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 Incorporating Heart Failure Patients  Incorporating Heart Failure Patients

Incorporating Heart Failure Patients - PowerPoint Presentation

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Incorporating Heart Failure Patients - PPT Presentation

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

heart care failure patient heart care failure patient disease management training symptoms exercise physical activity patients assessment prescription cardiac

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Slide1

Incorporating Heart Failure Patients into Cardiac Rehabilitation Kentucky Cardiac Rehabilitation Association 2015 Annual Meeting

Lynne Hamilton Weir, PT, CYT

Slide2

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

Slide3

Heart 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

Slide4

Heart 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

Slide5

The 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

Slide6

HFrEF

HFpEF

Slide7

Slide8

Classification 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

Slide9

Classification 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

Slide10

Classification 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

Slide11

NYHA 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

Slide12

Classification 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

Slide14

Usual 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

Slide15

2013 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

Slide16

Cardiac 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

Slide17

CR has a unique

o

pportunity to provide

HF disease management significantly

impacting clinical outcomes.

Slide18

Facilitate self care skills leading to self management – Health Care 90% Self CareHealth coaching and motivational interviewingSupport families/caregivers

CR in HF Disease Management

Slide19

Identify barriers – comorbidities (cognition/depression), financial, transportation, educationIdentify resourcesMedication reconciliation

CR in

HF Disease

Management

Slide20

Track 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

Slide21

And importantly….Collect data and track outcomes with AACVPR

CR in

HF Disease

Management

Slide22

Report tracking HF admissions/discharge Inpatient visitsAutomatic CR referrals at dischargeHeart Failure Clinic and Provider OfficesTransitions/Home Health

HF CR Program

Referrals

Slide23

CMS 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.

Slide24

6

week waiting period is an opportunity for CR

to

impact HF care at their facility

Slide25

6 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

Slide26

Obtain 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

Slide27

Develop 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

Slide28

Do 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

Slide29

Seek 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

Slide30

Monitor 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

Slide31

Patient Assessment – Hx, Medication, Symptom Management, Physical Nutrition CounselingWeight ManagementBlood Pressure ManagementLipid ManagementDiabetes ManagementTobacco CessationPsychosocial ManagementPhysical Activity/Training

CR CORE COMPONENT ELEMENTS FOR THE ITP

Slide32

Medical 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

Slide33

Medication 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

Slide34

Pharmacologic Treatment for Stage C HFrEF

Slide35

LCZ696 from Novartis ………may replace ACEI

New HF Medication

Slide36

Current and recent:Dyspnea Fatigue AnginaLightheadedness

Patient Assessment – Signs/Symptoms

Slide37

Current and recent:Edema – LE’s and abdominal Cough Orthopnea -how many pillowsCachexiaSleep Apnea – Berlin Sleep Apnea Questionnaire

Patient Assessment – Signs/Symptoms

Slide38

Determine the following:ACCF/AHA - Heart Failure Stage (C or D) NYHA Functional Class I-IVACCF/AHA Risk Stratification – High based on EF

Patient Assessment

Slide39

Weight and height BP - symptomatic hypotension or orthostatic hypotensionEKG – HR, BBB, pacing, ectopy, atrial fibO2 Sat % - undiagnosed pulmonary componentWaist circumference - abdominal edema?

Patient

Assessment-Physical

Slide40

Edema LE 1+ to 4+Lung sounds – baseline rales ?Gait, strength and balance Fall risk, frailty index

Patient

Assessment-Physical

Slide41

Assessments Dietary habit assessment toolDaily Caloric Intake- undernourished?Daily Sodium Intake

Nutrition Counseling

Slide42

Assessments HR-QOL – Minnesota Living with HF Questionnaire Kansas City Cardiomyopathy QuestionnaireDepression - Beck Depression Inventory Patient Health Questionnaire-9

Psychosocial Management

Slide43

Assessments Anxiety, anger/hostilitySocial isolation, marital/family distress Substance abusePsychotropic medications and provider

Psychosocial Management

Slide44

Assessment 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

Slide45

TypesCardiorespiratory Endurance TrainingResistance TrainingFlexibilityBalance

Exercise Training and Prescription

Slide46

Type - 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

Slide47

High 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

Slide48

Type – 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

Slide49

Type – 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

Slide50

Rate 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

Slide51

Weight 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

Slide52

Disease 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

Slide53

Summary

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

Slide54

Slide55

Yancy, 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

Slide56

Incorporating HF Patients into Cardiac Rehabilitation

Lynne Hamilton Weir, PT, CYT

Lynne.Hamilton.Weir@gmail.com