Intensity and focus of heart failure disease management after hospital discharge

Interventions Linked to Decreased Heart Failure Hospitalizations During Ambulatory Pulmonary Artery Pressure Monitoring

OBJECTIVES

This study sought to analyze medical therapy data from the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in Class III Heart Failure) trial to determine which interventions were linked to decreases in heart failure (HF) hospitalizations during ambulatory pulmonary artery (PA) pressure-guided management.

BACKGROUND

Elevated cardiac filling pressures, which increase the risk of hospitalizations and mortality, can be detected using an ambulatory PA pressure monitoring system before onset of symptomatic congestion allowing earlier intervention to prevent HF hospitalizations.

METHODS

The CHAMPION trial was a randomized, controlled, single-blind study of 550 patients with New York Heart Association functional class III HF with a HF hospitalization in the prior year. All patients undergoing implantation of the ambulatory PA pressure monitoring system were randomized to the active monitoring group (PA pressure-guided HF management plus standard of care) or to the blind therapy group (HF management by standard clinical assessment), and followed for a minimum of 6 months. Medical therapy data were compared between groups to understand what interventions produced the significant reduction in HF hospitalizations in the active monitoring group.

RESULTS

Both groups had similar baseline medical therapy. After 6 months, the active monitoring group experienced a higher frequency of medications adjustments; significant increases in the doses of diuretics, vasodilators, and neurohormonal antagonists; targeted intensification of diuretics and vasodilators in patients with higher PA pressures; and preservation of renal function despite diuretic intensification.

CONCLUSIONS

Incorporation of a PA pressure-guided treatment algorithm to decrease filling pressures led to targeted changes, particularly in diuretics and vasodilators, and was more effective in reducing HF hospitalizations than management of patient clinical signs or symptoms alone.

Heart failure symptom monitoring and response training

OBJECTIVE

The purpose of this study was to test the efficacy of a heart failure (HF) training program on patients' ability to recognize and respond to changes in HF symptoms. The primary aim was to compare event-free survival at 90 days.

METHODS

A total of 99 HF patients randomized to the HF symptom training intervention or usual care completed instruments about self-care (Self-Care of HF Index) and at baseline and 3 months. Demographic, clinical, and comorbidity data were collected by interview and chart review. Time to first event (death or a HF-related hospitalization) was tracked by electronic records and patient interview.

RESULTS

The sample was predominately male (67.7%), elderly (67.7 yrs ± 12.1) and Caucasian (88.9%). The intervention group reported more events but the difference was not significantly different (χ(2) = 1.18, p = 0.26). There was no difference in survival time between groups (χ(2) = 1.53, p = 0.216). In paired t-tests, the intervention group had significantly improved self-care maintenance, management and confidence scores (all p < 0.01). The usual care group had significantly improved self-care maintenance and management (both p < 0.01). Improvements in self-care maintenance and confidence were higher in the intervention group compared with usual care (18.0 vs. 12.9 points).

CONCLUSIONS

HF symptom awareness training appeared to have an early but not sustained benefit resulting in no difference in 90-day event-free survival. However, larger improvement in self-care maintenance and confidence scores in the intervention group compared to usual care is promising. Embedding meaningful symptom monitoring strategies in self-care maintenance interventions requires further investigation.

The challenge of treating congestion in advanced heart failure

Volume overload is a common manifestation of heart failure decompensation. Interaction between impaired renal and heart function constitutes an important pathophysiologic mechanism that leads to congestion. In addition to improving symptoms and volume status, reduction of rehospitalization rates, maintenance of renal function and improvement of survival are all important goals of every therapeutic strategy. Currently, the use of diuretics, vasodilators, inotropes and ultrafiltration, together with investigational agents such as oral vasopressin antagonists and adenosine A1-receptor antagonists, constitute the main therapeutic options for the congested heart failure patient.

Reduction in mitral regurgitation during therapy guided by measured filling pressures in the ESCAPE trial

BACKGROUND

Dynamic mitral regurgitation (MR) contributes to decompensation in chronic dilated heart failure. Reduction of MR was the primary physiological end point in the ESCAPE trial, which compared acute therapy guided by jugular venous pressure, edema, and weight (CLIN) with therapy guided additionally by pulmonary artery catheters (PAC) toward pulmonary wedge pressure

METHODS AND RESULTS

Patients were randomized to PAC or CLIN during hospitalization with chronic heart failure and mean left ventricular ejection fraction 20%, and at least 1 symptom and 1 sign of congestion. MR and mitral flow patterns, measured blinded to therapy and timepoint, were available at baseline and discharge in 133 patients, and at 3 months in 104 patients. Changes in MR and related transmitral flow patterns were compared between PAC and CLIN patients. Jugular venous pressure, edema, and weights decreased similarly during therapy in the hospital for both groups. In PAC but not in CLIN patients, MR jet area, MR/left atrial area ratio, and E velocity were each significantly reduced and deceleration time increased by discharge. By 3 months, patients had clinical evidence of increased jugular venous pressure, edema, and weight since discharge, reaching significance in the PAC arm, and the change in MR was no longer different between the 2 groups, although the change in E velocity remained greater in PAC patients.

CONCLUSIONS

During hospitalization, therapy guided by PAC to reduce left-sided pressures improved MR and related filling patterns more than therapy guided clinically by evidence of systemic venous congestion. This early reduction did not translate into improved outcomes out of the hospital, where volume status reverted toward baseline.

Collapse

Key Words

• hemodynamics
• heart failure
• cardiomyopathy
• mitral regurgitation

Collapse

MESH Headings

• Adult
• Aged
• Body Weight
• Catheterization, Swan-Ganz
• Central Venous Pressure
• Chronic Disease
• Edema/etiology
• Edema/physiopathology
• Edema/therapy
• Female
• Heart Failure/etiology
• Heart Failure/physiopathology
• Heart Failure/therapy
• Hemodynamics
• Hospitalization
• Humans
• Jugular Veins/physiopathology
• Male
• Middle Aged
• Mitral Valve Insufficiency/complications
• Mitral Valve Insufficiency/physiopathology
• Mitral Valve Insufficiency/therapy
• Patient Discharge
• Predictive Value of Tests
• Pulmonary Artery/physiopathology
• Pulmonary Wedge Pressure
• Stroke Volume
• Time Factors
• Treatment Outcome
• United States
• Ventricular Function, Left

Collapse

Grants

• N01HV98177 NHLBI NIH HHS
• R01 HL067691 NHLBI NIH HHS
• R01 HL067691-01 NHLBI NIH HHS
• N01-HV-98177 NHLBI NIH HHS

Collapse

Affiliation(s)

Maryse Palardy Brigham and Women's Hospital, Boston, Mass; Duke Medical Center, Durham, NC, USA
Lynne W Stevenson
Gudaye Tasissa
Michele A Hamilton
Robert C Bourge
Thomas G Disalvo
Uri Elkayam
James A Hill
Sharon C Reimold

Collapse

Cardiorenal interactions: insights from the ESCAPE trial

OBJECTIVES

We examined the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) database to understand the impact and pathophysiology of renal dysfunction in patients hospitalized with advanced decompensated heart failure (HF).

BACKGROUND

Baseline renal insufficiency (RI) (estimated glomerular filtration rate [eGFR] <60 ml/min) and worsening renal function (WRF) (upward arrow serum creatinine [SCr] >or=0.3 mg/dl) during treatment of decompensated HF are associated with adverse outcomes.

METHODS

We used a Cox proportional hazards model to evaluate the impact of renal function on 6-month outcomes. Renal parameters were correlated with hemodynamic measurements. The impact of a strategy using pulmonary artery catheter (PAC) guidance on WRF and outcomes in patients with baseline RI was compared with treatment based on clinical assessment alone.

RESULTS

Baseline and discharge RI, but not WRF, were associated with an increased risk of death and death or rehospitalization. Among the hemodynamic parameters measured in patients randomized to the PAC arm (n = 194), only right atrial pressure correlated weakly with baseline SCr (r = 0.165, p = 0.03). There was no correlation between baseline hemodynamics or change in hemodynamics and WRF. A PAC-guided strategy was associated with less average increase in creatinine but did not decrease the incidence of defined WRF during hospitalization or affect renal function after discharge relative to clinical assessment alone.

CONCLUSIONS

Among patients with advanced decompensated HF, baseline RI impacts outcomes more than WRF. Poor forward flow alone does not appear to account for the development of RI or WRF in these patients. The addition of hemodynamic monitoring to clinical assessment does not prevent WRF or improve renal function after discharge.

Pharmacists' role in the post-discharge management of patients with heart failure: a literature review

BACKGROUND AND OBJECTIVE

The incidence of heart failure is increasing in developed countries. In the aged population, heart failure is a common cause of hospitalization and hospital readmission, which in conjunction with post-discharge care, impose a significant cost burden. Inappropriate medication management and drug-related problems have been identified as major contributors to hospital readmissions. In order to enhance the care and clinical outcomes, and reduce treatment costs, heart failure disease management programmes (DMPs) have been developed. It is recommended that these programmes adopt a multi-disciplinary approach, and pharmacists, with their understanding and knowledge of medication management, can play a vital role in the post-discharge care of heart failure patients. The aim of this literature review was to assess the role of pharmacists in the provision of post-charge services for heart failure patients.

METHOD

An extensive literature search was undertaken to identify published studies and review articles evaluating the benefits of an enhanced medication management service for patients with heart failure post-discharge.

RESULTS

Seven studies were identified evaluating 'outpatient' or 'post-discharge' pharmacy services for patients with heart failure. In three studies, services were delivered prior to discharge with either subsequent telephone or home visit follow-up. Three studies involved the role of a pharmacist in a specialist heart failure outpatient clinic. One study focused on a home-based intervention. In six of these studies, positive outcomes, such as decreases in unplanned hospital readmissions, death rates and greater compliance and medication knowledge were demonstrated. One study did not show any difference in the number of hospitalizations between intervention and control groups. The quality of evidence of the randomized controlled trials was assessed using the Jadad scoring method. None of the studies achieved a score of more than 2, out of a maximum of 5, indicating the potential for bias.

DISCUSSION

The DMPs carried out by pharmacists have contributed to positive patient outcomes, which has highlighted the value of extending the traditional roles of pharmacists from the provision of professional guidance to the delivery of continuity of care through a more holistic and direct approach.

CONCLUSION

This review has demonstrated the effectiveness of pharmacists' interventions to reduce the morbidity and mortality associated with heart failure. However, there is an on-going need for the development and evaluation of pharmacy services for these patients.