Cardiology

Disease Management Programs: Patient Selection and Outcomes

I. Disease Management Programs: What every physician needs to know.

Optimizing outcomes for patients with heart failure

Disease management (DM) programs provide a systematic approach to optimizing care and outcomes for patients with heart failure (HF), the treatment of which is often complicated by one or more coexisting conditions, polypharmacy, psychosocial factors, health literacy issues, and economic concerns. DM generally uses a multidisciplinary approach to ensure that all of these factors are appropriately addressed.

The principal objectives of DM are to maximize quality of life and self-efficacy and to reduce HF exacerbations, hospital admissions, and mortality. Cardinal features of DM include patient and family education, emphasis on self-care, and close follow-up, especially during and after care transitions (e.g., hospital to home).

II. Diagnostic Confirmation: Are you sure your patient has Heart Failure?

The history, physical examination, chest x-ray, and selected laboratory studies provide the foundation for diagnosing HF. Each of these is discussed briefly below.

A. History Part I: Pattern Recognition:

The classic symptoms of HF include exertional shortness of breath, exercise intolerance due to shortness of breath and/or fatigue, orthopnea, paroxysmal nocturnal dyspnea, and pitting edema of the feet and ankles. Additional symptoms may include abdominal bloating or fullness, diminished appetite, altered bowel function, nocturia, and altered sensorium (e.g., confusion, irritability).

Shortness of breath, exercise intolerance, and fatigue are prominent HF symptoms at all ages, but with increasing age, atypical symptoms, such as anorexia and confusion, become increasingly more common.

B. History Part 2: Prevalence:

The incidence and prevalence of HF increase exponentially with age. The prevalence of HF doubles for each decade after age 50 and approaches 10% among persons 80 years of age or older. The incidence and prevalence of HF are higher in men than in women at all ages; however, because women greatly outnumber men in the older age groups, women account for over 50% of prevalent HF cases.

C. History Part 3: Competing diagnoses that can mimic Heart Failure?

The differential diagnosis of HF includes acute and chronic lung diseases (e.g., pneumonia, COPD, interstitial lung disease), pulmonary hypertension (primary or secondary), acute or chronic pulmonary emboli, obstructive sleep apnea, obesity, and poor physical conditioning. In some cases, diseases of the kidneys and liver can also mimic HF.

D. Physical Examination Findings.

The classic physical findings of heart failure include elevated heart rate and respiratory rate, decreased pulse pressure (i.e., the difference between the systolic and diastolic blood pressure), distended neck veins reflecting elevated jugular venous pressure, moist pulmonary crackles (most commonly at the lung bases), hepatomegaly, abdominojugular reflux, and pitting edema of the feet and/or ankles. In advanced cases, ascites or anasarca may be present.

Cardiac findings, in addition to tachycardia, may include an S3 gallop (reflecting intracardiac volume overload), an S4 gallop (indicative of intracardiac pressure overload), or a combination S3 + S4 gallop (summation gallop). In patients with valvular heart disease, murmurs suggestive of aortic or mitral stenosis or regurgitation or tricuspid regurgitation may be present.

E. What diagnostic tests should be performed?

The diagnostic evaluation often includes a chest x-ray, electrocardiogram, troponins (or other cardiac biomarker proteins to rule out an acute coronary syndrome), B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) level, and routine blood tests (complete blood count and standard chemistries). As discussed in more detail below, imaging studies, especially echocardiography, play a prominent role in the diagnostic evaluation of patients with suspected HF.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

If the history and physical examination suggest a diagnosis of heart failure, a chest x-ray should be obtained to evaluate heart size and assess for the presence and severity of pulmonary congestion.

If the diagnosis of HF is uncertain, a BNP or NT-proBNP level should be obtained. Markedly elevated levels of these hormones strongly suggest active HF, whereas normal levels indicate that HF is much less likely to be the cause of symptoms.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

All patients with newly diagnosed HF or unexplained clinical deterioration should have an evaluation of left ventricular function. In most cases, a transthoracic echocardiogram is indicated for assessment of left ventricular size, wall thickness, and systolic and diastolic function.

In addition, the echocardiogram provides information about the left and right atrium, right ventricular size and function, structure and function of all four valves: the pericardium, the aorta, and pulmonary arteries, and the inferior vena cava. Compared to other imaging modalities, echocardiography has the additional advantages of being noninvasive and less expensive, and it does not expose the patient to either ionizing radiation or iodinated contrast media.

Alternative imaging modalities for assessment of left ventricular function include radionuclide ventriculography, magnetic resonance imaging, computed tomographic angiography (CTA), and, in patients undergoing cardiac catheterization or coronary angiography, left ventricular contrast ventriculography. Each of these techniques may have advantages in specific clinical situations.

For example, magnetic resonance imaging provides superior quantification of left and right ventricular mass and ejection fraction compared with echocardiography, which may be clinically important in patients with cardiomyopathy.

III. Management.

In addition to implementing evidence-based evaluation and treatment of patients with HF, an assessment should be performed to estimate functional status, HF health literacy (i.e., understanding of the disease and its management), capacity to provide self-care, level of emotional and social support, risk for hospital admission or readmission, and prognosis.

From the practical standpoint, the simplest and most widely used method for assessing functional status in HF patients is the New York Heart Association (NYHA) functional class (http://www.abouthf.org/questions_stages.htm; accessed 4-30-2012). The NYHA functional classification has the additional advantage of being used in the HF guidelines to determine indications for certain HF therapies (e.g., ICD, CRT, aldosterone antagonists).

The main disadvantages of the NYHA classification schema are that it is imprecise with few gradations and substantial overlap between categories, and that there is considerable variation between clinicians in assigning class to individual patients, as well as significant discordance between physicians and patients in assessing functional class.

Alternative methods for assessing functional status include the Duke Activity Status Index (DASI; www.cebp.nl/vault_public/filesystem/?ID=1308; accessed 4-30-2012), the Minnesota Living with Heart Failure Questionnaire (http://www.healthmeasurement.org/pub_pdfs/_QUESTIONNAIRE_Minnesota%20Heart%20Failure.pdf; accessed 4-30-2012), and the Kansas City Cardiomyopathy Questionnaire (http://cvoutcomes.org/pages/3214; accessed 4-30-2012). The latter two instruments also provide an assessment of HF-related quality of life.

All of these methods for evaluating functional status provide greater detail and are more reproducible than the NYHA classification, but they are also more time-consuming and are not widely used outside specialized HF programs.

Information on health literacy and care of the HF patient is available through the Heart Failure Society of America (http://www.hfsa.org/pdf/health_literacy.pdf; accessed 10-25-2011). Factors associated with lower health literacy in the U.S. include older age (especially over 75 to 80 years old), lower education level, lower income, chronic illness (especially multiple chronic illnesses), cognitive impairment, poor mental health, and having English as a second language.

As the number of these factors increases, so too does the likelihood that the patient has low health literacy. Alternatively, the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R; http://www.adultmeducation.com/AssessmentTools_1.html; accessed 10-25-2011) is a simple instrument for rapidly assessing patients for low health literacy.

The ability of HF patients to care for themselves (i.e., manage medications, obtain and record daily weights, adhere to dietary recommendations, engage in physical activities) is critically important to optimizing clinical outcomes and quality of life. Self-care capacity is diminished in patients with low functional status (especially NHYA class IV symptoms), low health literacy, and/or impaired cognitive function.

In addition, patients with limitations in the ability to perform basic activities of daily living (ADLs; including feeding, dressing, bathing, toileting, transfers, and continence) or instrumental activities of daily living (IADLs; e.g., using the telephone, housekeeping, shopping, managing finances) are less likely to be able to successfully manage their HF without supervision. (Link for ADLs and IADLs: http://son.uth.tmc.edu/coa/FDGN_1/RESOURCES/ADLandIADL.pdf; accessed 10-25-2011).

For reasons which have not been fully elucidated, patients with chronic HF often have impaired cognitive function, ranging from subtle deficits to manifest dementia. In general, it is appropriate to screen for cognitive impairment in all HF patients age 75 or older, and in younger patients for whom impaired cognition is suspected.

The Mini-Mental Status Examination (MMSE: http://www.oocities.org/travelnair/mini-mentalStateExamination.pdf; accessed 10-25-2011) is the most widely used screening instrument for assessing cognitive impairment. The Short Portable Mental Status Questionnaire (SPMSQ; http://www.npcrc.org/usr_doc/adhoc/psychosocial/SPMSQ.pdf; accessed 10-25-2011) and the Clock Drawing Test (http://www.healthcare.uiowa.edu/igec/tools/cognitive/clockdrawing.pdf; accessed 10-25-2011) are alternative screening methods that have the advantage of brevity.

Although several multidimensional instruments have been developed to assess emotional and social support, Krumholz et al reported that a "no" response to the single question "Can you count on anyone to provide you with emotional support (talking over problems to help you with a difficult decision)?" was a strong independent predictor of nonfatal and fatal cardiac events during the 1-year period following HF hospitalization in 292 patients 65 years of age or older.

Despite major advances in HF therapy over the past 30 years, resulting in significant reductions in incident HF hospitalization rates and improved survival, all-cause 30-day readmission rates have remained stable at about 20%, and up to 50% of patients are readmitted within 6 months. Identification of HF patients at increased risk for hospitalization has been the subject of several studies with somewhat inconsistent findings.

In general, repetitive hospitalization in the recent past (i.e., three or more admissions for any reason in the past 12 months; one or more HF admissions within the past 6 months) is the strongest predictor of HF admission during the subsequent 6 month period.

Other factors associated with high hospitalization rates include persistent NHYA class III-IV symptoms, history of nonadherence to medications and/or low sodium diet, multiple comorbid conditions, cognitive impairment and/or depression, and, as noted above, inadequate social support.

More recently, failure of B-type natriuretic peptide (BNP) or N-terminal pro-BNP levels to decline significantly during hospitalization have also been shown to identify patients at increased risk for early readmission.

Assessment of HF prognosis has also been the subject of several studies, among which the Seattle Heart Failure Model has been validated in several populations and is accessible online (http://depts.washington.edu/shfm/; accessed 10-21-2011). The model incorporates clinical characteristics, laboratory data, medications, and devices to estimate mean duration of survival and 1, 2, and 5 year mortality rates for HF patients 18 to 85 years of age.

A. Immediate management.

The management of acute HF exacerbations is discussed in detail elsewhere in Clinical Decision Support: Cardiology. Briefly, in almost all patients without end-stage renal disease, prompt diuresis should be initiated with a loop diuretic (i.e., furosemide, bumetanide, or torsemide) administered either orally or intravenously depending on symptom severity.

In the recently published Diuretic Optimization Strategies Evaluation (DOSE) trial, continuous intravenous infusion of furosemide was not superior to bolus dosing in facilitating diuresis in patients with acute decompensated HF. Therefore, bolus dosing, which is cheaper and less burdensome, is appropriate in most cases.

In addition to diuresis, comorbid conditions contributing to worsening HF should be identified and treated accordingly. Common cardiovascular factors that may precipitate a HF exacerbation include poorly controlled hypertension, acute coronary ischemia, and atrial fibrillation.

Noncardiac precipitants of HF decompensation include infections (especially pneumonia), acute kidney injury, anemia, thyroid disorders, major surgery, and various medications (e.g., nonsteroidal antiinflammatory drugs, prednisone, calcium channel blockers, and antiarrhythmia drugs).

Behavioral factors, especially nonadherence to prescribed medications and dietary sodium restrictions as well as excess fluid intake (e.g., drinking 6 to 10 glasses of water every day, as often promulgated in the lay press), are among the most common causes of HF exacerbations.Therefore, all patients with a HF exacerbation should be questioned about recent adherence to medications, recent dietary habits (specifically with respect to high sodium foods, such as canned soups and vegetables and "fast foods"), and recent fluid intake.

In patients who acknowledge nonadherence to medications, the reasons forthis behavior should be explored (e.g., cost, side effects, uncertaintyabout rationale or benefits, polypharmacy).

B. Physical Examination Tips to Guide Management.

Physical findings indicative of a favorable response to therapy include significant weight loss (at least 1 to 2 lb/day), reductions in heart rate and respiratory rate, decrease in jugular venous pressure and abdominojugular reflux, resolution of pulmonary rales, and reduction in the amount of dependent edema and ascitic fluid.

In patients with an S3 gallop, there may be a reduction in intensity or resolution of the gallop rhythm with slowing of the heart rate and effective treatment of the volume overload state.

Blood pressure should also be monitored during treatment, and excessive reduction in blood pressure should be avoided to reduce the risk of worsening renal function, especially in patients with preexisting renal insufficiency [i.e. estimated glomerular filtration rate (GFR) <60 cc/min/1.73 m2].

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

The basic metabolic profile (BMP) should be monitored to assess electrolytes and renal function. Potassium and magnesium should be replaced as needed to maintain levels in the normal range.

Significant increases in creatinine (≥ 0.5 mg/dl) and/or blood urea nitrogen (BUN; ≥10 mg/dl) suggest overdiuresis, excessive reduction of blood pressure, adverse effects of medications (e.g., ACE inhibitors), contrast nephropathy (in patients who have received intravenous contrast), or a combination of these factors.

In most cases, diuretic dosages should be reduced and further titration of renin-angiotensin system inhibitors should be avoided until renal function has stabilized.

A repeat chest x-ray is not usually needed in patients with clinical improvement based on symptoms and physical findings. The value of routine monitoring of natriuretic peptides (i.e., BNP and NT-proBNP) in patients with acute decompensated HF is undefined and the subject of ongoing investigation.

Data indicate that patients with persistently elevated BNP or NT-proBNP levels are at increased risk for adverse outcomes, including HF readmissions. Conversely, readmission rates are lower among patients with 50% or greater reductions in natriuretic peptide levels prior to hospital discharge.

However, it is unclear if changes in BNP and NT-proBNP are simply risk markers or if they are useful therapeutic targets. At present, this author does not routinely follow natriuretic peptide levels in either in-patients or out-patients with HF.

D. Long-term management.

Optimal long-term management of HF involves a combination of close medical follow-up and day-to-day self-management behaviors by patients and caregivers.

Disease management (more properly termed patient management) provides a framework for achieving desirable patient-centered outcomes using a multidisciplinary team approach that addresses all aspects of care.

Medical management of HF should be in accordance with established guidelines, as discussed in detail elsewhere in Clinical Decision Support: Cardiology. This section focuses specifically on the role of DM in the long-term treatment of patients with HF, and addresses several frequently asked questions (FAQs).

1. Which patients are candidates for a HF DM program?

In my view, any patient who is at increased risk for adverse outcomes if left to their own devices is a suitable candidate for DM. This includes most older patients with a new diagnosis of HF, who are likely to be given multiple new prescriptions and a long list of instructions about diet and other lifestyle changes that they don't really understand.

They basically need some coaching to get them through the transition period; otherwise they're likely to be "noncompliant" (despite best intentions) and wind up back in the hospital with an HF exacerbation in short order. Patients with multiple coexisting conditions are also at increased risk, especially if they are taking five or more drugs in addition to their HF medications.

Another group is those who have a track record of "revolving door" admissions, which I would define as two or more admissions for HF or three or more admissions for any reason in the most recent 12-month period. Patients who live alone with poor social support are also at increased risk, as well as those with depression or any degree of cognitive impairment.

Virtually all patients age 80 or older fall into one or more of these categories, so I consider anyone in this age group to be a candidate for DM. Finally, any patient with persistent advanced HF symptoms (New York Heart class III or IV) despite appropriate therapy will likely benefit from the support provided by an HF DM program.

2. What does DM entail?

In the United States, most HFDM programs are coordinated by a registered nurse or nurse practitioner with HF expertise in collaboration with one or more cardiologists or HF specialists. Other members of the HF DM multidisciplinary team may include a pharmacist, social worker, dietitian, home health nurse, and/or physical or exercise therapist. Standard components of an effective HFDM program include:

  • Individualized education and counseling

  • Promotion of self-care, including weight monitoring and self-adjustment of diuretic dosages (if appropriate)

  • Emphasis on behavioral strategies to foster adherence to treatment recommendations (e.g., medication aids, such as pill boxes)

  • Optimization of medical therapy, including a structured plan for titration of beta-blockers, renin-angiotensin system inhibitors, and other medications

  • Proactive management of signs and symptoms of worsening volume overload (e.g., adjustment of diuretic dosages)

  • Assistance with social and financial concerns (e.g., stress management, acquisition of medications)

  • Vigilant follow-up, particularly during periods of transition (e.g., hospital to home)

  • Home health visits on an individualized basis

  • 24-hour access to providers via telephone

3. What are the most important elements of DM?

Since DM programs typically comprise multiple components delivered by multiple care providers, it is difficult to "tease out" whether there are specific elements that have the greatest impact or if it is really the "whole package" that leads to improved outcomes. However, in my opinion there are three factors that are most critical to success.

The first and most important is "the human element" (i.e., conveying to the patient [and family)] through direct face-to-face interactions that someone cares, understands their issues and concerns, and is available to help whenever needed.

This knowledge helps empower the patient and builds confidence that this new, mysterious, and frightening condition called HF can be kept under reasonable control. This in turn fosters a positive attitude and motivates the patient to adhere to prescribed medications and other behavioral recommendations.

The second critical element is ensuring effective care transitions, especially from hospital back to the home environment. A common scenario is that an HF patient is discharged from the hospital with a handful of new prescriptions and a bewildering list of instructions about diet, fluid intake, daily weights, and exercise.

In the absence of some process for ensuring care continuity and a smooth transition from hospital to home, it is likely that, despite best intentions, some aspects of care will not be appropriately adopted. It is therefore critical that patients at moderate to high risk for early readmission be contacted at home within 48 hours of discharge, either by a home health nurse visit or by telephone.

The purpose of this contact is to ensure that the patient has acquired any newly prescribed medications, discontinued any previously prescribed medications that are no longer appropriate, understands recommended dietary and fluid restrictions as well as procedures for monitoring and recording daily weights, recognizes symptoms and signs of worsening HF, and knows how to contact the HF DM team in the event that there is clinical deterioration or if any other questions or issues arise.

The third key element is maintaining ongoing communication through a combination of telephone calls, home visits (if appropriate), and office visits (including HF nurse, primary care physician, cardiologist, and/or HF specialist). The frequency of these contacts should be individualized based on patient needs and HF severity, but there should be some interaction at least weekly for the first 30 days following hospital discharge in moderate to high risk patients.

At a minimum, each contact should assess symptom status, weight changes (if monitored), and adherence to medications and dietary sodium restrictions. Patients should also be asked about perceived medication side effects and if they have any questions about their disease or its management.

4. Who pays for DM?

At the present time, there is no specific CPT code for HF DM. However, as part of legislation incorporated into the Affordable Care Act (ACA), hospitals now have substantial financial incentives to reduce readmission rates following hospitalizations for HF, myocardial infarction, and pneumonia. Therefore, many hospitals have already implemented HF DM programs or are in the process of developing such programs.

Similarly, as public reporting of individual physician quality of care and outcomes becomes more commonplace and linked to reimbursement, there will be incentives for physicians to ensure that their HF patients are being treated in accordance with existing quality standards and that risk-adjusted readmission and mortality rates are consistent with (or superior to) national averages.

Thus, as health care reform evolves, it is likely that HF DM programs will increasingly become the standard of care, and that the costs will be absorbed by higher reimbursement rates for hospitals and physicians.

In addition, initiatives are currently underway to expand coverage for cardiac rehabilitation programs to include patients with a recent hospitalization for HF.

If this comes to pass, many of the elements of HF DM could be readily incorporated into existing cardiac rehabilitation programs, thus producing "economy-of-scale" cost minimization while increasing revenues for cardiac rehabilitation programs, many of which face challenges in maintaining fiscal solvency.

5. What options are available for patients who do not have access to, or who cannot afford, a DM program?

A substantial proportion of HF patients in the U.S. do not have access to a structured HF DM program. Nonetheless, to the extent feasible, all patients should be provided with educational materials about HF and written instructions about medications, diet, and other behavioral aspects of care prior to discharge from the hospital.

Similarly, moderate and especially high risk patients should be contacted at home within 48 hours of discharge by a hospital representative or someone from the physician's office.

The primary goal of this contact is to identify any "red flags," such as worsening symptoms since discharge, problems with medications or diet, or significant uncertainty about implementation of the management plan.

The presence of any of these indicators should prompt either a home health nurse visit or physician office visit as soon as possible and within 1 week.

E. Common Pitfalls and Side-Effects of Management

The two most common pitfalls in HF management are undertreatment and inadequate follow-up. Undertreatment includes inadequate diuresis and failure to titrate medications to recommended dosages based on evidence-based guidelines.

Inadequate follow-up includes lack of effective communication with patients and caregivers, particularly at the time of care transitions (e.g., hospital to home); failure to schedule follow-up contacts (e.g., home visits or telephone calls) and office visits at suitable intervals commensurate with the patient's needs; and failure to provide sufficient education to patients and caregivers regarding the indications for contacting the physician or DM team (e.g., increasing weight or worsening symptoms).

Ideally, both of these pitfalls are addressed through successful implementation of a DM program as outlined above.

All HF medications have potential for significant adverse effects. In addition, since most HF patients are taking at least 5 to 10 medications, there is substantial potential for clinically relevant drug interactions. The risk for adverse effects and drug interactions is further increased any time a new medication is added to the regimen (e.g., an antibiotic or psychotropic drug).

Minimizing the risk for adverse effects requires close coordination of care across providers, frequent review of medications with the goal of discontinuing any unnecessary medications and simplifying the regimen wherever possible, maintaining a high index of suspicion for adverse drug effects any time a patient reports new symptoms, and carefully considering the potential for drug interactions any time a new medication is prescribed or the dose of an existing medication is changed.

Routine access to a clinical pharmacist with expertise in medication side effects, drug-drug interactions, and drug-disease interactions is invaluable in reducing the risk of adverse consequences associated with therapeutic interventions.

IV. Management with Co-Morbidities

Patients with HF often have multiple cardiac and noncardiac comorbidities, many of which affect the clinical manifestations, management, response to therapy, and prognosis. Common cardiovascular comorbid conditions include hypertension, coronary artery disease, atrial fibrillation, and peripheral arterial disease.

Common noncardiovascular comorbidities include diabetes, renal insufficiency, chronic pulmonary disease, sleep-disordered breathing, arthritis, obesity, anemia, depression, and cognitive impairment.

The high prevalence of coexisting conditions in HF patients also contributes substantially to the complexity of DM, the frequency of rehospitalizations (the majority of which are related to causes other than HF), and the pervasiveness of polypharmacy and associated drug-drug and drug-disease interactions.

A detailed discussion of comorbid conditions and polypharmacy in HF patients is beyond the scope of this chapter, but brief commentaries on several especially common clinical scenarios are provided.

1. Renal insufficiency

Renal insufficiency, defined as an estimated glomerular filtration rate (eGFR) <60 cc/min/M2, is highly prevalent in HF patients, and the prevalence increases progressively with advancing age due to the age-related decline in renal function. Moreover, worsening HF is often associated with worsening renal function and vice-versa (the cardiorenal syndrome).

Standard HF therapies, such as diuretics and renin-angiotensin-aldosterone-system (RAAS) antagonists may exacerbate renal insufficiency. Further, even small decrements in renal function are a powerful predictor of adverse outcomes in patients hospitalized with acute decompensated HF.

Limited data are available on how best to manage cardiorenal syndrome. Nonessential nephrotoxins, such as NSAIDs, intravenous contrast, and certain antibiotics, should be avoided.

Overly aggressive diuresis should also be avoided, and it may be necessary to reduce the dose or withhold RAAS antagonists until renal function has stabilized. As a general principle, I tend to avoid RAAS inhibitors in patients with an eGFR <30 cc/min/M2 unless the patient is on dialysis, and prescribe hydralazine/nitrates as alternative vasodilators.

In patients with eGFR 30-60 cc/min/M2, I titrate RAAS inhibitors slowly while monitoring renal function closely. Finally, in some cases it may be necessary to accept a modest amount of edema and volume overload to avoid excessive deterioration in renal function.

2. Chronic lung disease and sleep-disordered breathing

Use of tobacco products should be strongly discouraged in all persons, but especially in those with established cardiovascular and/or pulmonary disease. Sleep-disordered breathing (including both central and obstructive sleep disorders) is prevalent in up to 59% of HF patients.

Therefore, all HF patients should be asked about their sleep habits, sleep quality, and presence of snoring and daytime somnolence. Patients with suspected sleep-disordered breathing should undergo additional evaluation with a sleep study and referral to a sleep specialist or pulmonologist if indicated.

3. Arthritis

Osteoarthritis is among the most common chronic conditions in the U.S., and it is often treated with NSAIDs and/or glucocorticoids, both of which may promote fluid retention and adversely affect renal function, thereby worsening HF. Indeed, initiation of an NSAID has been associated with an up to 20-fold increase in the risk of HF hospitalization, even among persons without prior known cardiovascular disease.

In many patients, arthritis limits activity and impairs quality of life to an equal or greater extent than HF, although the effect on mortality is much less. To minimize the effects of antiarthritic therapy on HF and renal function, patients with significant arthritic symptoms should be preferentially treated with analgesics with low risk for cardiorenal toxicity, such as acetaminophen for mild symptoms, tramadol for moderate symptoms, and opioids for severe symptoms along with rheumatologic or orthopedic consultation.

4. Obesity

In the U.S., up to two thirds of adults are overweight or obese, and there is evidence that obesity contributes to the development and progression of HF. Management of obesity in patients with HF is, however, controversial, as there is evidence that patients with mild to moderate obesity (BMI 30-40 kg/M2) have a better prognosis than patients with a normal BMI of 18.5-25 kg/M2 (the obesity paradox).

Moreover, decline in dry weight in patients with HF is a marker for adverse prognosis, in part because it may reflect cardiac cachexia and a catabolic state. Conversely, intentional gradual weight loss may improve exercise tolerance and quality of life.

Clearly, additional data on management of obesity in HF patients is needed. In the meantime, I do not recommend weight loss in HF patients with BMIs of 25-35 kg/M2. I also do not generally recommend weight loss in individuals over 75 years of age (with or without HF), although there are exceptions. In patients less than 75 years of age with BMIs of 40 or higher, I recommend gradual weight loss (1 to 2 lb/mo), although data on the wisdom of this recommendation are lacking.

5. Depression and cognitive impairment

Depression is associated with decreased adherence to medications and behavioral interventions, diminished quality of life, and increased mortality in HF patients. Therefore, all patients with HF should be screened for depression as discussed above, and patients with clinical depression should be treated with cognitive behavioral therapy and/or medication.

Although there is no evidence that treatment of depression improves cardiovascular outcomes, it does improve quality of life and is therefore clearly indicated.

Cognitive impairment is common in HF patients and exceeds 50% in some series. Although additional study is needed, current evidence suggests that HF contributes directly to cognitive impairment through decreased cerebral perfusion, microemboli (especially in patients with atrial fibrillation), or other mechanisms.

Cognitive impairment reduces patients' capacity to comply with complex medication regimens and behavioral interventions. All HF patients 75 years of age or older should be screened for cognitive impairment as described above.

Patients younger than 75 should also be screened if cognitive impairment is suspected. If appropriate, patients with possible or probable cognitive impairment should be referred to a neurologist or geriatrician for further evaluation and management. The presence of cognitive impairment, even if mild, should also trigger increased involvement of the patient's family or other sources of social support in providing care.

6. Hypertension, coronary artery disease, atrial fibrillation, and diabetes

Management of these conditions should be conducted in accordance with published guidelines.

7. Polypharmacy

HF patients take an average of about 9 or 10 prescription medications, and many patients also use a variety of nonprescription drugs (e.g., vitamins) and other dietary supplements.

Since the risk of drug interactions increases exponentially as the number of medications increases, and exceeds 90% in patients taking 10 or more agents, the likelihood of clinically significant drug interactions is quite high in the majority of HF patients.

While many common drug interactions can be identified with current screening tools (e.g., electronic medical and pharmacy records), many others go undetected.

Ideally, patients taking multiple medications (5 or more) should have their medication regimens reviewed by a clinical pharmacist with expertise in identifying potential drug interactions and in making recommendations for alternative therapies if appropriate. Since this is often not feasible, at a minimum the prescribing physician should review the patient's full medication list (including over-the-counter drugs and nutraceuticals), discontinue any unnecessary medications (e.g. ,the proton pump inhibitor that was started when the patient was in the hospital and continued indefinitely), and simplify the medication regimen wherever possible (e.g. converting from a short-acting to a long-acting formulation, thereby allowing a reduction in the number of pills and doses).

In addition, the physician should maintain a high index of suspicion that any new symptoms reported by the patient may in fact be related to medication side effects or drug interactions.

Patients with HF comprise an extremely heterogeneous population in terms of symptom severity, comorbidity burden, prognosis, and goals of care. Therefore, HF management, including selection of diagnostic tests and therapeutic interventions must first and foremost be individualized, taking into consideration disease stage, overall prognosis (i.e., related to HF and coexisting conditions), and personal preferences.

Thus, some patients may express desire to live as long as possible, even if quality of life is less than optimal, while others may emphasize quality of life as the main therapeutic objective, sometimes at the expense of length of life.

Since individual preferences impact therapeutic decision making (e.g., disease-modifying interventions versus therapies aimed primarily at alleviating symptoms and improving quality of life), it is essential that the physician and/or other health care provider (e.g., nurse practitioner) discuss these issues with the patient early in the course of management, and periodically thereafter as clinical circumstances evolve (i.e., recognizing that goals of care may change as symptoms progress and quality of life becomes more compromised).

These same issues (i.e., personal preferences and goals of care) also impact patients' willingness to accept risk in exchange for benefit. For example, a 75-year-old patient with three-vessel CAD, ischemic cardiomyopathy, NYHA class III symptoms, ejection fraction 22%, positive stress test, and moderate renal insufficiency (creatinine 1.8 mg/dl, estimated GFR 30 to 44 cc/min, CKD stage IIIB) may have a 30% to 40% 1-year mortality without revascularization.

This may be reduced to perhaps 10% to 20% with successful coronary bypass surgery, but with the upfront risks of acute renal failure related to cardiac catheterization, 5% to 10% perioperative mortality, significant risk of other perioperative complications (including atrial fibrillation and cognitive dysfunction), and potential for a protracted convalescence period following surgery.

Nonetheless, the patient who wishes to live as long as possible may be willing to accept these upfront risks in exchange for a better long-term prognosis. Conversely, patients whose main goal is focused on quality of life would likely decline catheterization and surgical intervention.

Similarly, the same considerations would apply to discussions about ICD implantation in the case scenarios described above. Moreover, the patient who values length of life would likely desire "optimal medical therapy" with proven disease-modifying agents, such as ACE-inhibitors, beta-blockers, and aldosterone antagonists.

In contrast, "optimal medical therapy" for the quality of life of an avid patient may consist of digoxin and diuretics, especially in cases where side effects have been problematic with disease-modifying drugs.

Finally, prevalent comorbidities also come into play. For example, patients with "sick sinus syndrome" who value quality of life may decline beta-blocker therapy if faced with the need for pacemaker implantation, whereas longevity-oriented patients might readily undergo pacemaker insertion in order to maximize treatment with beta-blockers.

Similarly, patients with stage IV CKD may have different views about their willingness to undergo cardiac catheterization or treatment with RAAS-inhibitors given the potential trade-offs between worsening renal function (including possible need for dialysis) and the prospect of longer survival.

Prognosis

Patients with newly diagnosed HF have a 1-year mortality rate of 20% to 30% and a median survival of about 5 years. Factors that adversely affect prognosis include older age, male gender, lower LVEF, more severe symptoms, worse renal function, hyponatremia, lower systolic blood pressure, higher BNP or NT-proBNP, CAD, chronic lung disease, anemia, depression, and cognitive impairment (among others).

Interventions that have been shown to favorably affect prognosis in appropriately selected patients include ACE-inhibitors, ARBs, beta-blockers, aldosterone antagonists, ICDs, and cardiac resynchronization therapy (CRT).

Although it is difficult to accurately assess prognosis in an individual patient, the Seattle Heart Failure model (discussed above) has been shown to provide a reliable estimate in various HF populations (see http://depts.washington.edu/shfm/).

Patient counseling

Patients with HF should be routinely counseled about:

  • The nature of HF, including symptoms, signs of progression, and likely disease trajectory

  • Importance of adherence to prescribed medications and avoidance of nonprescribed medications (including over the counter drugs, dietary supplements, and nutraceuticals)

  • Dietary sodium restrictions (typically less than 2 g/day in patients with class I-II HF, less than 1.5 g/day in patients with class III-IV HF)

  • Avoidance of excess fluid intake (i.e., the oft-cited dictum that people should drink 8 to 10 glasses of water every day does not apply to patients with HF and other fluid-retaining states); patients with advanced HF and/or significant renal insufficiency may require more stringent fluid restriction (e.g., less than 32 oz/day)

  • Monitoring daily weights with instructions on self-adjustment of diuretic dosages or parameters for contacting the physician or other health care provider

  • Under what circumstances to contact the HF team (e.g., new or worsening symptoms), who to contact (i.e., nurse, physician, or other individual), and how to contact that person at any time

  • Development of an advance directive and appointment of durable power of attorney

V. Patient Safety and Quality Measures

A. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

As discussed in detail above, measures designed to reduce the risk of readmission include ensuring continuity of care and a successful transition from the hospital to the home environment, close follow-up by telephone or other means (e.g., home or office visit) within 48 hours of discharge in moderate and high risk patients, and providing patients with 24/7 access to a nurse or other health care provider in the event that questions arise or symptoms worsen.

Patients should also receive detailed written instructions about medications, diet, fluid restrictions (if any), daily weight monitoring, and physical activity. When feasible, the patient's spouse or other caregiver/significant other should be included in the education process.

B. What's the Evidence for specific management and treatment recommendations?

The 2013 ACCF/AHA Guideline for the Management of Heart Failure (1) provides the following recommendations relevant to HF DM programs:

Class I:

  1. Effective systempatient with chronic HF that facilitate and ensure effective care that is designed to achieve guideline- of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcardis of care coordination with special attention to care transitions should be deployed for every rected medical therapy (GDMT) and prevent hospitalization. (Level of Evidence: B)

  2. Every patient with HF should have a clear, detailed, and evidence-based plan of care that ensures the achievemente team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient's healthcare team. (Level of Evidence: C)

  3. Palliative and supportive care is effective for patients with symptomatic advanced HF to improve quality of life. (Level of Evidence: B)

The Guideline also notes that although HF patients often have multiple comorbidities, there is insufficient evidence to provide recommendations for management of multimorbidity in HF patients.

The 2010 Heart Failure Society of America Comprehensive Heart Failure Practice Guideline provides similar recommendations (2).

References

Yancy, CW, Jessup, M, Bozkurt, B. "2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. vol. 62. 2013. pp. e147-239.

"Heart Failure Society of America. The 2010 Heart Failure Society of America comprehensive heart failure practice guideline. Disease management, advance directives, and end-of-life care in heart failure: HFSA 2010 comprehensive heart failure practice guideline". J Card Fail. vol. 16. 2010. pp. e98-e114.

C. DRG Codes and Expected Length of Stay.

MS-DRG 291-293 Heart Failure and Shock

Expected length of stay: 3 to 7 days

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