Google+Links To And Excerpts From "2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee" - Tom Wade MD
Links To And Excerpts From “2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee”
Today I review, link to, and excerpt from 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. J Am Coll Cardiol. 2019 Oct 15;74(15):1966-2011. doi: 10.1016/j.jacc.2019.08.001. Epub 2019 Sep 13.
All that follows is from the above resource.
Heart failure (HF) makes up 1% to 2% of the total healthcare budget in the United States (3), with inpatient admissions accounting for more than one-half of this expenditure 4, 5. Inpatient mortality ranges from 4% to 12% and may increase to 20% to 25% in high-risk subgroups 6, 7, 8, 9, 10, 11. Readmissions and events are common, and the age-adjusted risk for all-cause mortality is tripled compared with non–HF patients 3, 6, 12.
While the typical hospital course includes rapid improvement in signs and symptoms and discharge after 4 to 5 days, episodes of worsening HF nevertheless mark a fundamental change in the HF trajectory; patients admitted with HF have a 20% to 30% risk of death within a year. Goals of hospitalization thus include not only clinical response, but also the assessment and optimization of therapy to address the long-term trajectory after discharge.
This ECDP focuses on patients hospitalized with HF and complements existing tools for outpatient management. We have construed our task broadly to comprise assessment extending from the original emergency department (ED) visit through the first post-discharge visit.
This document focuses on assessments and goals of therapy.
The document is structured into 5 nodes: Admission, Trajectory Check, transition to Oral Therapies, Discharge, and First Follow-Up Visit (Figure 1).
3. Assumptions and Definitions
1.
The committee decided not to distinguish HF on the basis of ejection fraction (EF) except where specifically noted. Although the evidence base for therapeutic interventions differs, the goals of decongestion and the importance of consideration of comorbidities and factors that influence adherence are common to patients admitted with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). Management of patients with midrange ejection fraction (HFmrEF) shares similarities with management of both HFrEF and HFpEF 22, 23, 24.
2.
The expert consensus writing committee endorses the evidence-based approaches to HF therapy and management enumerated in the 2013 ACCF/AHA Guideline for the Management of Heart Failure and the 2016 and 2017 ACC/AHA/HFSA focused updates 15, 25, 26.
3.
These algorithms assume that a broad multidisciplinary approach is ideal, with input anticipated from experienced physician and nurse specialists, as well as other disciplines such as pharmacy, social work, psychiatry, physical therapy, and nutrition.
4.
Therapeutic decisions should be governed by clinical judgment in accordance with patient preferences.
5.
These algorithms are based on the best available data, but given the relatively limited current data concerning a number of aspects of the HF hospitalization, they will require revision as new data emerge.
3.1. Definitions
GDMT: Guideline-directed medical therapy
Optimal therapy: Treatment provided at either the target or the highest tolerated dose for a given patient.
EF: Ejection fraction
HFrEF: Heart failure with reduced left ventricular ejection fraction (EF ≤0.40)
HFpEF: Heart failure with preserved left ventricular ejection fraction (EF ≥0.50)
HFmrEF: Heart failure with midrange ejection fraction (EF <0.50 but >0.40)
Graphic depiction of course of heart failure admission, showing the degree of focus on clinical decompensation (red), discharge coordination (blue), ongoing coordination of outpatient care (light blue), and optimization of guideline-directed medical therapy (green), with ongoing assessment of the clinical course (circle with arrows), and key time points for review and revision of the long-term disease trajectory for the HF journey (compass signs).
5. Description and Rationale
5.1. Key points
1.
The pathway to improve outcomes after HF hospitalization begins with admission, continues through the process of decongestion and transition to oral therapies before the day of discharge, and connects through the first post-discharge follow-up.
2.
Clinical trajectory of HF should be assessed continuously during admission. Three main in-hospital trajectories have been defined: improving towards target, stalled after initial response, or not improved/worsening. These translate into different management strategies throughout hospitalization and post-discharge.
3.
Evaluation of the long-term course of HF should be part of the initial comprehensive assessment, reviewed on the day of transition to oral therapy, and re-assessed at the first follow-up visit for persistent or new indications of high risk leading to consideration of advanced therapies or revision of goals of care.
4.
Key risk factors modifiable during hospitalization include the degree of congestion as assessed by clinical signs and natriuretic peptides and the lack of appropriate guideline-directed medical therapies. Improvement in these factors is associated with improved prognosis, but failure to improve, including failure to tolerate guideline-directed medical therapy (GDMT) for HF, is associated with a much worse prognosis.
5.
Common comorbidities, including diabetes; anemia; and kidney, lung, and liver disease, should be assessed during initial evaluation and addressed throughout hospitalization and discharge planning.
6.
The day of transition from intravenous to oral diuretic therapy should trigger multiple considerations related to the overall regimen for discharge, verification of completion of patient education components, caregiver education, and plans for discharge.
7.
The discharge day should be a time to review and communicate with identified providers rather than to initiate new therapies.
8.
The elements of the hospitalization events and plans that are most crucial for continuity of care after discharge should be documented in a format that is available to all members of the outpatient team and easily accessible when a patient calls or returns with worsening symptoms.
9.
Principles of palliative care applied by the in-hospital care team or by palliative care specialists may be particularly relevant when an unfavorable trajectory warrants communication about prognosis, options, and decision-making with patients and families.
10.
The first follow-up visit should address specific aspects, including volume status, hemodynamic stability, kidney function and electrolytes, the regimen of recommended therapies, patient understanding, adherence challenges (including insurance/coverage issues), and goals of care.
6. Node: Admission
6.1. Evaluation in the ED
ED data show that 80% of all HF hospitalizations are admitted from the ED 27, 28. Although many advances have improved chronic HF management, there is sparse evidence regarding strategies for triage and management in the ED 13, 15, 16, 17, 18, 19, 25, 26, 29, 30. Most patients with acute decompensated heart failure (ADHF) are admitted for symptomatic treatment of congestion with intravenous diuretics and to a much lesser degree for respiratory failure, cardiogenic shock, incessant ventricular tachycardia, or the need for urgent diagnostic or therapeutic procedures 6, 20, 21, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40. Although fewer than 10% of ED visits with ADHF have acute life-threatening illness, and the majority of patients presenting are clinically stable 11, 38, 39, 41, the post-discharge event rate is high even though over 80% to 90% of patients are admitted 28, 42, 43.
A framework for risk stratification in the ED is shown in Figure 2, intended as a guide to thought processes during initial evaluations rather than a formal description of admission criteria and administrative processes surrounding admission.
Patients who are critically ill at presentation or those with new-onset HF are admitted. Patients with known HF and a marked degree of congestion and those not at low risk (Table 1) are also usually admitted.
Early therapy for acute HF is crucial even if patients are ultimately admitted. Medical therapy is discussed in Sections 7.2, 7.4, 7.5, and 7.6. Diuretic dosing for decongestion is considered in detail in Section 7.2.
6.2. Comprehensive Initial Assessment—Setting the Inpatient Goals
The two central themes of care for patients hospitalized for decompensated HF are decongestion and optimization of the therapies recommended for HF, but multiple other goals also need to be met.
Decompensation should not be too quickly ascribed to nonadherence, as most patients describe occasional lapses in salt restriction and medication schedules; this likely also occurs in patients without HF decompensation.
Table 2. Common Factors That Can Contribute to Worsening Heart Failure
Acute myocardial ischemia
Uncontrolled hypertension
Atrial fibrillation and other arrhythmias
Nonadherence with medication regimen, sodium, or fluid restriction
Medications with negative inotropic effect
Medications that increase sodium retention (NSAIDs, thiazolidinediones, steroids)
ACCF = American College of Cardiology Foundation; AHA = American Heart Association; NSAIDs = nonsteroidal anti-inflammatory drugs.
Adapted from Yancy, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure (15).
6.2.1. Assessing Hemodynamic Profiles
Most patients present with at least 1 symptom and 1 sign of congestion that can be tracked as targets during decongestion and may serve as sentinel symptoms for recurrent congestion after discharge 70, 74, 77, 78 (Table 3). The jugular venous pressure (JVP)* reflects elevated right-sided filling pressures and is also a sensitive indicator of elevated left-sided filling pressures in patients with HF 75, 79. Rales, when present, usually indicate higher filling pressures than baseline, but are often absent in chronic HF due to pulmonary lymphatic compensation. Extensive pitting edema, ascites, or large pleural effusions reflect large extravascular reservoirs that may take many days to mobilize.
Figure 3. Classification of Patients Presenting With Acutely Decompensated Heart Failure
Clinical profiles of patients with HF are shown in Figure 3. Patients identified with congestion should be further considered for whether filling pressures are elevated in proportion for both the right heart and the left heart (right atrial pressure >10 mm Hg and pulmonary capillary wedge pressure >22 mm Hg; 75% to 80% of patients with chronic HFrEF, less defined for HFpEF) 42, 80. The wet and warm clinical profile without evidence of hypoperfusion characterizes over 80% of patients admitted with reduced EF and almost all with preserved EF except those with small left ventricular cavities of restrictive or hypertrophic cardiomyopathies 39, 42. The cold and wet profile describes congestion accompanied by clinical evidence of hypoperfusion, as suspected from narrow pulse pressure, cool extremities, oliguria, reduced alertness, and often recent intolerance to neurohormonal inhibition. Sleepiness, impaired concentration, and very low urine output may also be present. These patients may require adjunctive therapy with vasodilator or inotropic agents or decrease of medications with negative inotropic effects to improve cardiac output and facilitate diuresis. Patients who appear to have low cardiac output without clinical congestion (cold and dry profile) often have unrecognized elevation of filling pressures, which may be revealed by invasive hemodynamic measurement. Uncertainty regarding hemodynamic status is associated with worse outcomes and is an indication for invasive hemodynamic assessment 15, 81. True hypoperfusion without elevated filling pressures accounts for fewer than 5% of admitted patients (39) and usually reflects aggressive prior therapy with tight adherence. A patient hospitalized with apparent decompensation in whom both filling pressures and perfusion appear to be normal should be carefully evaluated for other causes of symptoms, such as transient ischemia or arrhythmias, or noncardiac diagnoses such as pulmonary disease.
6.2.2. Consideration of Comorbidities
A key component of the comprehensive initial assessment is evaluation of patient comorbidities (Table 4).
A key component of the comprehensive initial assessment is evaluation of patient comorbidities (Table 4). These comorbidities and their therapies should be carefully considered for their role in HF decompensation and as independent targets for intervention. For example, diabetes mellitus and pulmonary disease are each present in 30% to 40% of patients hospitalized with HF and play a role in disease severity and risk for decompensation (82). Kidney dysfunction can precipitate congestion and can also limit initiation of GDMT. Frailty is another common comorbidity in HF, particularly for the elderly 83, 84, and its association with health, functional status, and late-life disability is an increasingly important focus for patients with HF and their caregivers. Approximately 50% to 70% of older patients admitted with ADHF present with some degree of frailty, although this may be reversed or attenuated with interventions 85, 86. Consideration should be given at the time of hospitalization to the need for physical therapy consultation.
