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Management of End Stage Heart Failure PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Management of End Stage Heart Failure" by Dr Sharon Chadwick FRCP.

This medical PowerPoint presentation talks about Management of End Stage Heart Failure.

End-stage heart failure (HF) is a severe and life-limiting condition that requires intensive management. The key points for managing end-stage heart failure include Medications, Implantable devices, Cardiac rehabilitation, Palliative care, Heart transplant and End-of-life care.

Tags : Management of End Stage Heart Failure, End Stage Heart Failure, heart failure, cardiology, cardiology PowerPoint presentation

Published on : Mar 19, 2023 | Views : 1745 | Downloads : 0

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Slide 1-

Best Practice Management of End Stage Heart FailureDr Sharon Chadwick FRCPConsultant in Palliative Medicine
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Objectives By the end of this session you will: Feel more confident to manage end stage heart failure Understand the complexities of managing advanced heart failure Feel able to address symptom control needs Be more pro-active in discussing advance care planning Be aware of the ethical dilemmas that might arise Consider what is right for the individual patient and family Consider how best to foster relationships locally to provide the best care for patients and families Know who to ask for help
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The Facts ‘A burgeoning clinical cohort with left ventricular systolic dysfunction’ Approx 900 000 people affected in the UK 60 000 new cases per year Many with multiple comorbidities A progressive, incurable and ultimately fatal long term condition End of Life Care in Heart Failure: A Framework for Implementation. NHS End of Life Care Programme 2014
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Typical course of heart failure
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Increasing age Dependent for more than 3 activities of daily living Cardiac cachexia Resistant hyponatraemia Serum albumin less than 25g/l BNP ≥ 400 pg/ml Multiple shocks from ICD Comorbidities especially cancer poor prognosis End of Life Care in Heart Failure: A Framework for Implementation. NHS End of Life Care Programme 2014
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considerations Patients with advanced heart failure are likely to have multiple hospital admissions in the last year of their life Patients are walking a tightrope between renal impairment and fluid overload Prognosis is more difficult to predict in heart failure than in any other life limiting illness
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Prognostic Paralysis Fears of HCPs around introducing about palliative care too early mean People dying unprepared Indaequate symptom control No advance care planning = no choice
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Potential problems for the individual patient Multiple comorbidities LVF Angina Atrial fibrillation COPD Peripheral vascular disease Impaired renal function Diabetes mellitus Cerebrovasular disease Osteoarthritis Depression Falls Polypharmacy
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Potential problems for the individual patient Multiple symptoms Dizziness Breathlessness Peripheral oedema Nausea Constipation Immobility Constipation Pain Low mood Fatigue Social isolation
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Breathlessness ‘I feel old’ ‘I feel depressed and unwell’ ‘I’m not sleeping’ ‘I’m spending too much time in hospital’ ‘Too many tablets’ ‘Can’t talk to my family -I don’t want to burden them’ ‘I just can’t get my head round it all’ End stage heart failure- what is it like for the patient
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Whatever the aetiology there is a high symptom burden (O’Leary N et al 2009) Quality of life can be poor for both patients and carers (Squire I et al 2017) Often multiple comorbidities Inevitable deterioration Life limiting illness with increasing hospital admissions due to either fluid overload or acute on chronic renal failure in the final stages of the disease (Brännström M, et al 2014) Palliative Care in Heart Failure
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Palliative Care in Heart Failure Symptom control (physical)
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SYMPTOM CONTROL Breathlessness - non pharmacological measures (fan, pacing) - opioids, start low go slow. Morphine liquid 1 -2ml (2 to 4mg) twice or three times daily or oxycodone 1 to 2 ml twice daily Leg swelling - elevation, light compression stockings. Whose problem? Increase diuretics? Difficulty sleeping - why? Sleep hygiene, reduce fluid intake during evening, screen for depression Swollen abdomen - is this constipation, is it ascites Confusion - check electrolytes, check drugs, possibly vascular dementia, always screen for infection
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Depression and anxiety – consider CBT as well as drugs Adjustment reactions Guilt Fear of being a burden Fear of dying and fear of being dead Why me? Legacy Palliative Care in Heart Failure Symptom control (psychological and existential)
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Palliative Care in Heart FailureThe Calman Gap Calman K 1984
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Potential problems for the individual clinician Too many symptoms Too many drugs Devices that we are unfamiliar with Don’t know where to start Not enough knowledge Fear of making things worse Reluctant to stop drugs colleagues have started New drugs, new interventions, difficult to keep up
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New developments in heart failure So many!!! Entresto – sacubitril/valsartan – reduces death and hospitalisations form HF Ivabradine- direct action on SA node Iron infusions- improve exercise capacity, reduce hospitalisations and improve renal function SGLT2 inhibitors – improve cardiovascular and renal outcomes even in those without type 2 DM CRT-Ds
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Don’t panic!! Help is at hand Community heart failure team –previously only for those with LVSD. Now able to help with valvular HF, HF-PEF, RV failure. Palliative care – variable experience and knowledge. But…. will work together with the HF team to help with symptom control
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Let the patient set the agenda for the consultation Beware oxygen for breathlessness in heart failure Remember non-pharmacological management of breathlessness Fatigue is often a key symptom-check for reversible causes including anaemia, low potassium, hypotension Always check pulse, blood pressure, heart rate and renal function before making any changes Review medication but don’t rush this and whenever possible consult with the heart failure nurse specialist. Deprescribing is as important as prescribing. Top tips
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Medication review-key points Remember that in heart failure, beta blockers, ACE inhibitors and diuretics and spironolactone improve prognosis and symptom control Be wary about stopping anti-anginals too quickly ESPECIALLY if there is any suggestion that the patient has had recent chest pain Be very cautious about stopping beta blockers and if you do plan to stop them, do this gradually Stop the statin, the calcium and vitamin D supplements, the bisphosphonates, the iron, folate and vitamin supplements
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Atrial fibrillation Focus on rate control (beta blocker, rate limiting calcium channel blocker-diltiazem, verapamil, or digoxin) Risk calculated according to CHADS-Vasc score Score of 6 = 18.2% risk of CVA Score of ≥ 2 give anticoagulation Options are: warfarin, apixaban, dabigatran etexilate, rivaroxaban.
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Chads2-vasc Age in Years Sex Congestive Heart Failure Hypertension CVA/TIA/Thromboembolism Vascular Disease Diabetes Mellitus <65yrs=0, 65-74yrs=+1, ≥75yrs=+2 M=0, F=+1 Yes=+1, No=0 Yes=+1, No=0 Yes=+2, No=0 Yes=+1, No=0 Yes=+1, No=0 Score 0-9 Score ≥2 is high risk Atrial fibrillation: diagnosis and management NICE guideline Published: 27 April 2021 www.nice.org.uk/guidance/NG196 1.2.2 Use the ORBIT bleeding risk score because evidence shows that it has a higher accuracy in predicting absolute bleeding risk than other bleeding risk tools. Accurate knowledge of bleeding risk supports shared decision making and has practical benefits, for example, increasing patient confidence and willingness to accept treatment when risk is low and prompting discussion of risk reduction when risk is high.
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ORBIT Bleeding Risk Score for Atrial FibrillationPredicts bleeding risk in patients on anticoagulation for AF. Sex Male Female Age >74 years No 0 Yes+1 Bleeding history Any history of GI bleeding, intracranial bleeding, or hemorrhagic stroke No 0 Yes+2 GFR <60 mL/min/1.73 m2 No 0 Yes+1 Treatment with antiplatelet agents No 0 Yes +1 Score: 2 points= low bleeding risk. 2.4 bleeds per 100 patient years 3 points= medium bleeding risk. 4.7.bleeds per 100 patient years 4 points =high bleeding risk 8.1 bleed per 100 patient years
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Devices (ICDs & PPMs) Its complicated! PPMs-for heart block CRTDs- for heart failure with LBBB at risk of VF or VT CRT-P for those with HF and LBBB for whom defibrillation would not be appropriate ICDs for those at high risk of persistent VT or previous VF. 20% patients dying with an active ICD in situ receive shock(s) as they are dying
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AN ILLUSTRATION
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Mr PW 84 years old. Severe heart failure, EF 23%. CRT-D, atrial fibrillation, COPD, NIDDM, renal impairment, gout, peripheral vascular disease, previous CVA 3 admissions in last 6 months. 2 for decompensated heart failure, 1 with infective exacerbation of COPD. General significant decline in last 6 months Some cognitive impairment CRT-D has never fired
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MR PW Current medication Bisoprolol 7.5 mg twice daily Allopurinol 100 mg dailyLansoprazole 30 mg at night Ultibro Breezhaler one puff dailyEzetimibe 10 mg daily Bumetanide 1 mg dailySodium chloride nebulisers Metformin 500mg twice daily Entresto 97/103 1 tablet twice daily Salbutamol inhaler used if needed Prednisolone 15 mg daily (reduced from 40 mg daily, to be further reduced by 5 mg every three days for gout) Ferrous sulphate 200mg three times daily Movicol 2 sachets twice daily
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Current issues: Nausea Fatigue Aching in legs Constipation/diarrhoea Breathlessness on exertion Too may drugs Too many hospital appointments Frustrated in not being able to do the things that he wants to do
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On examination Pulse 48 regular, BP 95/55. Chest clear. No ankle swelling. Blood results Na 136, K 4.5, Ur 14 Cr 142 eGFR 50 LFTs –mildly deranged in keeping with hepatic congestion BNP 1435 BMs 4 to 6
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Hospital Appointments Cardiology- 3 hospital consultants and a heart failure nurse Respiratory- 2 hospital consultants with associated CT chest booked and PFTs and an arms length respiratory nurse specialist Rheumatology-investigations and F/U clinics (for gout) Vascular-Investigations and followup clinics Diabetes specialist clinic Nephrology- initial appointment and associated investigations
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Plan Rationalise medication Reduce Bisoprolol Stop ezetimibe Consider need to restart edoxaban Titrate up allopurinol according to renal function Try reducing/stopping lansoprazole once prednisolone has stopped Stop Movicol and start sodium picosulphate Rationalise hospital appointments Check ECG, check bloods ACP discussion Consider deactivating ICD Following chest CT and PF
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Key moral/ethical considerations Stopping drugs that improve prognosis to achieve better quality of life To anti-coagulate of not to anti-coagulate in AF Deactivation of ICDs Has the device recently fired or fired at all Need to explain that deactivation does not mean certain or imminent death Risk of VF less as disease progresses DNACPR in those with an active ICD Would prevent CPR in the event of an irreversible asystolic arrest or PEA
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A Plea from me Please, in your daily work Consider referral to palliative care for deteriorating symptomatic patients both those with cancer and non-cancer (including frailty) Consider if you would be surprised if your patient dies in the next year If you would not be surprised, address advance care planning including preferred place of care, preferred place of death, if they want to go to hospital if they deteriorate, DNACPR, prescription of JIC medicines. Make sure that you discuss this with family members too. If you can do this, it will make life so much easier for you and your colleagues and will improve the way that people die
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An opportunity! To help patients understand that they may have a poor prognosis To explain choices that individuals may or may not have To start conversations in families about what might lie ahead To help people to understand that they are not going to live forever! Advance Care PlanningWhat is it?
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Advance Care Planning Preferred place of care DNACPR ‘Just in Case’ drugs List of contact numbers Power of Attorney Resuscitation Discussion about wills and funerals Planning for the worst, hoping for the best’
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Just in case drugs Morphine 2.5 to 5mg s/c prn or if eGFR <30ml/min, oxycodone 1.25 to 2.5mg s/c prn. For pain or breathlessness Midazolam 2.5 to 5mg s/c prn For breathlessness or agitation Haloperidol 1.5mg to 3mg For nausea or hallucinations Glycopyrronium 200 to 400mcg s/c For excess secretions Furosemide 40mg s/c prn (2 x 20mg/2ml) For peripheral or pulmonary oedema
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When should we do it? Following a change in circumstance New diagnosis Deterioration in condition Hospital admission Admission to a care home If given a relevant cue by a patient Use of the GSF (Gold Standard Framework) Prognostic Indicator Guide or SPICT (Supportive and Palliative Care Indicators Tool)
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Remember……. Always know the indication for each individual drug Beta blockers for heart failure, angina, rate control Warfarin for AF or metallic valve Always consult with the heart failure nurse or if not known to them consult with GP Verapamil & diltiazem should be avoided Make sure you know about other PMH including TIAs, CVAs, bleeds etc Gradually wean off medicines and check pulse, BP and bloods regularly during periods of change
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And finally……. For patients with a pacemaker/ICD be even more cautious about discontinuing drugs with a potential rate controlling or anti-arrhythmic effect Always discuss with a cardiologist Be very clear about what you are trying to achieve when adjusting medication and explain clearly to patients and when appropriate, their families Think carefully about DNACPR discussions with those who have an active ICD