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Canadian Cardiovascular Society Recommendations on Heart Failure: Focus on the Elderly

Canadian Cardiovascular Society Recommendations on Heart Failure: Focus on the Elderly. Symposium on Changes and Challenges in Geriatric Care Waterloo, May 7, 2008. George Heckman MD MSc FRCPC. Disclosures. Consultant and speaker fees from Janssen-Ortho, Novartis, and Pfizer

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Canadian Cardiovascular Society Recommendations on Heart Failure: Focus on the Elderly

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  1. Canadian Cardiovascular SocietyRecommendations on Heart Failure:Focus on the Elderly Symposium on Changes and Challenges in Geriatric Care Waterloo, May 7, 2008 George Heckman MD MSc FRCPC

  2. Disclosures • Consultant and speaker fees from Janssen-Ortho, Novartis, and Pfizer • Research support from the Canadian Institutes of Health Research, Novartis

  3. The Demographic Imperative

  4. The Elderly HF patient • Generally excluded from clinical trials • treatment by “extrapolation” • Multiple co-morbidities • Concurrent geriatric syndromes common • frailty • functional impairment • cognitive impairment • depression

  5. Objectives • Using illustrative case, review • therapies • assessment and management of frail elderly HF patient • transitional care

  6. A typical “atypical” presentation • 83 year old woman: confusion and falls for 3 days • ischemic cardiomyopathy (EF 25%) • diabetes, hypertension, gout, mild chronic renal failure • meds • furosemide 80 mg bid • ramipril 2.5 mg od • amlodipine 10 mg od • ibuprofen 200 mg prn • lorazepam 1 mg qhs prn, gravol (for sleep)

  7. Assessment: salient features • Physical exam • O2 sat 78% on room air, RR 40 • atrial fibrillation with rate 100-110 • high JVP, leg edema • bibasilar crackles • S3 • Neurological exam • delirious, no focal deficits

  8. Investigations • hemoglobin 105, normocytic, mild neutrophilia • glucose 22.1 • creatinine 130, electrolytes normal • TSH, calcium, urine normal • ECG: LBBB • chest x-ray: cardiomegaly, pulmonary oedema

  9. Course in hospital • Diagnoses: delirium and heart failure • Oxygen and diuresis • Medications optimized • ramipril 10 mg od • bisoprolol 2.5 mg od initiated • metformin initiated • warfarin • amlodipine, gravol, NSAID discontinued, lorazepam reduced

  10. Recommendation (2006) • Heart failure therapies in elderly heart failure patients should be similar to those in younger patients, although their use may depend primarily on concomitant conditions (level 1, class B)

  11. Recommendation (2007) • Beta-blockers should be initiated as soon as possible after diagnosis of heart failure, including during the index hospitalization, provided that the patient is clinically stable. Clinicians should not wait until hospital discharge to start a beta-blocker in stabilized patients (class I, level B)

  12. ACE-I and HF in elderly: Observational data • Fewer deaths, hospitalizations • including with chronic renal insufficiency • Administrative database, LTC age 85 yrs • slower functional decline vs. digoxin • Retrospective cohort,1220 hospital pts, 79 years • greater cognitive improvement in hospital, dose-response observed Philbin Am J Cardiol 96; Arling Ann Long Term Care 98; Ahmed J Am Geriatr Soc 02; Hutcheon Heart 02; Gambassi Arch Intern Med 00; Zuccala Eur Heart J 05

  13. ACE-I in frail older HF patients • RCT 60 geriatric day hospital pts with HF • aged 81+/- 6 years yrs • NYHA II-III, LV systolic dysfunction • perindopril 2 to 4 mg daily vs. placebo • Improved 6 minute walk at 10 weeks • perindopril +37.1 m vs. –0.3 m in placebo (p<0.001) Hutcheon Heart 02

  14. ACE inhibitors and depression • Cross-sectional survey 1223 LTC pts, 245 with HF • 85.9 ± 7.5 years • Antidepressants prescribed to 101 of HF pts • HF pts with history of depression less likely to receive antidepressants if appropriate ACE inhibitor doses • OR 0.11 (0.02-0.76) Heckman et al J Am Geriatr Soc 2006

  15. ACE inhibitors and insomnia • Cross-sectional Irish primary care survey • 353 pts with HF, 72 yrs • 18% getting ACE inhibitors, most low dose • HF pts more likely to get • hypnotics : 14.7% vs. 8.3% (p<0.001) • insomnia : 11.8% vs. 6.9% (p<0.001) Connolly Pharmacoepi Drug Safety 1998

  16. Beta-blockers • Cardiovascular Health Study • 950 pts, incident HF, 80+/-6 yrs • lower mortality: HR 0.74 (0.56-0.98) • SENIORS: RCT (Nebivolol) • 2128 pts 70 yrs and over, f/u 2 years • Systolic AND Diastolic failure • lower death/CV hospitalization: HR 0.86 (0.74-0.99) • Geriatric outcomes?? Chan Am Heart J 2005; Flather Eur Heart J 2005

  17. Other heart failure therapies • Exercise may improve cognition • Digoxin: high normal levels associated with benzodiazepine use in LTC • Angiotensin blockers, aldosterone antagonists, nitrates and hydralazine: no geriatric data • Rehab: cardiac and / or geriatric Heckman J Am Geriatr Soc 2006; Arnold Liu Can J Cardiol 06; Tanne Int J Cardiol 05

  18. Practical tips • HF medications: start low and titrate slowly • Monitor orthostatic vitals (supine and standing) • As ACE-I and Beta-blocker optimized • consider reducing diuretic dose if patient stable • reassess need and dose of other vasodilators, such as long-acting nitrates, if no longer clinically needed

  19. Course in hospital • Slow to mobilize • significant deconditioning • Geriatric consultation: GRU admission • function, strength, endurance improve • medications optimized further • bisoprolol titrated to 10 mg od • spironolactone 25 mg • metformin 1000 mg bid

  20. Discharge planning • cognition: MoCA: 16/30 • home care referral • home assessment • personal support worker • children / spouse given HF education • medication dosette

  21. Recommendation (2006) • Frail elderly HF patients should be referred to a geriatrician for comprehensive geriatric assessment (level 1, class B) • Elderly or frail heart failure patients who present with acute illness should be assessed for evidence of delirium and, before discharge, cognitive impairment (class IIa, class C)

  22. The post-discharge chasm • 86 yo male hospitalized mid-August 2007 with abdominal pain and distension • Past history: • Previous MI, CABG x 2 (1998), EF 40% (2006) • Type II diabetes, hyperlipidemia • Atrial fibrillation • Chronic renal failure (baseline creatinine ~115) • Previous hernia repair, cholecystectomy

  23. The Case • Ascites from right-sided heart failure • 1.5 litres drained, no malignant cells • LVEF 25%, regional wall motion abnormalities • In retrospect, patient had been getting more dyspneic over the past year (which was attributed to ‘age’?)

  24. Metoprolol 37.5 mg bid Ramipril 5 mg od Atorvastatin 20 mg Digoxin 0.0625 mg od Metolazone 2.5 mg od Furosemide 120 mg bid ECASA 81 mg od Discharged on these … Repaglinide 0.5 mg Slow-K 8 mg tabs bid Septra 1 od (SBP prophylaxis) Warfarin 2 mg od Prevacid 30 mg bid In hospital medications

  25. Course in hospital • Diuresed slowly but steadily • Able to walk up 24 steps, laps around the ward • Discharged Sept. 3, 2007 with home care (PSW), bedside commode, shower bench and walker • Referred to heart function clinic (earliest appointment October 3, 2007)

  26. Heart function visit • Significant decline since discharge • Seen by internist in interim • reduces Metolazone to Monday/ Wednesday/ Friday • Wife reports patient had • increasing fatigue, weakness (6 steps with difficulty) • in bed most of the time since discharge • anorexic, weight loss of 5-6 kg • no chest pain or dyspnea

  27. Clinical assessment • Looks tired • BP 90/45 sitting, radial pulse barely palpable standing • HR 55, atrial fibrillation • Heart sounds and chest unremarkable • JVP flat, mucous membranes dry, no ascites • Labs • Creatinine 385, urea 61.3, Sodium 131, Cl 90, K 5.1 • Digoxin 2.6 mmol/L • CBC, calcium, albumin normal, CXR: nothing acute

  28. Caregiving situation • Wife frail finding it difficult to help him dress • not enough time to look after daily household issues • Live in a side-split, 6 steps up and down • Patient has had • memory loss for past 3-5 months • recent low mood, passive death wishes • Couple isolated, daughter 1.5 hours away

  29. Could this have been prevented?

  30. Transitional Care Processes to facilitate safe / timely transfer of patients from one level of care to another Multidisciplinary: APN, MD, others Focus on enhanced “self-care” Multiple f/u methods, including home visits Cost-effective Targets high risk HF patients previous hospitalizations, multiple comorbidities or medications frail elderly depression, limited social support Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008;24(1):21-40.

  31. Self Care components • Maintenance: adherence to treatment and positive health practices • diet, medications, exercise, daily weights • Management: more active process • recognize subtle changes in status • evaluate their significance • take appropriate action • evaluate effects of action

  32. Recommendation • Patients and caregivers should be educated while in hospital and soon after discharge on • Signs and symptoms of worsening HF • Self management skills • Factors that may aggravate heart failure • Reasons for and appropriate use of medications (Class I, Level C) • Effective means of communication and collaboration between patient, caregiver and health care providers should be identified (Class I, Level B)

  33. A written summary should be provided to the patient at the time of discharge and to the primary care physician within 48 hours of discharge, covering Diagnoses Significant interventions in hospital In-hospital complications Medications at discharge (including prescriptions and explicit instructions for adjustment) Plans for follow-up, including delineation of the roles of each caregiver (Class IIa, Level B) Recommendation Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008;24(1):21-40.

  34. RN/APNs with training and expertise in enhancing patient and caregiver HF management skills may assess the patient in hospital and then follow them at home The goals and directions of care should be shared and openly discussed among the patient’s health care professionals; any differences in perspective/opinion should be identified and a best solution agreed upon Personal contact with the referring or primary care physician should be considered at or before discharge Practical tips Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008;24(1):21-40.

  35. Health care institutions serving HF patients should provide resources for or access to appropriate disease management care for patients recently discharged from hospital with a primary diagnosis of HF (Class I, Level C) These have been shown to improve adherence to therapy, reduce readmission/resource use rates and may improve mortality and quality of life Recommendations Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008;24(1):21-40.

  36. Case resolution • Patient re-hospitalized from October 3-13, 2007 • cardiac medications adjusted • treated for depression • MMSE 24/30, abnormal clock (cognitive impairment) • At discharge: • enhanced home care for bathing and dressing • wife and daughter taught about fluid management and how to seek medical help if deterioration • seen in HF clinic within 2 weeks of discharge, followed since • referred to geriatric day hospital for outpatient rehabilitation • close follow-ups = no re-hospitalization

  37. Lessons to be learned • Classic patient: ‘fits the bill’ of ‘at risk’ senior • Multiple functional deficits • Polypharmacy • Limited social support system • 2+ total number of chronic health conditions • Transitional care is imperative • This patient fell through a 4 week ‘crack’/black hole • avoidable 11 day hospital readmission (at about $1000/day, for a grand total of $11,000.00)

  38. Final thoughts • Frail elderly are growing segment of HF population • multiple health issues require multidisciplinary approach • usual treatments apply, benefits on geriatric outcomes • Health care institutions (hospitals, LIHNs, CCAC) must collaborate to provide adequate HF management capacity to support primary care • multidisciplinary • heart function clinics • transitional care programs

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