HEART FAILURE Family Centered Approach IMANA/IMC December 28-29, 2014
Walid Hassan, MD, FACC, FAHA, FCCP, FACP Professor of Medicine International Medical Center Jeddah, Saudi Arabia
بسم ا الرحمن الرحيم الحمد لله رب العالمين ر ّ ب اشرح لي صدري و يّسر لي أمري و احلل عقدة من لساني يفقهوا قولي
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Walid Hassan, MD NO DISCLOSURE
4
Key points Introduction Heart Failure Internationally and in Saudi Arabia. Evidence supporting HF Pathophysiology and Management.
Role of the HF Family. Future plans of the HF management at IMC-JEDDAH
All Heart Talks
The heart is most frequent organ mentioned in:
The Glorious Qura’n Hadith “Prophet sayings” Poetry and literature by all languages Relation to emotions
IN THE HISTORY OF MEDICINE IBN EL NAFIS (1210-1288 A.D.)
Referred to as Avicenna the Second.
Abu Al Hassan Ala Addin Abu Al Hasm
He said that heart has only two ventricles and explained the coronary circulation. He discovered pulmonary circulation well before Harvey.
IN THE HISTORY OF MEDICINE William Harvey in 1628
The heart is a Unique Organ !
عضو فريد فى خلقه و تركيبه النسيجى وآدآئه الوظيفى
Unique in Resistance to Ischemia, Diseases and Tumors
Preconditioning
Stunning
Hibernation
Rarity of Oncogenesis
القلب لمقاومة المراض و الورام
Cardiac Functions
Blood
Hormones
Electrical Activity
وظائف القلب
?
Emotions
Neurological Activity
Electro Magnetic
HEART FAILURE EFFECT ON ORGANS
Heart Failure is a complex clinical syndrome that can result from any structural or functional cardiac or noncardiac disorder that impairs the ability of the heart to respond to physiological demands for increased cardiac output. (European Society of Cardiology 2012)
HF Epidemiology ď‚— Prevalence: 22 millions HF patients in the world.
ď‚— Incidence: 2 millions new HF cases diagnosed / year.
WHO, 2005 AHA, Heart & Stroke statistical update 2006
Mortality of HF 700000 600000 500000 400000
Incidence Mortality
300000 200000 100000 0
USA
EUROPE
WHO, 2005
Saudi Arabia 64% of the Acute HF patients enrolled in the registry have Chronic HF and are 10 years younger than other patients enrolled in international registries.
HEARTS Registry European Journal of Heart Failure (2014)
IMC-Jeddah
2012 520 patients with BNP >400 pg/ml
2014
Surviving Patients: 360 Dead Patients: 160
The Prevalence, Clinical Characteristics, and Prognosis of 519 Elderly Patients with Heart Failure and Preserved Systolic Function.
A Clinical Study with a 5 years Follow-up period F.El Shaer , W.Hassan, et al. KFSH&RC Saudi Arabia. ESC, WCC 2006 CHFJ 2009
70%
61%
60% 50%
39%
40%
P R
30% 20% 10% 0%
Prevalence of DHF
Risk factors for HF in all patients 90.00%
81.30%
80.00% 70.00% 60.00% 50.00% 40.00%
HTN
46.10%
DM 34.50%
Hyperlipid
33.00%
IHD Smoker
30.00% 20.00% 5.40%
10.00% 0.00% Patients equal to or >65 yrs old
Cause of death?
Mainly Multi-organ failure & Septic shock
The process of failing of the human heart: review of the current knowledge of the mechanisms of heart failure.
Epidemiology of Heart Failure Clinical criteria – Prevalence ∼2 % Males ≅ Females; in 65+ Prevalence 7% 50% of LVSD is asymptomatic HFREF≅HFPEF
Maggioni et all. Eur J Heart Fail 2013;15:808-17
Pathophysiology of HF
Decreased cardiac output results in
Activation of Neurohormonal Mechanism
End Diastolic Pressure (LVEDP), LVH, LVD Pulmonary Capillary Wedge Pressure (PCWP) The development of pulmonary edema Renin-Angiotensin-Aldosterone- System (RAAS) Sympathetic Nervous System (SNS) Other circulating and paracrine effects
Counter-regulatory systems
Natriuretic Peptide System (BNP, pro BNP)
1
• Hemodynamic
2
• Neuro hormonal
3
• Autonomic
4
• Microenvironmental
Models of HF
Cardiac Remodeling Na and H2O retention, ď Š Performance Myocyte hypertrophy, death, fibrosis Dilated and spherical ventricle, thinned
Hemodynamic Model and targets Factor
Mechanism
Therapeutic Strategy
1. Preload (work or stress the heart faces at the end of diastole)
increased blood volume and -salt restriction increased venous tone---diuretic therapy >atrial filling pressure -venodilator drugs
2. Afterload (resistance against which the heart must pump)
increased sympathetic stimulation & activation of renin-angiotensin system ---> vascular resistance ---> increased BP
- arteriolar vasodilators NTG, ACEI, Hydralazine
3. Contractility
decreased myocardial contractility ---> decreased CO
-inotropic drugs (cardiac glycosides)
4. Heart Rate
decreased contractility and decreased stroke volume ---> increased HR (via activation of b adrenoceptors)
Heart rate lowering (BB, Dig)
V-HEFT I Cumulative Mortality from the Time of Randomization in the Three Treatment Groups
Cumulative Mortality Rate
0.6 Placebo Prazosin Hyd-Iso
0.5 0.4 0.3 0.2 0.1 0 0
6
12
N Engl J Med 1986;314:1547-52
18 24 Interval (months)
30
36
42
DIG Trial ď Ž
6800 chronic HFREF patients were randomized to digoxin and placebo
New Engl J Med 1997;336:525-33
Pathological Effects of RAAS
RAAS Axis and its Blockade
RAAS Blockade AGTNG • Renin • Aliskiren
AT-I
AT-II
• ACE • ACE-i
Bradykinin
• AT1R • ARB
AT2 AT4
Vasoprotection
ALDO • Renal • MRA
as
Sympathetic Nervous System CO activates baroreceptors - SNS Effects of Circulating Epinephrine & NE Increased Heart Rate Increased Blood Pressure Increased myocardial oxygen demand Toxic effects on myocardium – cell death Down regulation of β1 receptors in heart Decrease in parasympathetic activity
Effect of Norepinephrine in HF
Natriuretic Peptides in HF
HF Joint Neurohormonal Model
RAAS Sympathetic System
BNP
Medical Therapy for HF: Magnitude of Benefit Demonstrated in RCTs (Standardized to 36 mo)
RR Reduction in HF Hospitalizations
17%
26
31%
34%
9
41%
MRA
30%
6
35%
Hydralazine/nitrate
43%
7
33%
GDMT ACE inhibitor or ARB Beta blocker
RR Reduction in Mortality
NNT for Mortality Reduction
+ CRT
Levy W C et al. Circulation. 2006;113:1424-1433
Multidisciplinary Programs ď Ž
1.
2.
3.
Identified 3 crucial elements to success of multidisciplinary programs: Specially trained nurses/MDs should be key components of any intervention Importance of education provision to patients and family members. Provision of available access to HF clinicians when needed. McAlister and colleagues (2004)
Primary health care centers
Information technology
ECG & Echo techs.
Heart Failure Nurse Cardiologists
Patients and Caregivers
Family
Laboratory
Cardiac Rehabilitatio n
Pharmacists
Dieticians
Role of the Heart Failure Nurse ď‚— Systematic review of 29 RCTs of HF multidisciplinary management programs: 43% REDUCTION in HF admissions
McAlister and colleagues (2004)
Primary health care centers
Information technology
ECG & Echo techs.
Heart Failure Nurse Cardiologists
Patients and Caregivers
Family
Laboratory
Cardiac Rehabilitatio n
Pharmacists
Dieticians
Engaging family
In-patient assessment Assessment of learning needs
• Identify cognitive level • Determine the acuteness of their disease
Assessment of learning style
• To match a teaching strategy • Identify patient’s literacy
Family interview
• To fill missing information • Assess the home situation • Assess family member support and participation
Multidisciplinary Program Family
Knowledge
Empowerment
Confidence
Selfmanageme nt
Heart Failure Nurse Family Assessment of knowledge about Heart Failure, and readiness to learn Selfmanagement education
Education Discharge planning
Education Phone follow up within 3-7 days from discharge
Education Heart Failure clinic
Encourage diet and medication compliance, promote exercise, regular symptoms monitoring, and daily weight.
Conclusions Patients seeking ED care for decompensated HF had inaccurate HF beliefs and poor self-care adherence. Lack of association between HF beliefs and self care (and trend of an inverse relationship) reflects a need for pre-discharge HF education, including an explanation of what HF means and how it can be better controlled through self-care behaviors Journal of Emergency Medicine, 2014
Self-Family Management Education
Medication compliance
Daily weighing
Salt and fluid restriction
Activity and exercise
Smoking cessation
Signs and symptoms of Heart Failure
Patient will assume responsibility Maximizes individual’s independence
choose healthier life style
Reduces disease related complication
Increase satisfaction
Promote patient active involvement
Ensures continuity of care Improve medication adherence
Goals of the Heart Failure TT Improve exercise tolerance
Improve Quality
Symptom management
of Life
Reduce ER visits and readmission rates
Reduce mortality
Empowerment Reduce health care cost
Prevent progression of disease
Schematic depiction of comprehensive heart failure care
Goodlin, S. J. J.A.C.C. 2009;54:386-396
Copyright Š2009
Heart failure High
Function
Terminal Phase
Low
Begin to use hospital more often, self-care more difficult Time ~ 2-5 years. Death usually seems “sudden�
Modified from Lunney JR et al. JAMA 2003: 289: 2387.
Death
Transitions in life-limiting illness
Early
Transitions
Disease containment
Decompensation
Maintaining function
Experiencing life limiting illness
Transitions
Decline and terminal Dependency and symptoms increase Transitions
Time of Diagnosis
Time McGregor and Porterfield 2009
Transitions
Death and bereavement
Transitions
Assess: Patient and their Illness experience NEEDS and PREFERENCES
DIAGNOSIS SPREAD
DISEASE
OTHER PROGNOSTIC FACTORS
BENEFITS
TREATMENT BURDENS
PATIENT CULTURE VALUES, BELIEFS EXPERIENCE BACKGROUND (SUFFERING)
GOALS of CARE
Assess: Goals of care
Goals of care change over time and may include:
Maintaining and improving function.
Staying in control.
Relief of suffering.
Prolonging life for as long as possible or until a specific event (time limited trials of care).
Quality of life/ living well.
Assess: Goals of care (continued)
Pain and symptom management.
Strengthening relationships.
Preferences for location of care.
1.
Psychosocial care for person.
2.
Psychosocial care for family.
3.
Spiritual care.
.
Preferences for location of death.
.
Life closure/ dying well.
Communication: Vital for EOL care Patient experiences
Being seen.
Being heard.
Being met.
Family and caregivers’ experience
Support in transitions.
Establish partnership with clear goals of care and a plan for the future.
Who supports HF End of Life care?
Primary care physicians and HF Specialists Home and Community Care palliative teams Patients and families/caregivers Linking with...
Acute care hospitals and tertiary ambulatory services End of Life Care programs and services Local Hospice Societies and other community services
Produces patient- family centred interdisciplinary practice
Ambiguous dying
“There will not be a distinct terminal phase. The week we die will start out like any other and some unpredictable calamity will occur. Amongst those of us with advanced heart failure, we will have had a 50-50 chance to live for six months on the day before we died� Joanne Lynn: Sick to Death and Not Going to Take it Anymore (2004)
Integrating the palliative approach
Improved survival
Needs of the family/caregivers
CONCLUSIONS
Integrated care: Shifting the focus in HF Meeting the majority of people’s health care needs by providing high quality, accessible, community based health care and support services
Built around attachment to a family physician and an
integrated health care team (HF nurse). Stronger voice for the patient, family and local community in the design and delivery of healthcare services. More focus on proactive management of chronic HF Pt to remain independent.
IMC Team players
Patient and Family Family physician Community pharmacist Home Health / Community Care –
Nurses/rehab/home support
Nurse practitioners, community RT Disease specific specialists / services Hospice palliative care consult teams
Walid Hassan, MD NO DISCLOSURE
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ان هو ال ذكر" للعالمين ..و لتعلمن بعد حين "نبأه Thanks