Redesigning Heart Failure Management to Optimize Patient and System Outcomes
Published Online: October 10, 2013
Lori Wetmore, PharmD, BCPS; William N. Kelly, PharmD; and John F. Trowbridge, MD, CPE
Heart failure (HF) management involves drug therapies familiar to all, such as angiotensinconverting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers (BBs), and hypertension and statin therapies. However, on critical chart review, one typically finds lapses in care continuity and monitoring. Recently, Medicare and JCAHO in the United States and the National Health Service and NICE (National Institute for Health and Care Excellence) in the United Kingdom have focused on whether these therapies are linked into an orderly care process to optimize physical function and quality of life (QOL) for patients, and to decrease avoidable readmissions.
Readmissions are common, with 20% of hospitalized patients readmitted within 30 days and 56% within a year.1 For HF, 90-day readmission rates can range from 30% to 50%.2 High rates of hospitalization reflect patients with HF that are not cured during hospitalization, but stabilized where their care can be managed in an outpatient setting.
In 2003, the Centers for Medicare & Medicaid Services (CMS) reported that 14% of its beneficiaries carried a diagnosis of HF, yet this population accounted for 43% of the total Medicare spending.3 As CMS has moved toward paying for results rather than process, the healthcare industry has had to adapt to earn full reimbursement. Thus, pressure on system managers is intensifying as payers incorporate financial and regulatory penalties for organizations which do not provide connected and consistent care processes. This article reviews current evidence-based drug therapies for HF, and best practices that integrate these recommendations into a patient care framework, improve patient adherence and QOL, and minimize risk of unmonitored deterioration and readmission to acute care— or death.
Treatment Optimization for Progressing HF
HF has historically been divided into 2 distinct classes: those with preserved ejection fraction (HFpEF), and those with reduced ejection fraction (HFrEF). The 2013 American College of Cardiology Foundation/American Heart Association HF Guidelines add 2 subgroups to the HFpEF category: those with borderline ejection fractions (EF 41- 49%), and those with improved EF (patients with previously reduced EF, but now with an EF >40%).4 Several effective therapies have been proved to reduce morbidity and mortality in patients with HFrEF. However, so far, effective medication management has been limited to treating risk factors for patients with HFpEF.
Medication therapies shown to signifi cantly reduce mortality in HFrEF include ACEIs or ARBs, BBs, and aldosterone antagonists. In addition, in the IMPROVEHF analysis, the authors found significant reductions in mortality were additive with each successive therapy, plateauing at 4 to 5 treatments.5 Interestingly, they did not find that aldosterone antagonists provided additional mortality reduction when combined with BBs/ACEIs. This finding is contradictory to the EPHESUS trial which showed an additional relative risk reduction of 15% for all-cause mortality when eplerenone was added to ACEI/BB treatment.6
For all patients with congestion related to HF, managing volume status is essential to controlling symptoms and improving QOL. Loop diuretics are the first-line agent for diuresis because of their powerful effects in the ascending loop of Henle. While proved to reduce symptoms, these medications have shown no benefit on mortality reduction.
For patients classified as A or B (Table), treatments should be aimed at treating comorbidities, reducing risk factors (like hypertension, coronary artery disease, obesity), and introducing lifestyle modifi cations. Where appropriate, it is reasonable to initiate an ACEI/ARB and/or a BB.
As patients progress to stage C, therapies proved to reduce morbidity and mortality should be optimized. One of the challenges in HF management is achieving doses which have been proved effective in clinical trials. Initiation of therapy with a low dose, followed by slow upward titration until maximum benefi t is achieved, is ideal for reducing adverse effects and improving tolerability. This requires a collaborative effort between inpatient and outpatient practitioners, as well as early follow-up upon hospital discharge.
The newest HF guidelines specifically recommend an outpatient practitioner visit within 7 to 14 days of release from the hospital.4 Follow-up is also important for discussions between patients and healthcare practitioners regarding progression to stage D and goals of therapy. HF education is thus crucial to the success of this population.
Once a patient transitions to stage D, medications which were optimized during stage C should be continued, but treatment options need to turn toward advanced heart care programs or palliation/hospice. At this point, medication therapy often becomes challenging due to the signifi cant weakening of the heart resulting in low blood pressures and worsening cardiac output.
Electrolyte management may also pose a problem due to renal insufficiency from poor kidney perfusion. Intravenous inotropes may provide benefit for symptom management, but this is a relatively short-term solution. Established relationships between hospitals, outpatient practitioners, advanced heart care centers, and hospice providers help transition patients once they have reached stage D.
Managing HF Through the Continuum
Having an Evidence-Based Formulary—Most patients are newly diagnosed with significant HF while in the hospital. Thus, the starting point for improving an HF patient’s QOL is having an evidence-based formulary that only includes HF drugs that have been proved to be better (more effective and safer) than other HF drugs.7
Providing Evidence-Based Therapy—The next step is to provide the evidence-based therapy according to the latest clinical guidelines.4 The evidence showing that providing evidence-based therapy in HF patients is robust. The number needed to treat (NNT)—the number of people needed to be treated, on average, to prevent 1 more event—is often used to judge the effectiveness of therapy. For example, a systematic review of the impact of BBs on the secondary prevention of HF discovered the numbers needed to treat to prevent death or hospitalization and death after 1 year were 17 and 12, respectively.8 When using ACE inhibitors, the NNT was 20 for death and 3 for hospitalization after 3 years of therapy.9
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