None Lucas Zier, MD, MS Rachel Stern, MD February 21 st , 2020 - PDF document

2/12/2020 Disclosures Caring for the Vulnerable and Underserved Heart Failure Patient None Lucas Zier, MD, MS Rachel Stern, MD February 21 st , 2020 Zuckerberg San Francisco General Zuckerberg San Francisco General 2 Learning objectives Understand the Challenges in Caring for Vulnerable and ▪ Underserved Heart Failure Patients Challenges in Caring for Vulnerable and Define Best Practices for Caring for Inpatient Heart ▪ Failure Patients Underserved Heart Failure Patients Describe key components of outpatient heart failure ▪ management Identify how systems of care can be built to support ▪ vulnerable patients with heart failure. Zuckerberg San Francisco General 3 Zuckerberg San Francisco General 1

2/12/2020 Comparison of Total Heart Failure Visits by Site Audience Response Question FY 2016-2018 Safety net hospitals are, as a group, financially penalized in the following way for heart failure readmissions compared to non safety net hospitals in programs like the hospital readmissions reduction program: 1. Over penalized 2. Under penalized 3. No difference in penalties ZSFG Stanford UCSF Source: Vizient. Zuckerberg San Francisco General Zuckerberg San Francisco General Heart Failure Update 6 Humble Inquiry: “You Picked an 2017 Heart Failure Readmits compared to Peer Institutions Unsolvable Problem” 25% Social determinants ▪ - Homelessness and substance use lead to non-adherence Almost 50% 20% higher than LA People with heart failure are just sick County USC ▪ 15% - Readmission rate reflects co-morbidities we can’t change Inpatient: pressure to discharge as soon as patients can walk ▪ 10% - PCPs can titrate diuretics and neurohormonal blockade Outpatient: PCPs don’t have the expertise to manage 5% ▪ advanced heart failure 0% Aren’t readmissions correlated with decreased mortality? ▪ ZSFG Santa Clara LAC USC* Harbor UCLA* UCSF Med ctr Vizient Valley* Zuckerberg San Francisco General Heart Failure Update 7 Zuckerberg San Francisco General Heart Failure Update 8 2

2/12/2020 System-Wide Challenges Inpatient Care Transitions Outpatient • Varied adherence to • • Limited heart failure Antiquated best practices and appointment system expertise Best Practices for Inpatient guideline directed • Infrequent visits for a therapies • Varied adherence to high touch disease Management of Heart Failure • best practices PCPs managing HF with limited help Patients with a complex, outpatient disease were being managed with repeated hospital admissions Zuckerberg San Francisco General Heart Failure Update 9 Zuckerberg San Francisco General Inpatient Management Goals of Heart Failure Audience Response Question Heart failure patients should be discharged when the following criteria have been met: Decongestion Neurohormonal Blockade 1. No longer symptomatic from heart failure (Reduce Mortality) (Systemic Unloading) 2. Euvolemic 3. Initiated on guideline directed medical therapy Diuresis Guideline directed 4. Initiated on guideline directed medical Dialysis medical therapy therapy and euvolemic Zuckerberg San Francisco General Zuckerberg San Francisco General 3

2/12/2020 Relationship between HF Length of Stay and Readmission Rate Inpatient Management Timeline • Long length of stay associated with increased rates • Short length of stay is associated readmission and mortality. Aggressive Diuresis with increased rates of readmission • Reason: these patients are • Reason: Patients not euvolemic on sick. discharge Internal data: most HF Diagnostics admissions shorter than national average, tight correlation between LOS and readmission rate Sud M, et al. Days to Readmission JACC: HF. 2017. Zuckerberg San Francisco General Heart Failure Update 13 Zuckerberg San Francisco General The Everest Score and Mortality Principles of Effective Diuretic Use Zuckerberg San Francisco General Zuckerberg San Francisco General 4

2/12/2020 Some require sequential nephron blockade Principles of Effective Diuretic Use Acetazolamide Chlorthiazide Metolazone ▪ Establish dose responsiveness ▪ Employ sequential nephron blockade if indicated Spironolactone Mannitol ▪ Set daily diuresis goals based upon: Eplerenone - Clinical Exam (IVC ultrasound exam) - Weight - I/Os - Labs Tolvaptan ▪ DIURESE TO EUVOLEMIA! Conivaptan Furosemide Bumetanide Torsemide Ethacrynic Acid Zuckerberg San Francisco General Zuckerberg San Francisco General Initiate diuresis by doubling the patient’s outpatient diuretic dose (give IV) Daily goal: Diurese the patient as rapidly and completely as possible without OR exceeding the plasma refill rate Administer 20-40 mg IV furosemide if diuretic naive Double the IV diuretic dose Q4-6 hours until patient responds to diuretics (i.e. patient is net negative 200-300 cc per hour) and add afterload reduction Extravascular Space with hydralazine or ACEI/ARB • Peripheral edema If the patient is not responsive to 160 mg IV furosemide or 4 mg IV bumex • Pulmonary edema then add 250-500 mg IV chlorthiazide to next diuretic bolus • Pleural effusions to assess responsiveness Plasma Refill Rate (4 L/day) If patient is not responsive to high dose loop diuretic and adjunctive thiazide then Intravascular Space initiate furosemide or bumex drip at furosemide 20 mg/hr or bumex 0.5 -1 mg/hr with chlorthiazide 500 mg IV Q6 +/- acetazolamide 500 mg IV Q12 • Jugular venous pressure • Ventricular filling pressures (S3) If patient is not responsive to maximal nephron blockade (bumex gtt @ 1 mg/hr, chlorthiazide 500 mg IV Q6, azetazolamide 500 mg Q12) then start a low dose inotrope and call renal for PUF Zuckerberg San Francisco General Zuckerberg San Francisco General 5

2/12/2020 Daily Diuretic Goals Euvolemia Severely volume overloaded  3-4L net ▪ ▪ JVP/IVC is flat and collapsing (intravascular euvolemia) negative ▪ No peripheral edema or crackles are present (extravascular euvolemia) Moderately volume overloaded  2-3L net ▪ ▪ The patient does not report orthopnea, or dyspnea (symptoms) negative ▪ Patient is pre-renal by labs or creatinine has bumped slightly Mildly volume overloaded  1-2L net ▪ negative Zuckerberg San Francisco General Zuckerberg San Francisco General Inpatient Management Goals of Heart Failure Inpatient Management Timeline Aggressive Diuresis Decongestion Neurohormonal Blockade (Systemic Unloading) (Reduce Mortality) Uptitrate ACEI/ARB (HFrEF) Uptitrate MRA Uptitrate BB (HFrEF) Diagnostics Diuresis Guideline directed Dialysis medical therapy Zuckerberg San Francisco General Zuckerberg San Francisco General 6

2/12/2020 The Magic of Neurohormonal Blockade A Word about HFpEF… NNT to Prevent One Death Over 1-2 Years There are no evidence based medications for the neurohormonal treatment of HFpEF 7-22 9-33 18-26 Zuckerberg San Francisco General Zuckerberg San Francisco General Inpatient Management Timeline Aggressive Diuresis Diuretic Trial Uptitrate ACEI/ARB (HFrEF) Stable Dose Transitioning to Outpatient Care… Uptitrate MRA Stable Dose Uptitrate BB (HFrEF) Stable Dose Diagnostics LHC/RHC Zuckerberg San Francisco General Zuckerberg San Francisco General 7

2/12/2020 Discharge Diuretics Early Follow-up Decreases Hospital Readmission ▪ Convert active IV diuretic dose to oral dose then reduce dose by one half to estimate maintenance, outpatient diuretic dose ▪ Approximate outpatient diet and fluid intake and monitor patient in the hospital for 24 hours ▪ If the patient is negative 500-1000 ml in the 24-hour period you have identified the maintenance, oral diuretic dose Early Follow-up = Within 7 days of discharge Hernandez et al. JAMA. 2010; 303 (17):1716-1722 Zuckerberg San Francisco General Zuckerberg San Francisco General ZSFG Heart Failure Discharge Planning Tool Volume Status Medications Follow-up Patient on a STABLE Dry weight clearly dose of ORAL Edema present? Yes documented in No diuretics with net No discharge summary? output of negative 500- 1000ml over the last s Ye 24 hours? No Ye s Prescription for 30 No EF <40%? No days of medications? Best Practices for Outpatient JVP visible above the Ye s clavicle at 90 Yes Ye s degrees? Patient prescribed carvedilol or No Cardiology follow up Management of Heart Failure No metoprolol XL? within 7 days? No s Ye Ye s Patient prescribed ACEI No PCP follow up within or ARB? No IVC < 2.1 cm and > 7 days? No 50% collapsible? Ye s Ye s Patient prescribed No Yes spironolactone? Discharge Patient MRN: s Ye Discharge Date: Service Attending: Primary Care Provider: Euvolemic HFrEF Guideline Directed Medical Therapy If all are criteria are NOT met prior to discharge please briefly explain on the reverse of this sheet Zuckerberg San Francisco General Zuckerberg San Francisco General 8