readmission rate: 17.8%

    The Burden of Heart Failure in South West LHIN Acute care utilization

    Quick Facts - FY 1516

    13

    Data source: CIHI DAD/NACRS FY 2015/16

    Case: Any diagnostic code is : "I255*" "I500*" "I501*" "I509*"

    Note- data represents Ontario residents with valid HCN, age 20+ years using acute care services

  • Worsening chronic heart failure ( 75%)

    De novo heart failure ( 23%)

    Advanced/ end-stage heart failure (2%)

    Fonarow GC. Rev Cardiovasc Med. 2003; 4 (Suppl. 7): 21

    Cleland JG et al. Eur Heart J. 2003; 24: 442

    The Major Reason for Heart Failure

    Hospitalizations

  • Risk increases after every ADHF episode

    1. Gheorghiade et al. Am J Cardiol 2005;96:11G–17G; 2. Setoguchi et al Am Heart J 2007;154:26026; 3. Benjamin et al. Circulation 2017;135(10):e146-e603; 4. Roger et al. JAMA 2004;292:344–50

    C lin

    ic a

    l s ta

    tu s

    Compensated

    Chronically

    decompensated

    Acutely

    decompensated

    50% mortality rate at 5 years3,4

    Disease

    Progression

    Adapted from1

    Death

    0.0 1st

    hospitalization (n=14,374)

    0.5

    1.0

    1.5

    2.0

    2.5

    3.0

    3.5

    4.0

    2nd hospitalization

    (n=3,358)

    3rd hospitalization

    (n=1,123)

    4th hospitalization

    (n=417)

    Median survival (50% mortality) and 95% confidence limits in patients with

    HF after each HF hospitalization.2

    M ed

    ia n

    Su rv

    iv al

    ( ye

    ar s)

    MED/ENT/0374

  • GAPS IN Heart Failure Care

    Diagnosis and

    Optimized

    Treatment

    • Understanding the

    diagnosis

    • Tailoring the plan

    to the diagnosis

    and the patient

    Patient Issues

    ( Social issues , Cognitive issues

    , co-morbidities, financial issues ,

    access to care )

    Post Discharge Care

    • Transition of Care

    • Community Providers

    • Access to Specialist Care

    Acute Care

    • Hospital Care

    • Access to

    Specialist Care

  • Definition of Heart Failure

    HF is a clinical syndrome characterized by typical 1

    symptoms (e.g. breathlessness, ankle swelling and

    fatigue) that may be accompanied by 2 signs (e.g.

    elevated jugular venous pressure, pulmonary

    crackles and peripheral oedema) caused by a 3 structural and/or functional cardiac abnormality,

    resulting in a reduced cardiac output and/or elevated

    intra-cardiac pres

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