Heart Failure management
in long term care
PMDA 19th Annual Symposium
October 21, 2011
Leon S. Kraybill, MD, CMD
Geriatric Specialists, Lancaster General Hospital
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
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Dr. Kraybill has no conflicts of interest or financial
benefit from this presentation
Digital copy of powerpoint slides and handouts
available at: www.pamda.org/2011-handouts/
Email contact: leonkraybill@gmail.com
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Who gets heart failure?
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Primarily older people; female > male
Over age 65 = 10/100
80% of patients hospitalized for HF are > 65 yo
Multiple comorbidities (ie diabetes increases the
risk of HF by 80%)
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Why discuss heart failure?
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HF is the most common Medicare DRG
diagnosis, and consumes more Medicare dollars
than any other diagnosis
Common cause of death in LTC population
2005: 37% of all Medicare spending, and ~ 50%
of inpatient costs.
2008: Estimated US direct and indirect cost of
heart failure = $34.8 billion.
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
So……Heart failure is….
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Common
Expensive
Can we alter the course, management, outcome,
and cost?
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
LTC disease management
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Interventions to reduce hospitalizations from
nursing homes: Interact II, JAGS April 2011
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17-24% reduction in hospital admissions
Interact II website: a variety of tools and care
pathways to help reduce acute care transfers;
including dehydration, fever, mental status
changes, heart failure, lower respiratory infection,
and UTI --- http://interact2.net/tools.html
See attached Early Warning tool, and SBAR
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Lecture goals
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Efficient, compassionate, and cost effective
management of heart failure in LTC –
honoring the wishes of the people who entrust
their health decisions to us
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…..And not push ourselves over the edge in the process
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Heart failure definition (HF)
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A complex clinical syndrome that results from
any structural or functional disorder that impairs
the ability of the ventricles to fill with or eject
blood at a rate commensurate with the body's
needs
Congestive heart failure (CHF) = HF + clinical
signs and symptoms of volume overload
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
HF etiology
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The simple explanation - a failing heart
The more complex explanation - a consequence
of cardiac muscle remodeling, mediated by
neurohormonal responses (rennin-angiotensinaldosterone system)
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
HF is a clinical diagnosis
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A clinical constellation of symptoms and signs
Labs can only confirm clinical suspicions, or
demonstrate consequences
Older patients may not present typically
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Start and end with treatment goals
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Prolongation of life
Improvement of quality of life
Prevention of exacerbations
Prevention of hospital readmissions (and
associated cost)
Timely provision of palliative care
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Identify
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History of heart failure
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Look at the records! EKG, ECHO, chest x-ray,
consults.
Suspect if: hypertension, diabetes, CAD,
ischemic heart disease, cardiomyopathy, valvular
heart disease.
Do not be surprised by a diagnosis that is already
documented on the record.
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Symptomatic heart failure: Signs
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Ascites
Hypoalbuminemia
Increased jugular venous pressure
Positive hepatojugular reflux
Laterally displaced apical impulse
Peripheral edema not due to venous insufficiency
Rales on lung exam
Tachycardia
Third heart sound (S3)
Weight gain
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Symptomatic heart failure: Symptoms
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Abdominal symptoms (nausea, abdominal pain or distention)
Acute confusional state, delirium
Anorexia
Decline in functional status
Decreased exercise tolerance
Decreased food intake
Dyspnea at rest
Dyspnea on exertion
Fatigue
Orthopnea
Paroxysmal nocturnal dyspnea
Unexplained cough, especially at night
Weakness
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
What your staff may actually report to you:
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New or increasing lower extremity swelling
Clothing (shoes, pants) appears tight compared
previous week
Resident appears lethargic or mentally inert
Resident is less active
Resident has more difficulty breathing with or
without exertion
Unexplained cough
Unexplained weight gain
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Accurate weights are key!
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Same time of day
Same state of dress
Same scale (and staff members that know how to
use the scale)
How often?
What is your facility P&P?
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Identify and manage risk factors
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Anemia
Dysrhythmia (atrial fibrillation)
Hypertension
Chronic lung disease
CAD
Diabetes
Excessive alcohol
Noncardiac fluid volume overload
Sleep disordered breathing
Thyroid disease
Valvular heart disease
Medications – NSAIDs, metformin, glitazones (Actos), calcium channel
blockers
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
New York Heart Association HF classification
Class I (mild)
No limitation of physical activity. Ordinary physical
activity does not cause undue fatigue, palpitation, or
dyspnea (shortness of breath)
Class II (mild)
Slight limitation of physical activity. Comfortable at rest,
but ordinary physical activity results in fatigue,
palpitation, or dyspnea
Class III (moderate) Marked limitation of physical activity. Comfortable at
rest, but less than ordinary activity causes fatigue,
palpitation, or dyspnea
Class IV (severe)
Unable to carry out any physical activity without
discomfort. Symptoms of cardiac insufficiency at rest. If
any physical activity is undertaken, discomfort is
increased
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Differentiating types of HF
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HF with reduced left ventricular ejection fraction (systolic heart failure)
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Reduced myocardial contractility (CAD, cardiomyopathy)
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Generally worse prognosis
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EF cutoff – usually 35-45%
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More dyspnea, cough, wheezing, fatigue, hypotension, confusion, delirium
HF with preserved left ventricular ejection fraction (diastolic heart failure)
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Decreased left ventricular filling pressures (decreased rate of relaxation, rapid
heart rate, ventricular stiffness)
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Primary cause = hypertension
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More than 50% of HF patients > 70 yo
Right-sided heart failure
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Right ventricle changes
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Cause: pulmonary disease, left sided heart failure (most residents with advanced
HF have both L and R-sided HF
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More leg edema, nausea, vomiting, abd ominal sx, dependent edema
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Decide regarding evaluation
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Is there another terminal/end-stage condition?
Will the evaluation change the management?
(would the patient decline treatment?)
Will the burden of evaluation be greater than the
benefit of treatment?
Are there likely to be reasonable treatments?
Document, document, document
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Evaluation tools
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CXR
ECHO
Pulse oximetry
Labs: CBC, CMP (lytes, calcium, renal, liver),
magnesium, TSH, ?lipids
To BNP or not to BNP?
EKG – angina, dysrhythmia, hx of ischemia
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Reassess the individual’s goals and realistic options
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What does the resident want? QOL/comfort vs
prolongation of life?
Do the resident/family understand the availability
of palliative care in LTC?
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Possible reasons for transfer to hospital
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Acutely symptomatic and decompensating
Unstable cardiac ischemia
Limited reasonable treatment options in LTC
Resident wants full and aggressive intervention
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Dietary restrictions
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Restrictions should be consistent with the resident’s
prognosis and quality of life
Salt restriction (< 2 grams/day rarely feasible) - may be
helpful in moderate to severe heart failure
Fluid restriction - hyponatremia, unstable fluid balance
despite diuretics
 Maybe 1.5-2 L daily fluid restriction in advanced
heart failure (grades III & IV) – evidence grade B1
Nutritional supplements – generally not indicated
 CoQ10 - not recommended as a therapy for heart
failure by the ACC/AHA
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Heart failure medications
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Goal is euvolemia
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Most patients will need diuretics
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Low EF HF: Diuretics
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Thiazide diuretics usually ineffective once CrCl < 30 (? stop @ 50)
Loop diuretics improve symptoms and quality of life but do not
prolong life
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Few meaningful clinical differences between different meds
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Furosemide 20 – 40 mg daily, double until desired diuresis
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Bumetanide and torsemide may be more bioavailable with an
edematous bowel
Metolazone 2.5-5 mg prior to furosemide may improve diuresis (but
cause more ↓K and ↓Mg
When volume has stabilized, seek lowest possible diuretic dose
Follow renal function and electrolytes
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Diuretics: Hypomagnesemia
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Thiazides and loop diuretics increase Mg loss
↓Mg is often present with ↓K and ↓Na
Serum Mg levels are unreliable measures of total
body Mg
Magnesium gluconate is more soluble, and causes
less diarrhea
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Low EF HF : Angiotensin-converting enzyme inhibitors (ACEIs)
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Improve quality of life, ↓mortality by 23%, and
↓ risk of hospitalization by 35%
First-line agent in HF with EF < 35%
Caution: hypotension (?tolerate SBP of 80-90),
hyperkalemia, worsening renal function
Accept 20-30% rise in creatinine
Angiotensin receptor blocker (ARB) if intolerant
to ACEI
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Low EF HF: Beta blockers
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Good evidence for ↓symptoms and ↑sense of well-being,
↓risk of death (↓30-65%), and ↓hospitalization
Indicated for all patients with stable HF due to ↓EF, if no
contraindication
Should be used in combination with diuretics if fluid
retention is present
Proven benefit: carvedilol, metoprolol succinate,
bisoprolol (metoprolol has less hypotension than
carvedilol)
Titrate slowly to target dose (see chart) by doubling dose
every 2-4 weeks
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Low EF HF: Beta blockers
Initial Dose
Target Dose
Bisoprolol
12.5 mg daily
10 mg daily
Carvedilol immed release
3.125 mg BID
25 mg BID
Carvedilol ext. release
10 mg daily
40-80 mg daily
Metoprolol ext. release
12.5 mg daily
200 mg daily
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Low EF HF: Digoxin
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Less widely used
No mortality benefit but some improvement in
symptoms and hospitalization
Dosage – rarely > 0.125 mg daily
Serum levels – usually < 1.0
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Low EF HF: Aldosterone antagonists (spironolactone)
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May help to counter adverse effects of
aldosterone in NYHA Class III & IV
High risk for ↑K and ↑creatinine (esp if CKD, or
on ACEI)
Not good clinical data on age > 75-80 yo
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Low EF HF: Isosorbide dinitrate + hydralazine
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For African-American residents with HF –
↓ mortality, ↓hospitalizations, ↑ QOL
Adjunctive therapy if symptomatic despite
standard therapies
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Low EF HF: Other treatments
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Calcium channel blockers
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Nifedipine, diltiazem, verapamil-- ↑HF and mortality
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Amlodipine & felodipine okay for BP control - no HF benefit
Implantable cardioverter defibrillators
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Risk of sudden death if EF < 35
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Do not treat symptoms, only prolong life
Cardiac resynchronization therapy
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Consider if symptomatic HF despite optimal medical
management, EF< 35, QRS > 120 ms, Class III or IV, AND
prognosis for good functional status > 1 year
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Low EF HF treatment summary
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ACEIs - most patients
Beta blockers – most patients
Diuretics – most patients
Aldosterone antagonists – selected patients
Digoxin – selected patients
Isosorbide dinitrate/hydralazine - selected
African-American patients
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
HF with preserved EF (diastolic HF)
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Evidence based therapy is less clear
Goals – decrease fluid overload, and treat elevated filling
pressures
Control hypertension – perhaps most important
Diuretics – if fluid overload
ACEI/ARB – less clear benefit (unless concomitant
diabetes) – studies lean towards benefit
Beta Blockers – sparse data
Digoxin – if symptomatic despite other meds
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
HF with preserved EF: Summary
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Control of systolic and diastolic hypertension
Control of ventricular rate in patients with AF
Control of pulmonary congestion and
peripheral edema with diuretics
If ischemia – consider coronary
revascularization (if consistent with goals)
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Peripheral edema management
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Elevation of extremities
Support hose
Elastic tubular bandages
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
End of life care in HF
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Sudden death – up to 60% of HF patients, but can’t predict
Gradual deterioration with increasingly frequent acute episodes
Explain and offer palliative measures sooner rather than later
Discuss the goals of care, code status, intubation, hospitalization
Listen and give opportunity for questions
Deactivate the defibrillator
Dyspnea – diuretics, oxygen, thoracentesis, opiods
Hallucinations, delirium – atypical antipsychotics
Myoclonus, seizures - lorazepam
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
HF monitoring & assessment protocol & tools
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Early Warning Tool (general)
SBAR – a general preparation tool for the assessing nurse
to report any clinical change to provider
“BELLS WARN” – HF screening tool for direct
caregivers
Heart failure in long-term care monitoring protocol
Heart failure graphic flow sheet
LTC Heart Failure assessment tool
Digital versions at www.pamda.org/2011-handouts/
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Developing clinical assessment tools and treatment protocols
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PMDA has interest in developing further
If interested, contact
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Leon Kraybill – leonkraybill@gmail.com
Tom Lawrence - tomlawrence@comcast.net
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
Heart failure in LTC
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Common
Expensive in time and money
Proactive identification and management will help to
prevent subsequent complications and resident distress
The resident and the family must be engaged early and
throughout the process to identify their goals and wishes
This is a collaborative effort – none can do it alone, all
must be involved
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org
References
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Heart Failure in the Long-Term Care Setting, AMDA Clinical practice guideline, 2010,
www.amda.com/tools/guidelines.cfm
Interact2 - from Florida Atlantic University – dedicated to reducing acute care transfers, website contains
a variety of tools and resources: http://interact2.net/tools.html
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Interventions to reduce hospitalizations from nursing homes: Interact II, JAGS April 2011;
http://onlinelibrary.wiley.com/doi/10.1111/jgs.2011.59.issue-4/issuetoc
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Care path: symptoms of congestive heart failure: http://interact2.net/tools.html
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SBAR: Situation, Background, Assessment, Request- a conceptual tool for supervising nursing
staff to assess and report a LTC clinical change: http://interact2.net/tools.html
Assessing Heart Failure in Long Term Care Facilities; Harrington, C. University of Iowa Gerontological
Nursing Interventions Research Center, Research Translation and Dissemination Core; 2006 Oct 2006 –
an EBM practice guideline, 38 page PDF with a variety of tools: http://www.publichealth.uiowa.edu/icmha/outreach/documents/GerontologicalNursingInterventionsResearchCenter.pdf
DEFEAT heart failure: assessment and management of heart failure in nursing homes made easy. Ahmed
A, Jones L, Hays CI, J Am Med Dir Assoc. 2008 Jul;9(6):383-9. Epub 2008 Jun 3,
http://www.ncbi.nlm.nih.gov/pubmed/18585640
Clinical manifestations, diagnostic assessment, and etiology of heart failure in older adults, Ahmed A,
Clin Geriatr Med. 2007 Feb;23(1):11-30, http://www.ncbi.nlm.nih.gov/pubmed/17126753
PMDA: Pennsylvania's Association for Long Term Care Medicine
www.pamda.org