1. 2012 CCU Competency Heart Failure Module 1: Medical Management Issues

2. Heart failure is our disease specific focus area for 2012 competency. • There will be 2 modules, each with a specific focus. • Medical Management Issues • Nursing Driven Care • Quality Outcome Assessment Heart Failure Focus for 2012

3. The purpose of this module is to review key medical management areas where there is opportunity for improvement. • As part of the interdisciplinary team a thorough understanding of medical treatment goals will allow you to optimally contribute to the treatment plan and advocate for your patients with heart failure. Purpose

4. Stages of Heart Failure ACC / AHA

5. Classification of Heart Failure: New York Heart Association

6. Systolic Dysfunction (Reduced EF) Diastolic Dysfunction (Preserved EF)

7. Although the commonly used terms are systolic and diastolic heart failure, the current recommended terms are heart failure with preserved left ventricular function and heart failure with reduced left ventricular function. • The reason for the clarification is because most patients with “systolic heart failure” also have some abnormalities during diastole, and patients with “diastolic heart failure”, although their overall EF is normal do not have completely normal systolic function. Heart failure with preserved or reduced left ventricular function.

8. There are evidence based guidelines for the management of patients with heart failure with reduced LV function. • ACE-I (or ARB) • Beta blocker • Aldosterone antagonists (NYHA Class III or IV HF) • Hydralazine / Nitrate combination (for African Americans - in addition to standard therapy) • Cardiac resynchronization therapy if BBB (especially LBBB) and EF < 35% • Referral for ICD therapy if EF < 35% Evidence Based Guidelines for Heart Failure with Reduced LV Function

9. There are only three beta-blockers that are recommended for use in patients with reduced LVEF (<40%) • These are considered evidence based beta blockers • Carvedilol (Coreg) • Metoprolol succinate (long acting metoprolol) (ToprolXL) • Bisprolol (Zebeta) • This is the reason you may see patient’s switched from Lopressor, which is metoprolol tartrate (short acting metoprolol) Quality Indicator: In 2011 evidence based beta blockers were only prescribed 84.7% of the time. More on Beta-Blockers

10. In HF patients with preserved LVEF (diastolic dysfunction) the focus is on managing the patient’s comorbid conditions. This means rate control in atrial fibrillation, treatment of hypertension, and diagnosis and treatment of obstructive sleep apnea. Note: There are no clear evidence based guidelines for patients with preserved LVEF.

11. Our quality data indicates that only 60-65% of potentially eligible patients have documentation regarding counseling or referral for cardiac resynchronization therapy and / or ICD. • When caring for a heart failure patient with an EF < 35% ask / discuss during rounds if this patient is a candidate for CRT and / or ICD therapy. Focus areas to improve outcomes.

12. Cardiac Resynchronization Therapy (CRT) • Treatment modality for heart failure not just pacing • Used in patients with dysynchrony (QRS > 120 msec) • Used in conjunction with optimal drug therapy • In addition to the atrial lead there are two ventricular leads • RV Apex • LV lateral wall • Goal: Force biventricular pacing • Goal: Ventricular Pacing 90% of time or greater • Anticipated Outcomes: • Improve hemodynamics by restoring synchrony of ventricular contraction • Improve quality of life • Decrease mortality and morbidity

13. Implantable Cardiovertor Defibrillator - Indications • Secondary Prevention (Class IA Recommendation) • Symptoms of HF • History of cardiac arrest, VF, or hemodynamically destabilizing VT • Primary Prevention (Class IA Recommendation) • Non-ischemic dilated myopathy or ischemic heart disease > 40 days post-MI or > 90 days post intervention • EF < 35% • NYHA class II or III in optimal medical therapy • Not recommended in Stage D

14. Recognizing Potential Obstructive Sleep Apnea Another Important Opportunity for Improvement

15. Approximately 1 in 5 adults: mild • Approximately 1 in 15 adults: moderate / severe • 15 million Americans • > 85% have not been diagnosed • Adverse consequences may be greater in those < 50 years. • High prevalence of pathological daytime sleepiness in OSA • Almost all with OSA snore but not all snorers have OSA Obstructive Sleep Apnea

16. During Sleep

17. Physiological Impact of Obstruction

18. The prevalence of sleep apnea in heart failure has been reported to be approximately 50%. • This includes both obstructive and central sleep apnea. • In this study of 30,719 Medicare HF patients only 2% were tested for sleep apnea. • Those who were tested, diagnosed and treated had improved survival compared to those who were not. Source: Javaheri, et al. (2011). American Journal of Respiratory Critical Care Medicine, 183, 539-546.

19. The STOP-BANG Screening Tool for Obstructive Sleep Apnea.

20. Our focus is linking knowledge to practice and practice to patient outcomes. For this module we want to increase awareness of our practice patterns in the care of HF patients. • Find one patient in CCU admitted with HF with a reduced LVEF: • Does the patient have a LVEF of < 35% • If yes - does the patient have an ICD? If not – is there a notation regarding contraindication? • Does the patient have a LBBB and a LVEF of < 35% • If yes – does the patient have a CRT device? If not is there a notation regarding contraindication? • What is the patient’s STOP BANG Score? • Is the patient being treated for sleep apnea? • If not has the patient ever had a sleep study? To Complete this Module: Document the answers to the above patient questions in QUIA. Put the date, room number and initials of the patient you assessed.

21. For your Portfolio. Please include any examples of your input into rounding or collaborative discussion where you have identified potential candidates for ICD/CRT or sleep apnea testing. Thank you. Your commitment to excellence makes a difference!