FINISHING WELL: WHEN TO DISCHARGE THE ADHF PATIENT

1. BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE FINISHING WELL: WHEN TO DISCHARGE THE ADHF PATIENT

2. DISCLOSURES • NONE

3. 2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES • Journal of Cardiac Failure 2010; 16:e1-e194

4. AHA STATISTICS 2010 • > 1 million ADHF admissions /year • HF complicates the admission diagnosis in another 2 million admissions / year • In- hospital mortality for ADHF 4% • 90 day readmission rate for ADHF: >50% • Admission LVEF > 40%: 40- 50% • Cost of HF: $37 billion/year (most of cost is hospitalization)

5. WHAT’S WRONG WITH READMISSION? • If readmitted within 30 days: no reimbursement • Readmission increases the chances of readmission • Readmission increases mortality

6. MARKERS OF RISK OF READMISSION FROM ESCAPE, ADHERE, AND EFFECT • BNP • BUN AND CREATININE • CARDIAC ARREST OR MECHANICAL INTUBATION • SERUM Na • AGE • SBP • RESPIRATORY RATE • COMORBID CONDITIONS • HEART RATE

7. MARKERS OF 6 MONTH READMISSION RISK: ESCAPE • BNP > 500 (HIGH) AND > 1300 (HIGHER • BUN > 40 (HIGH) AND >90 (HIGHER) • DIURETIC DOSE > 240 mg/day FUROSEMIDE • SERUM Na < 130 • INABILITY TO TOLERATE BETA BLOCKERS • AGE >70 • 6 MINUTE WALK < 300 FEET

8. 2010 HFSA GUIDELINES: HOSPITAL DISCHARGE • It is recommended that criteria in the following table be met before a patient with Heart Failure is discharged from the hospital. (Strength of Evidence = C)

9. DISCHARGE CRITERIA FOR ALL HEART FAILURE PATIENTS • Exacerbating factors addressed • Near optimal volume status observed • Transition from IV to PO diuretic successfully completed • Patient and family education completed, including clear discharge instructions • LVEF documentation

10. DISCHARGE CRITERIA FOR ALL HEART FAILURE PATIENTS • Smoking cessation counseling initiated • Near optimal pharmacologic therapy achieved, including ACEI and beta blocker (for patients with reduced LVEF) or intolerance documented • Follow up clinic visit scheduled, usually for 7-10 days

11. HOSPITAL DISCHARGE • In patients with advanced Heart Failure or recurrent admissions for Heart Failure, additional criteria listed in the following table should be considered. (Strength of Evidence = C)

12. CRITERIA SHOULD BE CONSIDERED FOR PATIENTS WITH ADVANCED HF OR RECURRENT HF ADMISSIONS • Oral medication regimen stable for 24 hours • No IV vasodilator or inotropic agent for 24 hours • Ambulation before discharge to assess functional capacity after therapy • Plans for post discharge management (scale present in home, visiting RN or telephone follow up within 3 days after discharge) • Referral for disease management, if available

13. 2010 HFSA GUIDELINES: PRECIPITATING FACTORS • It is recommended that patients admitted with ADHF undergo evaluation for the following precipitating factors: • Atrial fibrillation or other arrhythmias • Exacerbation of hypertension • Myocardial ischemia/infarction • Exacerbation of pulmonary congestion • Anemia • Thyroid disease • Significant drug interaction • Other less common factors

14. COMMON AND UNCOMMON PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION • Dietary and medication related causes • Progressive cardiac dysfunction • Cardiac causes not primarily myocardial in origin • Non-cardiac causes • Adverse cardiovascular effects of medications

15. PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: DIETARY AND MEDICATION RELATED CAUSES • Dietary indiscretion - excessive salt or water intake • Nonadherence to medications • Iatrogenic volume expansion

16. PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: PROGRESSIVE CARDIAC DYSFUNCTION • Progression of underlying cardiac dysfunction • Physical, emotional, and environmental stress • Cardiac toxins: alcohol, cocaine, chemotherapy • Right ventricular pacing

17. PRECIPITATING FACORS ASSOCIATED WITH ADHF HOSPITALIZATION: CARDIAC CAUSES NOT PRIMARILY MYOCARDIAL IN ORIGIN • Cardiac arrhythmias • Atrial fibrillation with RVR • VT • Marked bradycardia • Conduction abnormalities • Uncontrolled hypertension • Myocardial ischemia or infarction • Valvular disease: progressive MR

18. PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: NONCARDIAC CAUSES • Pulmonary disease - PE, COPD • Anemia - bleeding, BM suppression, relative lack of erythropoietin • Systemic infection - especially pulmonary infection, UTI, viral illness • Thyroid disorders

19. PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION- ADVERSE CV EFFECTS OF MEDICATION • Cardiac depressant medications • Nondihydropyridine calcium antagonists • Type Ia and Icantiarrhythmic agents • Sodium retaining medications • Steroids • NSAID, COX-2 inhibitors, pregabalin, thiazolidinediones

20. PRECIPITATING FACTORS: MY HEARTS DIE • MYOCARDIAL DISEASE PROGRESSION • HIGH OUTPUT CAUSES/ HYPERTENSION • EMBOLISM (PE) • ARRHYTHMIAS • REDUCTION OF THERAPY • THE DEVELOPMENT OF A SYSTEMIC ILLNESS /TOXINS • SECOND HEART DISEASE • DRUGS, DEPRESSANTS, DOC • INFECTION, INFLAMMATION, ISCHEMIA, INFARCT • EXCESS IN ENVIRONMENTAL, EMOTIONAL, OR PHYSICAL EXTREME

21. 2010 HFSA GUIDELINES: EVALUATION OF HEART FAILURE • HISTORY AND PHYSICAL • PA AND LATERAL CHEST X-RAY • EKG • ECHOCARDIOGRAM • LABS • ISCHEMIA EVALUATION

22. 2010 HFSA GUIDELINES: LAB EVALUATION OF HEART FAILURE • LABS • CBC • ELECTROLYTES, BUN, CREATININE, GLUCOSE • FASTING LIPID PANEL • LIVER FUNCTION TEST • Ca AND Mg • THYROID FUNCTION • URINALYSIS • URIC ACID • BNP

23. 2009 ACCF/AHA OR 2010 HFSA GUIDELINES: ISCHEMIA EVALUATION • ANGINA + HF: CATH • HF + OBJECTIVE EVIDENCE OF ISCHEMIA: CATH • HF + HIGH PROBABILITY OF CAD: CATH • HF + KNOWN CAD: CATH • HF + LOW PROBABILITY OF CAD: STRESS OR CATH • HF + YOUNG PATIENT: CATH TO R/O CONGENITAL CORONARY ANOMALY

24. DISCHARGE PLANNING • Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues: • Details regarding medications, dietary sodium restriction, and recommended activity level • Follow up by phone or clinic visit early after discharge to reassess volume status • Medication and dietary adherence

25. DISCHARGE PLANNING • Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues: (Strength of Evidence=C) • Alcohol moderation and smoking cessation • Monitoring of body weight, electrolytes, and renal function • Consideration of referral for formal disease management

26. UNM SOLUTION • HEART FAILURE EDUCATOR: LORENA BEEMAN, RN • PAGER: 951-3113 • PHONE: 307-1242 • ALL INPATIENT EDUCATION GOALS MET • CARDIAC REHABILITATION CONSULT • PHONE: 272-2396 • EXERCISE AND OUTPATIENT EDUCATION GOALS MET • CORE MEASURES ORDERED ON EVERY PATIENT • SMOKING CESSATION IF SMOKED WITHIN THE PAST YEAR • LVEF ASSESSED IF NOT WITHIN THE PAST 6 MONTHS • ACEI/ARB OR CONTRAINDICATION DOCUMENTED FOR LVEF <40% • MEDICATION RECONCILIATION

27. UNM SOLUTION • HEART FAILURE CONSULT SERVICE 24-7 • PAGER: 951-0049 • HEART FAILURE CLINIC REFERRAL BEFORE DISCHARGE • CALL THE CLINIC 24-7 AT 925-6002 AND LEAVE MESSAGE • NAME, TELEPHONE NUMBER, DATE OF DISCHARGE, MRN • 72 HOUR TELEPHONE CALL DOCUMENTED • CLINIC VISIT WITHIN 7 CALENDAR DAYS OF DISCHARGE • HEART FAILURE POWER PLAN

28. IF DR. STEVENSON WERE TO DISCHARGE A PATIENT: • MANN’S HEART FAILURE: A COMPANION TO BRAUNWALD’S HEART DISEASE, SECOND EDITION (2011) • EDITED BY DOUGLAS MANN, M.D. • CHAPTER 48: “MANAGEMENT OF ACUTE DECOMPENSATED HEART FAILURE” BY LYNNE WARNER STEVENSON, M.D.

29. TEXTBOOK DISCHARGE: CLINICAL STATUS GOALS • No discharge until dry weight achieved • Bring the home scale to the hospital before discharge • This facilitates immediate disclosure of lack of home scale • Blood pressure range is defined • Walking without dyspnea or dizziness

30. TEXTBOOK DISCHARGE : STABILITY GOALS • 24 hours without changes in oral regimen for heart failure • > 48 hours off IV inotropic agents, if used • Even fluid balance on oral diuretics • Renal function stable or improving

31. TEXTBOOK DISCHARGE : DISCHARGE REGIMEN • Estimated diuretic dose, with plan for first escalation if needed • ACEI/ARB or documented contraindication • Beta blocker discharge dose, plans for outpatient initiation, or documented contraindication • Anticoagulation for atrial fibrillation unless contraindicated

32. TEXTBOOK DISCHARGE: PATIENT/FAMILY EDUCATION • Sodium restriction • Fluid limitation if indicated • Medication schedule • Medication effects • Exercise prescription

33. TEXTBOOK DISCHARGE : HOME INSTRUCTIONS • Monitoring of symptoms and weights • Instructions regarding when and whom to call • Scheduled call to patient within 3 days • Clinic appointment within 7 calendar days of discharge and information handed off to monitoring physician