Heart Failure J. Lynn Davis, M.D. Cardiologist CHI St. Vincent Heart Clinic Arkansas April 25, 2015

Heart Failure HFrEF reduced EF, usually defined <40% CMS:“acute systolic HF”, “chronic systolic HF”, “acute on chronic HF” must be specified at time of discharge HFpEF preserved EF, usually defined >50% CMS: “acute diastolic HF”, “chronic diastolic HF”, “acute on chronic diastolic HF” must be specified at time of discharge

HFrEF causes CAD dilated cardiomyopathy 50%idiopathic 9% Myocarditis 5%Infiltrative (ex.,amyloid) 1-4%Peripartum, HIV, connective tissue disease, alcohol, substance, chemotherapy each 10%other hypertension valvular disease

HFpEF causes hypertension CAD hypertrophic (obstructive) cardiomyopathy restrictive cardiomyopathy pericardial disease (constrictive) idiopathic older women

NYHA functional class Class I no sx with normal activity Class II sx with normal activity; no sx at rest Class III sx with less than normal activity; no sx at rest Class IV sx at rest

HF Stages Stage A no structural heart disease, no sx, high risk Stage B structural heart disease, no signs or sx, high risk Stage C structural heart disease, prior or current sx any functional class (usually I,II,III) Stage D refractory HF requiring special interventions

HF treatment - office loop diuretics ACE inhibitors ARBs beta-blockers hydralazine + nitrates aldosterone antagonists

HF treatment - office loop diuretics – furosemide – bumetanide – torsemide – main goal is sx improvement – monitor Na, K, Mg, BUN/Cr closely

HF treatment - office ACE inhibitors captopril enalapril lisinopril start low dose titrate to highest dose tolerated improves survival less effective in AA

HF treatment - office ARBs alternative to pts who cannot tolerate ACEI candasartan is most studied in HF HF benefits in ARBs may increase with age may be used if already on ARB for another reason may be added to ACEI in selected patients, if carefully monitored. do not use ARB if recent MI do not use with ACEI and aldosterone antagonist combination

HF treatment - office Beta blockers Metoprolol Succinate (XL) – Start mg daily – Benefit best 200mg/d Carvedilol – Start 3.125mg BID – Increase to 25mg BID if tolerated – May cause more hypotension than metoprolol Bisoprolol – Start 1.25mg daily – Increase to 5-10mg daily if tolerated

HF treatment - office hydralazine + nitrates if ACEI and/or ARBs not tolerated usually rising Cr, hyperkalemia, hypotension in AA, may be added to ACEI/ARB if HF sx persist in non-AA, little benefit to add to ACEI/ARB in original HF trials (1970’s/1980’s), hemodynamic benefits similar to ACEI but mortality benefit less

HF treatment - office aldosterone antagonists compete with aldosterone for mineralocorticoid receptor prolong survival NYHA class II-IV and EF <35% cannot use for GFR 5, monitor q 2weeks cannot use with ACEI/ARB combination spironolactone – inexpensive – has nonselective binding to androgen/progesterone receptors eplerenone – Expensive, less endocrine binding, use if spironolactone not tolerated

HF treatment JACC Heart Failure, vol 2, number 5, p 547, (Oct 2014)

Causes of HF decompensation CV Factors Ischemia or infarction Uncontrolled hypertension Unrecognized primary valvular disease Worsening secondary mitral regurgitation New onset or uncontrolled atrial fibrillation Ventricular arrhythmia Acute pulmonary embolism

Causes of HF decompensation Systemic factors Superimposed infection Medications that suppress LV function Anemia Uncontrolled DM Thyroid disorders Worsening renal function Pregnancy

Causes of HF decompensation Patient factors Medication noncompliance Salt Worsening obesity Alcohol abuse Substance abuse

HF treatment - inpatient Correct anything correctable infection hypoxemia hypertension Ischemia arrhythmias hypotension electrolyte disturbances renal failure thyroid disease

HF treatment - inpatient iv diuretics, morphine intubation, mechanical ventilation inotropic support intravenous vasodilators intravenous vasopressors hemodialysis ultrafiltration mechanical support hemodynamic monitoring urgent cardiac cath/intervention, urgent CV surgery transplantation

HF treatment – newer agents Tolvaptan vasopressin receptor antagonist used for hyponatremia Serelaxin (relaxin) Naturally occurring peptide vasodilator TRV-027 biased ligand of angiotensin II type 1 receptor (AT1R) BLAST-AHF trial underway

How do hospitals get paid? Diagnosis-related-groups (DRG) Core Measures Case Mix Index Multipliers for geographic factors related to labor, local wage index, interns/residents, “disproportionate care” ACA (2010): added Value Based Purchasing, started FY2013

Value Based Purchasing 45 quality measures tracked 13 quality measures used in 2013 report acute MI, HF, pneumonia, surgical meds patient satisfaction (30%) Modifier for mortality, readmission rates Total performance score calculated based on “achievement” and “improvement” Each hospital gets total score

Value Based Purchasing 2013: 1% of DRG payment at risk 2016: 2% at risk 2 midnight rule for inpatient payment (DRG) Hospitalcompare.com physician payment reform is probably next