Part 2 MHFS, how to build MDHFP
- 1. Dr Asadullah Khan Soomro Adult Cardiology department Dr Awwad Albishri Hospital Holy Makkah. MHFS Building Multidisciplinary Heart failure Programme ( MDHFP ) in KAMC/ Makkah Healthcare cluster Holy Makkah Part 2
- 3. MHFS Introduction Heart Failure is a complex clinical syndrome and leading cause of mortality and morbidity Globally and in KSA indeed. The cost of caring for HF patients is enormous , especially ( 77-80% ) on hospitalization. Overall prevalence of HF has declined but at the cost of increased rate of ist admission and re-admissions, despite our patients are 10-15 years younger than western counterpart. HF services are fragmented ,there are imminent communication gaps amongst stakeholders, with the result, there is suboptimal transition of care and gaps in implementation of GDMT.
- 4. MHFS Why Heart Failure is on rise? HF population is on rise and will continue to increase in coming decades, due to increased rates of metabolic syndromes, diabetes , improvements in treatment of myocardial ischemia & infarction , cancer , cardiac intervention & last not the least increased trend of offending drugs ( Captagon, Alcohol & hashesh) in young generation. Patients are also living longer due to the spectacular gains from heart-failure medications. This means that we will continue to see much more heart failure in the community in the coming years. Advances in heart failure therapies, including medications and devices, promise that this will continue to be a dynamic and changing chronic disease.
- 5. MHFS Need for MDHF Programme For these reasons, KAMC & MHC has shown interest in development and refinement of high performing MDHFP ( multidisciplinary heart failure programme ) & network of HF clinics in Makkah healthcare cluster, to provide guideline- directed, technology-enabled, high-quality comprehensive care at low cost. The specific consideration put forth are broadly categorized in two parts. 1) Patient Care Consideration for delivering Guideline directed & patient-centered care. 2) Operational consideration, which focus on optimizing the structure & efficiency of the programme.
- 6. MHFS Steps to build MDHFP Any institution seeking to launch a HF programme ,should be aware about following steps before beginning that endeavor ( HFSA tool kit approved by multiple stakeholders ). 1) Establish the goals of ( MDHFP ) multidisciplinary heart failure programme. 2) Develop referral criteria & publicize criteria within community. 3) Determine specific HF population ( Stage A to D ),and which patient to be seen where ( level I to III ).
- 7. MHFS Steps to build MDHFP 4) Assess physical location for the clinic, and type of HF patient ( RAHFC ) 5) Appoint MDHFP director / Governor and HF clinic leaders/Co- ordinators. 6) Determine/appoint MDHFP staffing model, HF physician/dedicated medical specialist interested in HF, Clinical/HF nurse. In addition , allied health professionals ( Pharmacist, educationist/nurse, nutritionist, exercise physiologist/physical therapist, psychologist/social worker, Financial/Admin Coordinator.
- 8. MHFS Steps to build MDHFP 7) Create clinic appointment structure, ( new patient, follow up, urgent ). 8) Develop clinical practice pathways & protocols ( Inpatient/outpatient) 9) Develop partnership with other relevant subspecialists ( Nephrology ). 10) Develop partnership with frequently used clinical services ( EKG, Echo, CMRI, CPET, Cath lab, cardiac rehabilitation ,palliative care.) 11) Develop a technology and Virtual visit infrastructure . ( Optional ) 12) Establish mechanism for patient follow-up . 13) Create hospital coverage plan. 14)Determine mechanism for quality improvement 15) Develop Business plan for HF clinic 16) Build research network ( Optional ) 17) Obtain appropriate accreditation ( JCI, AHA,ACC ) ( Optional)
- 9. MHFS Goals of MDHFP 1) Identify Patients with HF . 2) Evaluate etiology of HF and establish an appropriate diagnosis 3) Develop clinical care pathway . 4) Initiate & titrate guideline directed medical therapy ( GDMT) 5) Provide education & selfcare material to HF patients . 6) Refer patient with confirmed or suspected diagnosis to ( RAHFC ) to grade II HF clinic or advanced HF center if fullfill criteria ( Ref to “ I NEED HELP “ ) 7) Develop mechanism for continous quality improvement. 1) Same as grade I HF clinic . 2) Use structured medications up- titration to reach GDMT doses of medications. 3) Evaluate and consider for device therapy ( CRT, ICD ) . 4) Provide education & selfcare material to HF patients . 5) Refer patient with confirmed advanced HF to Grade III center if fulfill criteria ( Ref to “ I NEED HELP “ ) 6) Discuss prognosis with patient . 7) Develop mechanism for continuous quality improvement 1) Same as in Grade II HF clinic 2) Evaluate patient for home inotropic therapy ,mechanical circulatory support ( MCS ) ,and orthotopic heart transplant (OHT ) 3) Provide ongoing care ( as mentioned above. 4) Monitor quality improvement For Academic institutions, consider scholarships for fellows and nurses in heart failure ( National/International) Grade I Community HF Clinic Grade 11 General Cardiology /HF clinic Grade 111 Advanced HF Clinic
- 10. MHFS HF Care Considerations The specific consideration put forth are broadly categorized in two parts. 1)Patient Care Consideration for delivering Guideline directed & patient-centered care. 2)Operational consideration, which focus on optimizing the structure & efficiency of the programme.
- 11. MHFS HF Patient Care Considerations 1) New Patient Evaluation 2) Follow-up visits after initial assessment. 3) Medical therapy evaluation 4) Device Therapy Evaluation 5) Functional status assessment 6) Quality of Life Assessment 7) Administration of I/V diuretics ( Outpatient infusion center ) 8) Outpatient management of inotrope therapy 9) Palliative and End-of-life Care
- 12. MHFS New Patient ( De-novo HF ) Evaluation Main Goal of HF Service ( public or private model I to III ) for any new HF patient is to confirm diagnosis of HF and its etiology. Specific consideration should be given to several mimics of HF including primary pericardial diseases, chronic lung , renal and liver diseases . Diagnosis of HF is mainly based on detail history and thorough physical / CV examination ( sign & symptoms ) followed by blood work, EKG, X-ray and echocardiogram. Most of the patients with mild to moderate symptoms usually go to community family physicians and severe symptoms directly go to emergency department of nearby hospital and are usually admitted , or after symptom improvement go DAMA. If no appropriate action or alternative available ( like rapid access HF clinic RAHFC /SDHFC ),then they suffer a lot until diagnosis is established , they are either complicated to severe acute HF/Cardiogenic shock or die suddenly.
- 14. MHFS NEW ONSET HEART FAILURE JOURNEY RAHFC ( RAPID ACCESS HEART FAILURE CLINIC ) Patients with severe symptoms Before diagnosis of Heart Failure go to emergency. Patients with Mild to moderate symptoms Before diagnosis of Heart Failure usually go to family physician POST DISCHARGE With in 7-14 days Out Patient Multi disciplinary Clinic Phased based Inpatient Care Heart Failure Clinic Community HF Clinic Long Term Heart Failure Management NO Heart Failure Disposed Or Follow up as Stage A& B Heart failure Cath Lab OR CCU Ward Treated & go DAMA Admission
- 15. MHFS Follow Up Visits. After the initial assessment ,a focus should be placed on initiation of GDMT and escalation to the target or maximally tolerated doses with in 3- 6 months after confirmation of a diagnosis. It should be achieved in stepwise fashion with clinical and lab monitoring. Patients with HF and LV systolic dysfunction ,who do not have recovery Of EF to > 35% with target or maximally tolerated GDMT should also be assessed for for ICD or CRT. Emphasize on HF education and self care zones, for self-titration of diuretics according to home monitoring weight and worsening of symptoms .
- 16. MHFS Medical Therapy Evaluation Guideline Directed Medical Therapy ( GDMT ) prescription, dose titration and adherence ,is the cornerstone treatment for heart failure , and is primary responsibility of the heart failure clinic. In heart failure with LV systolic dysfunction, evidence from large clinical trials and clinical guidelines strongly support use of “triple therapy” at target doses as tolerated , which includes ACEI/ARB/ARNI ( class 1 recommendation to switch to ARNI ) , Beta-blockers and mineralocorticoid receptor antagonist ( MRA) . They all proven to improve. 1) Survival 2) Reduce hospitalization 3) Improve Quality of life
- 17. MHFS Medical Therapy Evaluation Despite strong guideline recommendations and evidence there remain major gaps in use , dosing and target dose titration ( as tolerated ) .These gaps have not meaningfully improved in the past decade ,but vary widely across practices. Across all components of triple therapy ,up to 50% - 80% of patients eligible ,remain on stable subtarget doses or no dose indefinitely. Each patient encounter should be recognized as an opportunity to initiate and up-titrate GDMT, up to target dose as tolerated. Stable symptoms should not be primary reason for not escalating GDMT ( Risk of mortality /SCD in HFrEF ) For patients not receiving GDMT or receiving subtarget doses , justification and clear documentation should be present in the medical record . If prior symptoms or adverse events on up-titration , should also be documented.
- 18. MHFS Device Therapy Evaluation The role of implantable cardiac devices for heart failure is rapidly evolving. ICD & CRT ( Cardiac resynchronization therapy ) remain with strong guideline recommendations, but field has expanded recently for CardioMEMS device as an implantable hemodynamic monitor, and transcatheter mitral valve repair ( Mitra clip )for significant mitral regurgitation .
- 19. MHFS Device Therapy Evaluation Before Device implant as per clinical guidelines , Do not hurry especially in de- novo heart failure with slow pace of GDMT initiation and dose titration. Take care of at-least few things 1) Thoroughly look for reversible causes of LV systolic dysfunction 2) 3-6 months should be allowed to assess LV recovery & MR regression especially in idiopathic non dilated non ischemic cardiomyopathy with optimal GDMT. 3) Life expectancy and functional class should be reviewed in context of clinical guideline recommendation ( Treat Patients not just MR /LVEF) 4) Open discussion amongst stakeholders regarding benefits of device therapy at the cost of long term risk ( like Device infection ) & alternative. Educate them about periodic device interrogation ,alerts ,inappropriate shocks & monitoring
- 20. MHFS Functional Status Assessment The functional status evaluation is an important component of all new onset and follow-up HF patients visit. Three methods have been subject to extensive research and clinical use. 1) New York heart Association ( NYHA 1-IV ) functional class .This is very old method ,and has been used as one of the eligibility criteria in HF trials. Worsening FC correlates with a stepwise increase in the risk of death and hospitalization. 2) 6 – minute walk test ( 6MWT ) The 6MWT is a simple and objective measure of functional capacity that correlates moderately with peak oxygen uptake .A threshold 6MWT of 300 m has been traditional benchmark for increased mortality risk . Ideally this test should be performed in HF clinic visit ( as feasible) in efforts to detect subclinical worsening of functional status. It has limitations in advanced age , obesity , artheritis & COPD patients.
- 21. MHFS Functional Status Assessment 3)Cardio-pulmonary exercise test ( CPET ) Measured peak oxygen uptake ( Oxygen consumption) .It is most objective means to evaluate exercise capacity in patients with HF. It can be performed via treadmill or bicycle protocol . CPET may be considered to inform patient candidacy and necessity for advanced HF therapies ,( like heart transplant or LVAD implantation ) and to differentiate cardiac versus non-cardiac causes of dyspnea and fatigue . This is specialized equipment and need trained personnel to conduct and interpret a CPET and is not available at all centers.( not in holy Makkah ) . Last not the least Novel wearable accelerometers to measure daily activity level.
- 22. MHFS Quality of Life Assessment 1) Monitoring and optimizing heath related quality of life and patient reported outcomes ( PRO) is an important goal of the HF clinic. 2) To ensure a patient centered experience ,it is important to accurately and validly capture patient s experience with HF. 3) PRO ( patient reported outcomes) is a instrument provide a “standardized history “ in that they directly ask patients relevant questions about their health the same way each and every time.
- 23. MHFS Quality of Life Assessment 4)There are multiple valid , reliable , and sensitive PRO instrument available ,the most well –studied is the Kansas City Cardiomyopathy Questionnaire ( KCCQ -12 ) and Minnesota Living with HF questionnaire. Last not the least is Euro QOL -5 dimension is generic instrument. 5) It is recommended that all HF clinics strive to incorporate a standardized and routine assessment of patient quality of life with a validated PRO instrument .PRO are strongly associated with subsequent risk of death and hospitalization.
- 24. MHFS (SDAHFC ) Same day access (out patient based ) Heart Failure Clinic Outpatient based I/V Diuretic therapy 1) Approximately 90% of patients hospitalized for HF may receive I/V diuretic therapy and many receive no other IV therapies before discharge. 2) Recognizing that diuresis is the primary intervention during most hospitalizations for HF and that some patients quickly improve with in few hours. 3) Therefore why not to offer this facility at outpatient level in selective patients ,which is less costly then recurrent visits to ER and hospitalization. 4) It just require dedicated space to administer I/V diuretic, observe them ,monitor renal function and electrolytes and can go home. 5) Same day access HF Clinic visit may be either scheduled in advance or walk-in visit for worsening of symptoms. Assigned staff has to be available .
- 25. MHFS (SDAHFC ) Same day access (out patient based ) Heart Failure Clinic Outpatient based inotropic therapy 1) There are two scenarios in advanced HF where ( Milrinone , dobutamine , dopamine ) is common treatment strategy . One advanced HF patient bridged to heart transplant or durable LVAD decision 2nd patients not eligible or declined for advanced therapies and is on palliative care at home or hospice .These patients may benefit from continuous infusion. Its difficult but not impossible alternative to ER and recurrent hospitalization. 2) This area can be utilized for dose monitoring ,increase or decrease , Vitals, blood sampling and to assess complication related to CVP line infection or ICD shocks . 3) These patients have bad prognosis, so advance planning by patient family and caregivers is critical.
- 26. MHFS Palliative & End-of-Life Care Despite the recommendations, palliative care for heart failure remains underused and is almost exclusively used in the inpatient setting. 30% Patients with heart disease especially heart failure are bedbound ,yet palliative care consultations occur in the last month of life. Patients with HF are more likely to die in a medical facility and less likely to die at home as compared to cancer. Recognizing common symptoms of heart failure ( Like breathlessness & edema ) are relatively easy ,but attention should be paid to less obvious HF symptoms ( Like pain, anorexia & depression ) and palliative care intervention improve quality of life in end stage HF syndromes. Dedicated palliative care specialist should be consulted early and advanced directives may be documented in electronic medical record. Discussion should involve not only patient but with caregivers and payers indeed. Disease prognosis ,goals ,transition to hospice care ,power of attorney and DNR may also be discussed and documented in EMR.
- 27. THANK YOU Living Longer, Living Well