Vulnerable phase in heart failure syndrome. How can

we manage?Haytham Soliman, MD

Lecturer of cardiovascular medicine Al Fayoum University

What’s the VULNERABLE PHASE? • is a period during which

microenvironmental changes in the cardiovascular milieu after an episode of AHF impose an increased risk for adverse cardiovascular events, including increased risk of death or rehospitalization for HF.

In English !

It is the period that follow stabilization of acute heart failure up to 6 month after discharge in which there Is increase risk of death and rehospitalization

Desai AS. The three-phase terrain of heart failure readmissions. Circ HeartFail. 2012;5(4):398-400.

Mortality is particularly high in the early phase after hospitalization

Marti NC, Fonarow GC, Gheorghiade M, Bulter J. Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail 2013;6:1095-1101

All-cause mortality after discharge for HF is high at the 1st month

Changes in risk profile after hospitalization. Hasard ratio of all-cause mortality after discharge from hospital for first hospitalization for heart failure

Rehospitalization is particularly high in the early phase after hospitalization1

1-Gheorghiade M, Shah AN, Vaduganathan M, et al. Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes academics’, clinicians’, industry’s, regulators’, and payers’ perspectives. Heart Failure Clin. 2013;9:285-290.2-Marti NC, Fonarow GC, Gheorghiade M, Butler J. Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail. 2013;6:1095-1101.3-Joynt KE, Jha AK. Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives. Circ Cardiovasc Qual Outcomes. 2011;4:53-59.4-Chun S, Tu JV, Wijeysundera HC, Austin PC, Wang X, Levy D, Lee DS. Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure. Circ Heart Fail. May 2, 2012. doi 10.1161/ CIRCHEARTFAILURE.111.964791. http://circheartfailure.ahajournals.org. Accessed April 19, 2012.

30 days from discharge

11 patient out of 4 is readmitted 1-2 11 patient out of 2 is readmitted 3-4

6 months from discharge

Classification

The vulnerable phase of heart failure. Abbreviations: AHF, acute heart failure; WHF, worsening heart failure.

• Very early phase: worsening HF in hospitalized patients requiring further intervention after stabilization

• Early phase: begins after discharge up to 2 months and related to existing co-morbidities and life style

• Late phase : up to 6 months after discharge and related to neuro-hormonal and hemodynamic changes

Definition and characteristics of the vulnerable phase in heart failure – Yilmaz and MebazaaMEDICOGRAPHIA, Vol 37, No. 2, 2015

Rehospitalization for Heart Failure Problems and Perspectives Mihai Gheorghiade, MD,* Muthiah Vaduganathan, MD, MPH,† Gregg C. Fonarow, MD,‡

Robert O. Bonow, MD, MSJournal of the American College of Cardiology Vol. 61, No. 4, 2013

Factors

• Measures taken to decrease hospital stay

• Dependency on clinical picture and weight

reduction to decide decongestion status

• Mismanaging other surrogate comorbidities

• Lack of post discharge plan

Measures to decrease hospital stay• Tendency to use large doses of diuretics

( increase its complications)

• Delaying shift to oral diuretics and anticipating its effects

• Proper dose adjustment of guideline-recommended therapies

may not be reached

• Some medications like β-blocker ( which may be stopped!)

and MRAs are not initiated at hospital stay

Dependency on clinical picture and weight reduction

• Clinical decongestion improve rapidly after standard treatment

• This is not translate to a same decrease in levels of N-PBNP

• At discharge patient which is clinically “dry” may have elevated levels of BNP = increase in LV filling pressures

• This leads to 46% increase in rate of re-hospitalization for theses patients

Ambrosy, A. P. et al. Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial. Eur. Heart J. 34, 835–843 (2013)

Body Weight and RV Diastolic Pressure Before Hospitalization

Mismanaging other surrogate comorbidities

• Short hospital stay decrease the detection of other non cardiac precipitating factors

• Missing: – Anemia – Depression – Thyroid dysfunction – Hepatic dysfunction – renal impairment – Hormonal instability – Chronic inflammatory diseases – oncology

Much more

Lack of post discharge plan

• Lack of Identification of high risk patient • Patient education and rehabilitation

• Setting Regular follow up period

• Investigation in regular follow up ( to detect subclinical heart failure)

Pathophysiology • Increase BNP pre-discharge readings

• Elevated LV filling pressures despite clinical decongestion at the early phase and pre discharge

• multiple maladaptive cardiac responses: - Increased ventricular sphericity - Functional mitral regurgitation - Subendocardial ischaemia - Increase risk of arrhythmogenesis.

Gheorghiade, M., Filippatos, G., De Luca, L. & Burnett, J. Congestion in acute heart failuresyndromes: an essential target of evaluation and treatment. Am. J. Med. 119, S3–S10 (2006).

• Persistent haemodynamic congestion at discharge leads to high rates of death and rehospitalization

• Poor haemodynamic reserve in high-risk patients might lead to the return or worsening of congestive symptoms with even a modest rise in filling pressures after discharge

Graph adapted from Adamson et al. Curr Heart Fail Reports, 2009.

Discharge elevated filling pressure

What's the current strategieswhat are we doing ?

• Dietary salt restriction remains a routine, but without sound evidence and might be associated with increased neurohormonal and inflammatory derangements, and risk of readmission1.

• Increase ordinary Follow up visits and repeated follow up calls is lacking of beneficial evidence and may increase the risk of readmission2!

• Increase index hospital stay in not also translated into decrease in rehospitalization rate

1-Paterna, S. et al. Medium term effects of different dosage of diuretic, sodium, and fluid administration on neurohormonal and clinical outcome in patients with recently compensated heart failure. Am. J. Cardiol. 103, 93–102 (2009).2-Bradley, E. H. et al. Hospital strategies associated with 30 day readmission rates for patients with heart failure. ‑ Circ. Cardiovasc. Qual. Outcomes 6, 444–450 (2013)

What should we do (proposed strategies)

• Treat congestion beyond symptoms and signs

• Optimize treatment for chronic HF

• Focus resources on high risk patients

• Address cardiac and non cardiac comorbidities

• Invasive monitoring for selective patients

• Need for future studies with different prospective

Treat congestion beyond symptoms and signs

•Sustained BNP elevation warrants strong consideration for continued aggressive diuresis or escalation of vasodilator therapy

•Optimization of LV filling pressure before and after discharge is crucial for improving patient outcomes.

Gheorghiade, M. & Peterson, E. D. Improving postdischarge outcomes in patients hospitalized for acute heart failure syndromes. JAMA 305,2456–2457 (2011)

Optimize treatment of CHF • Starting evidence based treatment inside the

hospital to better titrate the doses and classes • ACEI and β-blockers proper dosage at discharge

reduced risk of death or readmission at 60–90 days*

• Encourage the use of LCZ 696 if feasible and indicated to reduce hospitalization and mortality

• Plan for CRT and ICD during the hospital stay

* Fonarow, G. C. et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA 297, 61–70 (2007)

Focus resources on high risk patients • Not all HF patients are Vulnerable • Those with persistent clinical congestion, or

vital sign or laboratory derangements at discharge have substantially higher early risk

• Pre-discharge parameters that are particularlyeffective for risk stratification include BNP levels, systolic blood pressure, and plasma sodium levels

• Increase number of previous hospitalization with HF also indicates high risk

• early post-discharge hospital visit with targeted physical examination, laboratory data, and symptom measurement.

• comparison of BNP level with pre-discharge values to detect worsening subclinical congestion.

• laboratory monitoring for corresponding drug adverse effects

• planning for additional diagnostic and interventional procedures including device therapy

These patients will need

Addressing cardiac and non cardiac comorbidities

• Most of heart failure patient are old

• Half of all deaths and rehospitalizations within 60 days are secondary to conditions other than worsening HF

• These factors must be treated to avoid readmission

Invasive monitoring of LV filling pressure

• For selective resistant patients and who are frequently re-hospitalised

• Implantable devices to measure the PA pressure may be of benefit to decrease hospitalization as shown in the (CAMPION) trial*

Abraham WT, Adamson PB, Bourge RC, Aaron MF, Costanzo MR, Stevenson LW, Strickland W, Neelagaru S, Raval N, Krueger S, Weiner S, Shavelle D, Jeffries B, Yadav JS. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet 2011;377:658–666

Further studies needed • To address specifically the vulnerable phase

• The effect of BNP level reduction on post-discharge outcome (PRIMA II)

• The use of cardiac MRI to detect viable but non functioning myocardium

Conclusion• Vulnerable phase of HF may extend up to 6 months

after discharge

• It carries high risk of mortality and re-hospitalization

• Persistent subclinical elevation of LV filling pressure is the leading pathophysiology

• Many precipitating factors like short inhospital stay, improper drug intervention and not treating comorbidities

• Decreasing this phase may be through - Better monitoring of BNP levels - Applying guideline-recommended therapies - Targeting intense post discharge measures to high risk population - Consider invasive pressure monitoring in resistant patients

• Further dedicated trials to post discharge phase in needed

Thank you