FINISHING WELL: WHEN TO DISCHARGE THE ADHF PATIENT BART COX, M.D., FACC DIRECTOR, ADVANCED HEART FAILURE PROGRAM ASSOCIATE PROFESSOR OF MEDICINE UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE
Feb 24, 2016
FINISHING WELL: WHEN TO
DISCHARGE THE ADHF PATIENT
BART COX, M.D., FACCDIRECTOR, ADVANCED HEART FAILURE PROGRAM
ASSOCIATE PROFESSOR OF MEDICINEUNIVERSITY OF NEW MEXICO SCHOOL OF
MEDICINE
DISCLOSURES NONE
2010 HEART FAILURE SOCIETY OF AMERICA GUIDELINES Journal of Cardiac Failure 2010; 16:e1-
e194
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)
WHAT’S WRONG WITH READMISSION? If readmitted within 30 days: no
reimbursement Readmission increases the chances of
readmission Readmission increases mortality
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
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
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)
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
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
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)
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
2010 HFSA GUIDELINES: PRECIPITATING FACTORS It is recommended that patients admitted with
ADHF undergo evaluation for the following precipitating factors:Atrial fibrillation or other arrhythmiasExacerbation of hypertensionMyocardial ischemia/infarctionExacerbation of pulmonary congestionAnemiaThyroid diseaseSignificant drug interactionOther less common factors
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
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION: DIETARY AND MEDICATION RELATED CAUSES Dietary indiscretion - excessive salt or water
intake Nonadherence to medications Iatrogenic volume expansion
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
PRECIPITATING FACORS ASSOCIATED WITH ADHF HOSPITALIZATION: CARDIAC CAUSES NOT PRIMARILY MYOCARDIAL IN ORIGIN Cardiac arrhythmias
Atrial fibrillation with RVRVTMarked bradycardiaConduction abnormalities
Uncontrolled hypertension Myocardial ischemia or infarction Valvular disease: progressive MR
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
PRECIPITATING FACTORS ASSOCIATED WITH ADHF HOSPITALIZATION- ADVERSE CV EFFECTS OF MEDICATION Cardiac depressant medications Nondihydropyridine calcium antagonists Type Ia and Ic antiarrhythmic agents Sodium retaining medications Steroids NSAID, COX-2 inhibitors, pregabalin,
thiazolidinediones
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
2010 HFSA GUIDELINES: EVALUATION OF HEART FAILURE HISTORY AND PHYSICAL PA AND LATERAL CHEST X-RAY EKG ECHOCARDIOGRAM LABS ISCHEMIA EVALUATION
2010 HFSA GUIDELINES: LAB EVALUATION OF HEART FAILURE LABS
CBCELECTROLYTES, BUN, CREATININE, GLUCOSEFASTING LIPID PANELLIVER FUNCTION TESTCa AND MgTHYROID FUNCTIONURINALYSISURIC ACIDBNP
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
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
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 cessationMonitoring of body weight, electrolytes, and
renal functionConsideration of referral for formal disease
management
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
UNM SOLUTION HEART FAILURE CONSULT SERVICE 24-7
PAGER: 951-0049 HEART FAILURE CLINIC REFERRAL BEFORE
DISCHARGECALL THE CLINIC 24-7 AT 925-6002 AND LEAVE
MESSAGE NAME, TELEPHONE NUMBER, DATE OF DISCHARGE, MRN
72 HOUR TELEPHONE CALL DOCUMENTEDCLINIC VISIT WITHIN 7 CALENDAR DAYS OF
DISCHARGE HEART FAILURE POWER PLAN
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.
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
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
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
TEXTBOOK DISCHARGE: PATIENT/FAMILY EDUCATION Sodium restriction Fluid limitation if indicated Medication schedule Medication effects Exercise prescription
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