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 Failurein 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 yearsof age.2

Prevalence

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

Surv

ival

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

Surv

ivalWhy 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-yearrehospitalization

rate

30-dayrehospitalization

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 chronicheart failure ( 75%)

De novo heartfailure ( 23%)

Advanced/ end-stageheart 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

Clin

ica

l sta

tus

Compensated

Chronically

decompensated

Acutely

decompensated

50% mortality rate at 5 years3,4

Disease

Progression

Adapted from1

Death

0.01st

hospitalization(n=14,374)

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

2ndhospitalization

(n=3,358)

3rdhospitalization

(n=1,123)

4thhospitalization

(n=417)

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

HF aftereach HF hospitalization.2

Med

ian

Surv

ival

(ye

ars)

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 pressures at rest or during stress.

*** This definition restricts itself to stages at which heart failure symptoms are apparent AND makes no mention of EF

Heart Failure is a “syndrome” , not a disease .

Critical Care Western

Clinical Heart

Failure

Systolic Heart

Failure (LVEF < 40%) HFREF

Heart Failure with Preserved EF (

LVEF 45-50%) HFPEF

Ischemic

(66%)

Non-

Ischemic

(24%)

Other

(10%)

Wide Differential……..

~40% ~60%

Diagnosis – same algorithm

Treatment

Not Evidence

BasedEvidence

Based

Developing a Practical Treatment Plan

Getting More than Just the EF from the ECHO Report !

HF with LV Dysfunction

• EF ≤ 40 %

• Mild, mod or severe LV dysfunction ? Dilated ?

• Segmental or global ?

• Atrial enlargement?

• Valvular Regurg: MR ,TR

• Pul Ht RVSP > 40 - 50

• Right Sided Filling Pressures ie IVC > 2 cm

HF with Preserved Heart Function ( HFPEF)

• EF > 40-45% - 55%

• Degree of LVH

• Severity of atrial enlargement

• Valvular regurg: MR, TR

• Pul HT RVSP > 40-50

• Right Sided Filling Pressures ie IVC > 2 cm

American Heart Association “Approach to Heart Failure Management”

Patient Priority AND Priority of Care :

Decongest , Decongest , Decongest !

For both HFREF and HFPEF

Clinical Trials in HFPEF

DIURETICS Plus :

20

15

10

5

0

HFREF

Improved Survival with Each Addition of a New HF Therapy

ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; CI = confidence interval; CIBIS-II = Cardiac Insufficiency Bisoprolol Study II; CHARM = Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity; HF = heart failure; HR = hazard ratio; RRR = relative risk reduction; SOLVD = Studies of Left Ventricular Dysfunction

1. SOLVD Investigators. N Engl J Med 1991; 325:293-302. 2. CIBIS-II Investigators. Lancet 1999; 353:9-13. 3. Weir et al. Eur J Heart Fail 2008; 10:157-63.

25

Diuretic

digoxin

Diuretic

digoxin

ACEI

Diuretic

digoxin

ACEI

Diuretic

digoxin

ACEI

β-blocker

Diuretic

digoxin

ACEI

β-blocker

Diuretic

digoxin

ACEI

β-blocker

ARB

SOLVD (1991)1

RRR 23%

CIBIS-II (1999)2

RRR 34%

CHARM-Added (2003)3

(β-blocker subgroup)

RRR 33%

Re

sid

ua

l risk

One

-yea

r all-

cause m

ort

alit

y (

%)

NatriureticPeptide (NP )

System

Renin –Angiotensin Aldosterone

System ( RAAS)

Heart Failure• Cardiac Output•LV filling pressure• Volumes• atrial filling pressure

• Vasodilatation• Naturesis• diuresis• renin release

• LV remodeling

Inactive NPs

Reninproduction

ATGN AG I

AG II

AT1receptor AT2 receptor

Vasoconstriction• aldosterone• BP

Vasodilatation• naturesis• BP

ACE

✗Valsartan

Neprilysin✗LBQ657

(active)

Sacubitril(pro-drug)

Added Improvement In Mortality with Sacubitril/Valsartan versus Current Standard of Care (ACEis/ARBs)

10%

20%

30%

40%

ACEinhibitor

Angiotensinreceptorblocker1

0%

% D

ecre

ase in C

V M

ort

alit

y

17%

20%

Sacubitril /Valsartan

15%

Effect of ARB vs placebo derived from CHARM-Alternative trial

Effect of ACE inhibitor vs placebo derived from SOLVD-Treatment trial

Effect of Sacubitril/Valsartan vs ACE inhibitor derived from PARADIGM-HF trial

McMurray et al. Eur Heart J 2015;36(7):1434.439

Ivabradine reduces likelihood of HF Hospital Readmissions

Hospitalization expressed per patient for all patients and for patients actually hospitalized during the trial

Ivabradine (n = 3241)

Placebo (n = 3264)

P-value

Hospitalizations for worsening heart failure (number of patients)

No hospitalization 2,727 (84%) 2,592 (79%)

1 hospitalization 325 (10%) 389 (12%)

2 hospitalizations 99 (3%) 155 (5%)

≥3 hospitalization 90 (3%) 128 (4%)

Hospitalizations for worsening heart failure (number of events)

Total number of hospitalization events 902 1,211 0.0002

Number of events per patient

Whole population 0.3 0.4

Patients with ≥1 hospitalization 1.8 1.8

Therapeutic Approach to Patients with HFREF

Ezekowitz et al. Canadian Journal of Cardiology 33 (2017) 1342e1433

No

n-p

harm

acolo

gic the

rapies

(teach

ing se

lf-care, e

xercise

)

Diu

reti

cs t

o r

elie

ve c

on

gest

ion

Titr

ated

to

min

imu

m e

ffec

tive

do

se t

o m

ain

tain

eu

vole

mia

Ad

va

nc

e C

are

Pla

nn

ing

an

d D

oc

um

en

tatio

n

of G

oa

ls o

f Care

Patient with LVEF ≤ 40% and Symptoms

Triple Therapy ACEI (or ARB if ACEI intolerant), BB, MRATitrate to target doses or maximum tolerated evidence-based dose

NYHA I

Continue triple therapy

NYHA II-IVSR, HR ≥ 77 bpm

ADD ivabradine and SWITCH ACEI or ARB

to SAC/VAL for eligible patients

NYHA II-IVSR with HR < 77

bpm or AF or pacemaker

SWITCH ACEI or ARB to SAC/VAL for eligible patients

REASSESS SYMPTOMS

REASSESS SYMPTOMS AND LVEF

Four Key Emerging Themes

Challenging HF Care in Canada

Hayes SM, et al. BMC Health Serv Res. 2015 ;15(1):290.

Challenges in Promoting A Holistic Approach to Heart Failure Management

Ambulatory (Screening / Prevention)

Emergency Hospitalization Transition Ambulatory (Home, Long-term care)

Challenges in the risk assessment and early diagnosis of heart failure

OUTCOMES

Challenges in ensuring effective and consistent transitional care

Challenges with optimal treatment and management of HF patients by primary care providers

Success will only come with some sort of

“Transition of Care” Plan

Re-hospitalization risk among patients hospitalized for heart failure

Picture from: Desai AS and Stevenson LW. Circulation 2012;126(4):501-61. Greene et al. Nat Rev Cardiol 2015;12:220–29; 2. Langenickel et al. Drug Discov Today: TherStrateg 2012;9:e131–9

Red indicates period of highest risk for readmission immediately after discharge and

just before death

During patient transition

• From close supervision by the hospital cardiology team

• To less frequent ambulatory monitoring at home after discharge

Persists high risk of

• Hemodynamic instability1,2

• Neuro-hormonal over-activation1,2

Median time from hospital discharge

Rea

dm

issi

on

rat

e

Initialdischarge Death

Transition phase

Plateauphase

Palliation and

priorities

MED/ENT/0374

Inpatient Outpatient

The heart failure patient journey

Monitoring

Treatment adjustmentand/or intensification

Acute treatment

Initiate or reviseongoing HF treatment

In-hospital monitoring

Diagnosis

Pre-discharge, discharge and transition to home or care facility

ED PRESENTATION and/or HOSPITALIZATION

PRESENTATION

Device or cardiac transplantation

Diagnosis

Initial treatment choice

Referral

MED/ENT/0374

Better “Transition of Care” =

Better Patient Outcomes• Importance of Follow-up Care:

– A study of 3,136 patients in Alberta with Heart Failure found those

who received regular cardiovascular follow-up visits with a family

physician had better outcomes

Ezekowitz JA, et al. Impact of specialist follow-up in outpatients with congestive heart failure. CMAJ 2005;172:189-94.

Kaplan–Meier Survival Curves For Care Received, by Ambulatory Specialty

1.0

0.9

0.8

0.7

0.6

00 60 120 180 240 300 360

Cu

mu

lati

ve S

urv

ival

Days of Follow-up

Log-rank = 127.55p<0.0001

No follow-up care

Combined care (both specialist and family physician)

Care by family physician only

“Transition of Care” Strategies

• Dependent upon your resources but you need to be imaginative

• ~ 50% of readmissions occur within the 1st 10 days post discharge

• Strategies for Consideration:

• Educational packages for daily weights , etc

• Phone Call on Day 3 by….• Arrange Homecare to go in• Early follow-up with FMD

• Early Transitional Care Clinic• Early follow-up in HF Clinic• Automated Phone Call System • Implanted Devices

eg CardioMems , built into PPM/ICD

Channelling Our Efforts to Decrease 30 Day HF

Readmission Rates : Which Approach ?

Kociol R D et al. Circ Heart Fail 5:680-687 (2012)

Seamless “Transition of Care” not as simple as it sounds ….

HF is Very Complex but these are the Factors that We See that Drive the Problem

• Social ( lives alone , financial issues ,etc)

• Psychological ( Lack insight , anxiety)

• HF but one component of a patient with multiplesignificant co-morbidities

• No transition of care ie no specialist follow-up

• No Family Physician or FMD not involved

• Very Advanced Heart Failure

• Types of Patients : HFPEF >> HFREF

• Lack of specialists or specialists willing to see HF patients

People living in South West LHIN using acute care services related

to heart failure

FY 2016-2017

40

Factors That Affect Programs Moving Forward

Administration Issues(Lack of Plan , Lack of realistic vision , Not

Working with the Physicians / Nurses, Decisions driven by other things )

Physical Plant Issues( Space issues , Lack of Planning , “Squatters

Rights “ etc)

Physician & Nursing Issues( Practice Style issues , Work load ,

Unrealistic Expectations , Not Working with Administration , Not

working with each other )

Financial Issues( Lack of Money , “Shell Game”,)

1. Variations in access to care; sharing of EMR

2. < 5% patients receive palliative care

3. Small and solo practices4. Patients don’t have a FM

MD5. Wait times too long6. Referral criteria not

consistent7. Not funded by MOHLTC8. Hi proportion of ED Visits

and readmissions9. 3 Month readmission

rate varies 25-50%10. Poor “transition of care”

by specialist /FMD11. LTC patients hi users of

ER and lack access to recommended Rx.

Current Model : Heart Failure Care in London

Low Intermediate High

CCAC Services Palliative Care

LHSC HF Navigator RN Case Management

Connecting Care to Home:Transitional HF Care Program

SJHC HF Clinic

LHSC Transitional HF Clinic LHSC Advanced HF Clinic

Transplant / VAD Clinic /etc

EHMRG Score - UH Emergency Department/ Heart Failure Admission / Physician

SJHC Rapid Access HF Clinic

( seen within 48-72 hr)

Patient admitted for treatment of heart failure

Advanced Pul Ht(with Dr S Mehta /

Dr R Davey )

Integrated Congestion Assessment in the HF Patient Journey

Current HF Management:

Why aren’t current parameters working?

Graph adapted from Adamson PB, et al. Curr Heart Fail Reports, 2009.46

Conceptual Design of the Spoke-Hub-Node Model of Integrated Heart Failure Care

Ashlay Huitema et al ; Can J Cardiol 34: 863-870 (2018)

Do the “simple things” well !

Additional Slides

Heart Failure Service 2017

Clinical Service( Wards , CCU )

SJHC Heart Failure Clinic DAILY

UH Pre / Post-Transplant / VAD

HF Clinics (2 / week )

CC2H Transitional HF Clinics

• UH (low-Intermediate)• SJHFC ( Hi Risk )

[ Advanced Inpatient HF

Consult Service ]

Clinical Research “Undifferentiated” HF Intake Clinics ( 4

/ week )Resident

Education• Graphics Rounds• HF Journal Club • Supervise Projects

Collaborate• EP• Multiple Myeloma• Palliative Care• [ Mitra-Clip , etc ]• Pulmonary Ht• Upgrading of CCU• ECHO /Imaging

Transplant / VAD Program

Development of Regional Hub & Spoke Model

• Large Referral Centres• [ Small Hospitals in LHIN ]

HF Technical Skills

• Cath• ECHO• CPET• Axillary IABP

Note = [ provide on prn basis due to manpower]

Critical Care Western

Target Weight 150 poundsFurosemide 40 mg prn

Weight Furosemide Dose

152 lbs or less No Furosemide

153 lbs Furosemide 40 mg po once

daily

154 lbs Furosemide 40 mg po BID

** call HFC after 3 days

155 lbs or more Furosemide 80 mg po BID

**call HFC after 3 days

COACH : Comparison of Outcomes and Access to Care for Heart Failure

Adamson PB et al. J Am Coll Cardiol. 2003; 41: 565

Pressure Change Hospitalization

Days Relative to the Event

Baseline -7 -6 -5 -4 -3 -2 -1 Recovery

Ch

ang

e (%

)

-10

0

10

20

30

40

RV Systolic Pressure

Estimated PA Diastolic

Pressure

Heart Rate

Congestion Precedes Hospitalization

Point of Care Ultrasoundfor Acute Assessment of HF Patients

Using Handheld U/S

to Detect Pulmonary Congestion

Detection of B Lines ( also known

as Comets)

Confirmation of Volume

Overload ( Elevated Right

Sided Filling pressures )

Quantification of Right Atrial Pressures

Opportunities• Collaboration with Pulmonary Hypertension

• Collaboration with ? IM , ? FHT , Palliative Care

• Collaboration with Oncology ( Cardio-Onc)

• Increasing role of Cardiac Rehab for HF , VADS and Post Heart Transplants

• As part of Teams involved in Hi Cost , Hi Tech treatment options ( eg Mitra Clip , etc)

• “Clinical Research”

• “Systems Research” – ie Demo project for MOH – “Hub and Spoke” with rural hospitals and FHT’s in LHIN

Current and Future Framework for Congestion Detection

Girerd et al : JACC HF 6: 273 -285 ( April 2018)

Possible Decongestion Targets at Discharge from Hospital

Girerd et al : JACC HF 6: 273 -285 ( April 2018)

Initial Model : Heart Failure Care in London

Low Intermediate High

CCAC Services Palliative Care

SJHC HF Clinic

LHSC Pre Heart Transplant / VAD

Clinic

Referral HF Post Admission / Emergency Department / Physician

Patient admitted for treatment of heart failure