into Cardiac Rehabilitation Kentucky Cardiac Rehabilitation Association 2015 Annual Meeting Lynne Hamilton Weir PT CYT List risk factorscauses of HF and discuss treatment List key self care skills for the heart failure patientfamilycaregiver to learn for self management o ID: 776589
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Slide1
Incorporating Heart Failure Patients into Cardiac Rehabilitation Kentucky Cardiac Rehabilitation Association 2015 Annual Meeting
Lynne Hamilton Weir, PT, CYT
List risk factors/causes of HF and discuss treatmentList key self care skills for the heart failure patient/family/caregiver to learn for self management of HFDevelop an exercise prescription for the heart failure patientIdentify the CMS HF eligibility criteria necessary for HF participation and reimbursement
Learning Objectives
Slide3Heart Failure Facts and GuidelinesCR in HF Disease ManagementStaff TrainingCMS HF CriteriaCore Components for CR HF ITPSelf Care BehaviorsExercise Training and PrescriptionCR Session Boarding Pass and Red Flags
Overview
Slide4Heart failure is “a complex clinical syndromethat can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood.”
Heart Failure
Slide5The main manifestations of HF are dyspnea, fatigue, limited exercise tolerance and fluid retention which may lead to pulmonary, and/or splanchnic congestion, and/or peripheral edema.
Heart Failure
Slide6HFrEF
HFpEF
Slide7Slide8Classification of Heart FailureDefinitions
Stage
Definition
A
At high risk for later HF but without current structural heart disease
B
Structural heart disease but without signs or symptoms of HF
C
Structural heart disease with current or prior symptoms of HF
D
Refractory HF
Slide9Classification of Heart FailurePatient Categories
HF Stage
Patients
with the following:
A
Risk
Factors
– smoking, HTN, HLD, DM, obesity, Metabolic Syndrome, known CAD
Exposure
cardiotoxins
– cocaine, some chemotherapies
Hx
of familial cardiomyopathy
B
Known structural heart changes-MI, valve,
CM, LVH,<EF
No
signs or
symptoms of HF
C
Known structural heart disease – MI, CM, Valve disease
PLUS
Signs and symptoms of Heart Failure: HFPEF
or
HFREF
D
Marked HF signs and
symptoms even
at
rest, hospitalizations despite GDMT
Slide10Classification of Heart FailureTreatment
HF Stage
Treatment
A
Risk factor modification
therapeutic lifestyle changes
drug therapies as indicated
B
Drug therapy – ACEI
or ARB, BB as indicated
Revascularization or valve surgery if indicated
C
Drug therapy
-
ACEI/ARB plus BB, diuretics
Aldosterone antagonists
Hydralazine/nitrates – African Americans
ICD, CRT, revascularization,
valvular
surgery as indicated
D
Drug therapy, LVAD, transplant, palliative care, hospice
Slide11NYHA Functional Capacity Classification
I
No
limitation
of physical
activity. Ordinary physical
activity does not cause symptoms.
II S
light
limitation of
physical
activity. C
omfortable at rest
.
Ordinary
physical
activity
results in
symptoms.
III
M
arked
limitation
of physical activity. Comfortable
at
rest
. Less
than
ordinary
activity
causes
symptoms.
IV I
nability
to carry on
any physical
activity without
symptoms. Symptoms may
be present even at
rest
.
Slide12Classification of Heart FailureTreatment
HF Stage
Cardiac Rehabilitation
A
CR for Primary Prevention for at risk population-self pay
B
CR
for MI, angina, PCI, CABG, Valve
C
CR for HF
<
35% EF Medicare/Medicaid
CR for all other HF covered by private carriers
D
Cardiac Rehabilitation for LVAD, transplant
Slide13>5.1 Million in US have HFIncidence of HF is increasingBy 2050 - 1 in 5 individuals will have HF Primary diagnosis for Medicare hospital admissionsHigh rate of hospital all cause 30 day readmissions – average 25%Cost of HF care in US >$30 billion/year with>50% due to hospitalizations
Heart Failure –
T
he Facts
Slide14Usual HF Patient Management Cycle
14
What
’s missing?
Diet non
adherence
RX non
adherence
Failure to seek
care
Care not readily available
Socioeconomic factors
Inappropriate
RX
Slide152013 ACCF/AHA Heart Failure Guidelines
Every patient with HF should have an evidence based plan of care that ensures GDMT goals, management of comorbid conditions, timely FU with health care team, dietary instruction and physical activities - updated regularly and made available to each patient’s healthcare team.
Effective systems of care coordination should be deployed for every patient with chronic HF to achieve GDMT and prevent hospitalizations.
HF
pts. should receive specific education to facilitate self-care
Slide16Cardiac Rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HR- QOL and mortality.Ex. training (or regular physical activity) is recommended as safe and effective for pts. with HF who are able to participate to improve functional status.
2013
ACCF/AHA Heart Failure Guidelines
Slide17CR has a unique
o
pportunity to provide
HF disease management significantly
impacting clinical outcomes.
Slide18Facilitate self care skills leading to self management – Health Care 90% Self CareHealth coaching and motivational interviewingSupport families/caregivers
CR in HF Disease Management
Slide19Identify barriers – comorbidities (cognition/depression), financial, transportation, educationIdentify resourcesMedication reconciliation
CR in
HF Disease
Management
Slide20Track and communicate clinical variances with physician Facilitate obtaining office visits with fast track interventionMedication adjustment according to diuretic protocol if authorized by physician
CR
in
HF Disease
Management
Slide21And importantly….Collect data and track outcomes with AACVPR
CR in
HF Disease
Management
Slide22Report tracking HF admissions/discharge Inpatient visitsAutomatic CR referrals at dischargeHeart Failure Clinic and Provider OfficesTransitions/Home Health
HF CR Program
Referrals
Slide23CMS Criteria for CR
HF patients….
C
linically stable,
HFrEF
<
35%
O
n optimal medical therapy for at least 6
wks
Cannot have had a
recent
(
<
6wk) and does not have a
planned
major CV hospitalization or procedure in the next 6 mo.
Slide246
week waiting period is an opportunity for CR
to
impact HF care at their facility
Slide256 Weeks of
ENGAGEMENT
Enrollment
telehealth
program
Follow up patient/family calls
S
elf care education/disease management skills – telephone, internet, 1:1 or classes
Schedule
appointment to begin
CR in 6 weeks
Slide26Obtain a reliable scale, record weight daily, monitor for excessive change in body weight – + 3 lb from baseline “dry” weightObserve changes in signs/symptoms of SOB, lightheadedness, swelling, fatigue, cough, nocturia, pillow countContact health care provider promptly for unexpected weight change or increasing symptoms
Self Care Skills/Behaviors for HF Patients
Slide27Develop a system for taking mediation as prescribed-pill organizer, timely refillsLimit dietary sodium intake (<2.0-2.3g/d in most cases)Avoid excess fluid intake (<1.5-2 L/d in most cases)
Self Care Skills/Behaviors for HF Patients
Slide28Do not use dietary supplements or herbal medicines unless approved by HCP or pharmacistAvoid all tobacco products/2nd hand smokeRestrict alcohol intake <2/d M;<1/d FAvoid recreational toxins, especially cocaine
Self Care Skills/Behaviors for HF Patients
Slide29Seek treatment for depression/anxietyDiscuss sleep disturbances w/HCP such as heavy snoringAchieve and maintain physical fitness by engaging in regular exerciseVisit HCP at regular intervals as advised
Self Care Skills/Behaviors for HF Patients
Slide30Monitor coexisting conditions, such as HBP, DM, cholesterol levels, obesity, renal diseaseMaintain current immunizations, especially influenza and pneumococcal pneumoniaFollow prescribed nutrition plan
Self Care Skills/Behaviors for HF Patients
Slide31Patient Assessment – Hx, Medication, Symptom Management, Physical Nutrition CounselingWeight ManagementBlood Pressure ManagementLipid ManagementDiabetes ManagementTobacco CessationPsychosocial ManagementPhysical Activity/Training
CR CORE COMPONENT ELEMENTS FOR THE ITP
Slide32Medical Record – hospital and providerMedical History from patient/caregiver Cardiac – ischemic or idiopathic, valve related, HTN Paced, CRT, ICD Comorbidities and Risk Factors Complex Patients: pulmonary disease, CKD, anemia, depression, sleep apnea, DM, musculoskeletal, neurological, cognitive
Patient Assessment – Medical History
Slide33Medication Reconciliation- dose/frequencyHave patient bring in list/bottles – compare DC instructions and physician OV listAny problems accessing medications? – financial, transportation, refillsMedication compliance – taking regularly what % of the time? Morinsky SurveyMedication scheduleWhat system do they have for taking – who manages? Is your patient on optimal GDMT??
Patient Assessment – Medication
Pharmacologic Treatment for Stage C HFrEF
Slide35LCZ696 from Novartis ………may replace ACEI
New HF Medication
Slide36Current and recent:Dyspnea Fatigue AnginaLightheadedness
Patient Assessment – Signs/Symptoms
Slide37Current and recent:Edema – LE’s and abdominal Cough Orthopnea -how many pillowsCachexiaSleep Apnea – Berlin Sleep Apnea Questionnaire
Patient Assessment – Signs/Symptoms
Slide38Determine the following:ACCF/AHA - Heart Failure Stage (C or D) NYHA Functional Class I-IVACCF/AHA Risk Stratification – High based on EF
Patient Assessment
Slide39Weight and height BP - symptomatic hypotension or orthostatic hypotensionEKG – HR, BBB, pacing, ectopy, atrial fibO2 Sat % - undiagnosed pulmonary componentWaist circumference - abdominal edema?
Patient
Assessment-Physical
Slide40Edema LE 1+ to 4+Lung sounds – baseline rales ?Gait, strength and balance Fall risk, frailty index
Patient
Assessment-Physical
Slide41Assessments Dietary habit assessment toolDaily Caloric Intake- undernourished?Daily Sodium Intake
Nutrition Counseling
Slide42Assessments HR-QOL – Minnesota Living with HF Questionnaire Kansas City Cardiomyopathy QuestionnaireDepression - Beck Depression Inventory Patient Health Questionnaire-9
Psychosocial Management
Slide43Assessments Anxiety, anger/hostilitySocial isolation, marital/family distress Substance abusePsychotropic medications and provider
Psychosocial Management
Slide44Assessment Duke Activity SurveyDays per week of exercise, minutes per dayOccupational and recreational needsActivity of Daily Living needsExercise Stress Test or 6 Min Walk TestMET level of 1st exercise session
Physical Activity
Slide45TypesCardiorespiratory Endurance TrainingResistance TrainingFlexibilityBalance
Exercise Training and Prescription
Slide46Type - Cardiorespiratory Endurance TrainingFrequency 2-3 (CR) progressing to 5+ days/weekIntensity ETT (recommended)55% progressing to 80% HRR=THRWithout ETT/Beta Blocker/ AfibInitial rest HR + 20/ RPE 10-12 …Progressing to RPE 13-14 = THRAfib – use RPE only
Exercise Training and Prescription
Slide47High Intensity Interval Training- selected pts 30 sec-4 min HII followed by LII, 3-5 minTime/Duration – 16-20 min progressing to 40 min-50 min Deconditioned pts. may need rest periods Mode – cardio equipment, walking +++
Exercise Training and Prescription
Slide48Type – Resistance Training Utilize fixed weight machines, hand held weights, body weight for 4-6 primary muscle groupsPost 2-4 weeks of cardio trainingIntensity – UE - 40% 1 rep max progressing to 70%LE – 50% 1 rep max progressing to 70%Frequency 1-2 days/wk, 1-2 sets/dayDuration 12-20 min total
Exercise Training and Prescription
Slide49Type – Flexibility Training Stretching exercises for major muscle groupsEnd of warm up and/or during cool down at least 3 x per weekPurpose to maintain joint flexibilityType – Balance Training Fall risk patients1-2 days per week
Exercise Training and Prescription
Slide50Rate SOB – Dyspnea Scale 0-4More swelling? 0 to 4Difficulty breathing at night/sleeping? Need more pillows?Take all medications? Out of any?Daily weight – chart, morning, trendingLightheadedness? Pain/discomfort? (angina or other) Where and ratingLab work? Next physician appt?
Session Boarding Pass
Slide51Weight Gain > 2-3 lb in a day or 5 lb within a weekWorsening dyspnea (on exertion or rest)Excessive fatigue, lack of energyIncreased edema legs, abdomenIncreased urination at night, nocturiaProductive coughIncreased orthopnea or nocturnal dyspneaLightheadedness/dizziness- hypotensionShock from ICD
HF Red Flags
Slide52Disease ManagementReview of 2013 ACCF/AHA Heart Failure GuidelinesClinical health coaching and motivational interviewingLVAD and Transplant Specific TrainingPalliative care, hospice and EOL decisions
CR Staff Training
Slide53Summary
Heart Failure Facts and
Guidelines
CR in HF Disease
Management
CMS HF
Criteria
Self Care Behaviors
Core Components for CR HF
ITP
Exercise
Training and
Prescription
CR Session Boarding Pass and Red
Flags
Staff Training
Slide54Slide55Yancy, CW, et al. ACCF/AHA Guideline for the Management of Heart Failure. JACC, 2013; 62:e147-e239.American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins: 2014. American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins: 2014.SJ Keteyian, SJ, et al. Incorporating Patients With Chronic Heart Failure Into Outpatient Cardiac Rehabilitation. JCRP, 2014:Volume 34, Number4
References
Slide56Incorporating HF Patients into Cardiac Rehabilitation
Lynne Hamilton Weir, PT, CYT
Lynne.Hamilton.Weir@gmail.com