Published in the May 2008 issue of Today’s Hospitalist
If you find that many of your acute heart failure patients are being re-admitted, you’re not alone. Nationwide, “the readmission rate is astoundingly high,” said John R. Teerlink, MD, director of the heart failure clinic at the San Francisco VA Medical Center. “We are not doing a very good job of taking care of these patients.”
At a conference on managing hospitalized patients held at the University of California, San Francisco (UCSF) last fall, Dr. Teerlink noted that 25% of these patients return to the hospital within 30 days for heart failure, and 50% are back within six to 12 months.
Mortality rates are likewise high “5% to 10% within 30 days and 20% to 40% within 12 months, said Dr. Teerlink, who is also associate professor of medicine at UCSF.
Those high rates are due in part, he said, to physicians’ habitual misuse of both acute and chronic therapies. Hospitalists can help reduce these numbers by better differentiating the type of heart failure; knowing what tests to use and what drugs and devices do or don’t work; and doing a better job educating and treating patients on discharge.
Know your patient
Acute heart failure, which accounts for 1 million hospital admissions every year, is not just chronic heart failure gone bad, Dr. Teerlink emphasized.
Patients’ mean age is 75, half are female and many have a previous history of heart failure with multiple severe comorbidities. They usually present not only with dyspnea but also with fatigue and edema, and half have blood pressure above 140 mmHg.
“These are not the crashing, burning, cardiogenic shock patients that heart failure specialists used to think of,” he said.
One of the challenges of making a diagnosis, said Dr. Teerlink, is that while acute heart failure is a heterogeneous syndrome, other etiologies such as ischemia, myocardial infarction and pulmonary embolus must be considered. That makes it important to look at factors such as increased vasoconstriction and to consider prevention, when appropriate, for such precipitating factors as diastolic and renal dysfunction.
Abdominal discomfort is one clue that’s often overlooked, Dr. Teerlink said. Patients with such discomfort are frequently discharged from the emergency department with a typical GI cocktail, only to return two days later with pulmonary edema and heart failure.
Other symptoms to watch for include bloating, anorexia, cough and fatigue. Hospitalists should also note any sleep disturbance, such as insomnia; more than half of heart failure patients have some form of sleep apnea. The best way to evaluate these patients is to actually touch them to look for perfused or cool extremities, Dr. Teerlink advised.
Perhaps the most critical diagnostic tool “though not always the easiest to assess “is jugular venous pressure. “Unfortunately, we are all very bad at this,” Dr. Teerlink said. “There’s nothing that says it has to be evaluated at 35 degrees. It can be 45 degrees, it can be 50. Pick the angle where you can see it best.”
B-type natriuretic peptides (BNPs) can help distinguish patients with heart failure from those whose shortness of breath is due to other causes. But as with any diagnostic test, BNP levels can be increased or decreased by conditions other than heart failure.
Dr. Teerlink advised physicians not to base a diagnosis on any one test, but to incorporate all of the clinical data. Finally, he urged hospitalists to use pulmonary artery catheters to help differentiate between non-cardiogenic and cardiogenic shock in appropriate patients. There is no evidence, he said, to suggest that such catheters hurt patients when used selectively.
The diuretic paradox
In terms of treatment, Dr. Teerlink continued, physicians often fall into a rut of putting patients on diuretics without finessing those therapies. As a result, many patients are either under- or over-diuresed, vasodilators are under-used, and physicians are often confused about when to use inotropes.
Diuretics can cause increased neurohormonal activation, electrolyte disturbances and arrhythmias, and they can worsen renal function. Some investigators have noted that high doses of diuretics are related to increased renal failure and mortality, suggesting that diuretics are over-dosed and too frequently used.
While it may seem obvious to give a diuretic to a patient with a lot of edema, it may be less valuable in some situations. Dr. Teerlink pointed out that there are many patients in whom volume redistribution, rather than volume overload, is the primary precipitant of acute heart failure. “If patients don’t have a lot of fluid or evidence of congestion peripherally,” he said, “they may not actually need a diuretic.”
However, many patients are discharged when they are still congested, which means that they haven’t been diuresed enough; one study found that 25% of these patients on discharge still had edema and 42% had persistent dyspnea on exertion. Dr. Teerlink chalked that up to the fact that physicians are under pressure to discharge patients as soon as possible.
Continuous IV infusion
While diuretics improve urine output, they also can increase creatinine “and if creatinine rises, the patient doesn’t go home. That leads to physicians stopping diuretics too soon, despite ongoing congestion. That also leads to the use of other interventions, such as starting inotropes and placing Foley catheters, which may worsen clinical outcomes.
The solution is to either use intravenous infusions or to lower diuretic doses to get a persistent diuresis and take weight off. “I am very enthusiastic about using continuous intravenous infusions of the diuretic of your choice,” Dr. Teerlink said.
Finally, he urged physicians to be cautious using morphine, which is associated with increased ICU admissions and an increased need for endotracheal intubation. While morphine is useful, Dr. Teerlink said, “it should not be given with impunity to these patients.”
Another common error is under-using vasodilators, even though the drugs are extremely important in patients with volume overload and/or worsening renal function.
All of the major vasodilators “nitroprusside, nitroglycerin and nesiritide “increase cycle GMP and cause venous and/or arterial vasodilation, which reduces pre- and after-load. These medications cause rapid symptomatic relief, are relatively safe, and are a better choice for patients who don’t have evidence of volume overload, such as peripheral edema, and may not need significant diuresis.
However, these agents also can cause hypotension, headache, some tolerance or tachyphylaxis, and they are not the best choice for cardiogenic shock patients.
Dr. Teerlink encouraged physicians to consider using nitroprusside for patients who need rapid, exquisite control of blood pressure and/or left ventricular filling pressures. Although cyanide toxicity is a serious complication, he said that it is exceedingly rare when nitroprusside is used for short durations at typical doses in patients with some renal function. In many centers, non-invasive monitoring can be used, instead of invasive arterial lines
Nitroglycerin lowers wedge pressure effectively, he said, is titratable, and works well in terms of hemodynamics and symptom relief. Nitrate tolerance can develop, but can be addressed in the short-term with aggressive up-titration.
The use of nesiritide, however, has been more controversial. Dr. Teerlink stated that nesiritide lowers wedge pressure, rapidly improves dyspnea and in most cases doesn’t need to up-titrated. While concerns about its effect on renal function and mortality have recently decreased its use, Dr. Teerlink noted that a large, international trial is underway to address these concerns.
Inotropes have a clear advantage because they directly increase cardiac output and organ perfusion. However, as Dr. Teerlink noted, their disadvantages “are legion.” Those include increasing myocardial oxygen consumption and unpredictable hypotension, particularly with bolus dosing. Because inotropes also increase arrhythmias and mortality, physicians should reserve these agents for patients with cardiogenic shock until safer agents can be developed.
Beta-blockers, other therapies
When it comes to beta-blockers, consider halving the dose upon admission, but don’t discontinue unless the patient is in cardiogenic shock. One recent study showed that patients who remained on beta-blockers during their hospital stay, when adjusted for all the reasons why they might have been taken off, had a lower rate of rehospitalization as well as of death. In fact, if patients are not on beta-blockers, Dr. Teerlink advised that you start them.
More physicians are using CPAP for acute heart failure patients, given meta-analysis findings that the therapy improves symptom relief. Other studies, however, have shown that the therapy doesn’t improve mortality when compared to standardized therapy.
“It definitely makes people feel better,” Dr. Teerlink said. “Just don’t do it because you think you’re going to save lives.”
Other effective approaches include hemofiltration, an ultrafiltration system. In one study in which Dr. Teerlink participated, ultrafiltration took off about two liters more liquid than standard diuretic care.
In addition, fewer ultrafiltration patients were re-hospitalized. It’s possible, said Dr. Teerlink, that the findings were due to the type of liquid taken off. Ultrafiltration takes off isotonic fluid, which has more salt than the hypotonic fluid removed by diuretics.
Looking ahead to potential future therapies, Dr. Teerlink pointed to levosimendan, a positive inotrope; vasopressin antagonists, such as tolvaptan; a number of other natriuretic peptides; cardiac myosin activators “positive inotropes that don’t work through a cyclic AMP mechanism; adenosine antagonists, which may improve renal function; endothelin receptor antagonists, which have not yet proved useful; and multiple devices that are being investigated.
Keeping patients out of the hospital
A key factor in preventing rehospitalization is initiating life-saving therapies prior to discharge. These include beta-blockers and ACE inhibitors in patients with reduced systolic function.
Patients also need education to stay out of the hospital, Dr. Teerlink stressed. They should be taught to weigh themselves regularly, to maintain a low-salt weight-reduction diet and to adjust their diuretics. Other professionals, such as nutritionists, physical therapists and occupational therapists, should be part of that educational effort.
It’s also critical for patients to have someone to talk to in the outpatient setting, perhaps through a heart failure management program, especially when they feel worse again. Otherwise, said Dr. Teerlink, “they are going to end up back in the hospital.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.