Care Coordination for Heart Failure Patients

1. Care Coordination for Heart Failure Patients Karol E. Watson, MD, PhD, FACC Professor of Medicine/Cardiology Co-director, UCLA Program in Preventive Cardiology Director, UCLA Barbra Streisand Women’s Heart Health Program Los Angeles, CA

2. Disclosure • Financial relationships with commercial interests listed below are not relevant to the CME activity: • Dr. Watson serves as a consultant/speakers bureau member for BoehringerIngleheim, and a consultant for Amgen

3. The burden of heart failure ECONOMIC BURDEN In 2012, the overall worldwide cost of heart failure was nearly $108 BILLION.3 21 MILLION adults worldwide are living with heart failure This numberisexpectedto rise.1,2 MORTALITY 50% of heart failure patients die within 5 years from diagnosis4 1. Mozaffarian D et al. Circulation. 2015;131(4):e29-e322. 2. Mosterd A et al. Heart. 2007;93(9):1137-1146. . 3. Cook C et al. Int J Cardiol. 2014;171(3):368-376. 4.  Fauci AS et al. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.

4. Learning Objectives • Discuss trends in heart failure readmissions and strategies to reduce re-hospitalizations • Discuss evidence – based management of chronic Heart Failure and adverse drug events (ADE) associated with HF medications

5. Why are we talking about Readmissions?

6. 1 in 5 Medicare beneficiaries were rehospitalized within 30 days • Estimated cost to Medicare: $17.4 Billion (2004) Jencks et. al. NEJM, 2009

7. Affordable Care Act: Reducing Readmissions

8. Phillips et al. JAMA 2004;291:1358-1367

9. Important elements for reducing readmissions Risk Assessment • Assess risk of readmission based on accepted risk factors Controlling Medications • High rate of readmissions due to ADEs, drug omissions, and poor adherence Patient Education/Self Management • Use teachback tools; clear patient instructions; empower patient to navigate healthcare system Clear Care Plan, • Anticipate needs; Clear home plan; Involve PCP and cardiologist Communication and Care Coordination • Follow up appointments made before hospital d/c; Clear plan to share relevant information

10. Risk Factors for Readmissions

11. Important elements for reducing readmissions Risk Assessment • Assess risk of readmission based on accepted risk factors Controlling Medications • High rate of readmissions due to ADEs, drug omissions, and poor adherence Patient Education/Self Management • Use teachback tools; clear patient instructions; empower patient to navigate healthcare system Clear Care Plan, • Anticipate needs; Clear home plan; Involve PCP and cardiologist Communication and Care Coordination • Follow up appointments made before hospital d/c; Clear plan to share relevant information

12. Controlling medications is essential • 110 patients recently discharged from an academic medical center. • Patients received a phone call from a pharmacist within 2 days of discharged and asked how they were feeling and if they understood all of their medications • Pharmacists corrected any medication related problems • Pharmacists communicated problems to the care team Am J Med 2001; 111 (9B) 26X

13. Controlling medications is essential • Patient satisfaction • Control – 61% • Intervention – 86% p=0.007 • ED visits within 30 days • Control – 24% • Intervention – 10% p=0.005 • Hospital Readmissions • Control 25% • Intervention 15% p = 0.07 • A key finding was that 19% of patients had difficulty obtaining all of their discharge medications Am J Med 2001; 111 (9B) 26X

14. Important elements for reducing readmissions Risk Assessment • Assess risk of readmission based on accepted risk factors Controlling Medications • High rate of readmissions due to ADEs, drug omissions, and poor adherence Patient Education/Self Management • Use teachback tools; clear patient instructions; empower patient to navigate healthcare system Clear Care Plan, • Anticipate needs; Clear home plan; Involve PCP and cardiologist Communication and Care Coordination • Follow up appointments made before hospital d/c; Clear plan to share relevant information

15. All patients with Heart Failure should purchase a scale

16. Home Daily Weights • The vascular bed can hold 10 pounds of fluid before it starts to seep out into the tissues • 2 pounds = 1 quart of water extra in the circulation • Usual recommendation: • Report a 2-pound weight gain in 1 day or a 3-pound gain in 1 week

17. Heart Failure Teaching • Monitor Daily weights • Same time • Same place • Same scale • 2 lb. increase in 24 hours or 3 lb. increase in 1 week is significant • Patients can be taught to adjust their diuretic dose / K+ based on changes in weight • Dietary sodium restriction (2-3 gm/d) • Routine fluid restriction is NOT necessary • Don’t forget to address weight reduction 17

19. Important elements for reducing readmissions Risk Assessment • Assess risk of readmission based on accepted risk factors Controlling Medications • High rate of readmissions due to ADEs, drug omissions, and poor adherence Patient Education/Self Management • Use teachback tools; clear patient instructions; empower patient to navigate healthcare system Clear Care Plan • Anticipate needs; Clear home plan; Involve PCP and cardiologist Communication and Care Coordination • Follow up appointments made before hospital d/c; Clear plan to share relevant information

20. GWTG HF Follow up after Hospital Admissions Follow-up by Physician Type Hernandez et al. JAMA , May 5, 2010 – Vol. 303, No. 17

21. GWTG HF Follow up after Hospital Admissions • 4.7% of patients died in the 30 days after discharge • 30-day mortality was significantly lower among patients admitted to hospitals which had a high rate of early follow-up with a cardiologist Hernandez et al. JAMA , May 5, 2010 – Vol. 303, No. 17

22. Important elements for reducing readmissions Risk Assessment • Assess risk of readmission based on accepted risk factors Controlling Medications • High rate of readmissions due to ADEs, drug omissions, and poor adherence Patient Education/Self Management • Use teachback tools; clear patient instructions; empower patient to navigate healthcare system Clear Care Plan, • Anticipate needs; Clear home plan; Involve PCP and cardiologist Communication and Care Coordination • Follow up appointments made before hospital d/c; Clear plan to share relevant information

23. Preventing HF Readmissions: a team effort Patient Cardiologist Primary Care Provider Heart Failure Nurse Family Pharmacist Others?

24. As HF readmissions are reduced, HF care must remain optimal JACC Volume 70, Issue 15, October 2017

25. Learning Objectives • Discuss trends in heart failure readmissions and strategies to reduce re-hospitalizations • Discuss evidence – based management of chronic Heart Failure and adverse drug events (ADE) associated with HF medications

26. Heart Failure (HFrEF) Management • Medications used in virtually all HFrEF patients • diuretics (most patients will need) • ß blockers • ACE inhibitors / ARBs or sacubitril/valsartan • Medications used in select HFrEF patients • Aldosterone antagonists • Hydralazine / Isosorbide • Digoxin • Ivabradine

27. Diuretics • Accepted Clinical Benefit: Diuretics relieve symptoms of dyspnea and edema • BUT • No good randomized trials • Activate RAAS and SNS • Electrolyte abnormalities • Over diuresis can lead to Renal Failure • High Doses correlate with poorer prognosis Aim for minimum effective dose to control symptoms

28. Figure references: Levin et al. N Engl J Med 1998;339:321–8; Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42 Kemp & Conte. Cardiovascular Pathology 2012;365–71 Schrier & Abraham. N Engl J Med 1999;341:577–85 3 key Neurohumoral systems affect HF β-blockers SNS Vasoconstriction RAAS activity Vasopressin Heart rate Contractility Natriuretic peptidesystem Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy RAAS Vasoconstriction Blood pressure Sympathetic tone Aldosterone Hypertrophy Fibrosis

29. -Blockers • Over 10,000 patients evaluated in long-term placebo-controlled clinical trials (carvedilol, bisoprolol, metoprolol) • Decrease in all-cause mortality by 30%-35% (P<.0001) • Decrease in combined risk of death and hospitalization by 35%-40% (P<.001); effect shown in 6 individual trials • Effect shown in patients already receiving ACE-I

30. ß Blockers Contra-indications: severe, brittle reactive airways disease Cautions: current or recent HF exacerbations; heart block Troublesome interactions: other rate reducing medications

31. Even low doses of B-blockade can have a dramatic effect Ejection Fraction* ‡ 8 P<.001 † 6 † LVEF (EF units) 4 2 0 Placebo 6.25 mg bid 12.5 mg bid 25 mg bid Carvedilol Patients receiving diuretics, ACE inhibitors, ± digoxin; follow-up 6 months; placebo (n=84), carvedilol (n=261). *Results from the Multicenter Oral Carvedilol Heart Failure Assessment (MOCHA) trial (n=345). †P.005 vs placebo. ‡P.0001 vs placebo. Adapted from Bristow MR et al. Circulation. 1996;94:2807–2816.

32. ACE Inhibitors • ~ 7000 patients evaluated in controlled clinical trials • Improvement in cardiac function, symptoms, and clinical status; equivocal effects on exercise tolerance • Decrease in all-cause mortality by 20%-25% (P<.001) and decrease in combined risk of death and hospitalization by 30%-35% (P<.001) Garg and Yusuf, JAMA. 1995 May 10;273(18):1450-6.1995.

33. ACE Inhibitor Adverse Effects • Hypotension • Renal Insufficiency • Hyperkalemia • Cough (20 %) • Angioedema • With captopril especially: neutropenia, nephrotic syndrome, skin rash, taste disturbances (SH group- related) • pregnancy risk category C (D in second and third trimesters)

34. Classification of Drug Risks in Pregnancy

35. ACE Inhibitor Drug : Drug Interactions • Digoxin: may increase digoxin level by 15% to 30%. • Iithium :increase lithium levels and symptoms of toxicity possible (monitor). • Potassium sparing diuretics , K supplements may cause hyperkalemia .(monitor pts closely). • Drug-food: • salt substitutes containing K : increase K level .

36. Angiotensin Receptor Blockers (ARBs) • Recommendations • ARBs are recommended in patients with HF and reduced LVEF who are ACEI intolerant • DO NOT USE ACE-I and ARBs TOGETHER ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult http://www.acc.org/clinical/guidelines/failure/hf_index.htm

37. ARB Adverse effects • Drugs in this class are usually tolerated. • Advantage over ACEIs is the low incidence of cough. • Angioedema is also rare. • Headach. • Fatigue. • Hyperkalemia. pregnancy risk category C (D in second and thrid trimesters) Cough is improved by switching ACE inhibitor to ARB

38. ARB Drug : Drug Interactions • Drug-drug: K sparing diuretics , K supplements may cause hyperkalemia .(monitor pts closely). • Drug-food: salt substitutes containing K : increase K level . DO NOT USE ACE-I and ARBs TOGETHER

39. Adapted from Bonow RO, et al. Global Cardiology Science and Practice. 2014; 34: dx.doi.org/10.5339/gcsp.2014.34. Background: Neprilysin Inhibition (NI) Natriuretic peptide system Renin-angiotensin system Natriuretic Peptides Sacubitril X ACE-I ARB X Angiotensin I Neprilysin Inactive Fragments Angiotensin II Vasodilation Natriuresis/diuresis Vasoconstriction

40. Angiotensin Receptor Neprilysin Inhibition (ARNI) • Sacubitril: Prodrug that inhibits neprilysin leading to increased levels of natriuretic peptides • Valsartan: Direct antagonism of angiotensin II receptors inducing vasoconstriction through aldosterone, catecholamine, arginine vasopressin release

41. Sacubitril/Valsartan (ARNI) • Tablet comes in 3 doses • 24mg/26mg • 49mg/51mg • 97mg/103mg • Indicated to reduce the risk of cardiovascular death and hospitalization for heart failure (HF) in patients with chronic heart failure (CHF) (NYHA class II-IV) and reduced ejection fraction • Recommended starting dose: 49 mg/51 mg BID • Target dose: 97 mg/103 mg BID

42. ARNI Precautions allow a 36 hour washout period when switching from or to an ACE inhibitor

43. Reducing Heart Failure Readmission • Readmission of patients with heart failure is common and costly. • Reducing HF Readmissions Is a national priority • Reducing Readmissions Requires a team approach • Hospitals that fail to reduce Readmissions will be penalized • Reducing Readmission is just good medicine