Published in the July 2014 issue of Today’s Hospitalist
NINE TIMES OUT OF 10, when a person with heart failure needs to be admitted, that’s due to congestion. And helping patients shed their excess fluid is usually the most important goal of their hospitalization.
Related article: “Are you over-testing troponins?,” September 2017
Unfortunately, according to a Johns Hopkins cardiologist who spoke about heart failure at a cardiology precourse during this spring’s Society of Hospital Medicine conference, that doesn’t always happen. Too often, patients are given a dose of diuretics, lose some water weight, feel better, and are sent home on oral diuretics and instructions to follow up with outpatient physicians.
“That is the wrong approach,” explained Ryan J. Tedford, MD, a heart failure specialist in the division of cardiology at Johns Hopkins School of Medicine in Baltimore. Before discharge, “we want to get rid of all of the fluid,” not just some of it. That way, patients have much more reserve if they gain a few pounds at home, instead of ending up “back in extremis and back in the hospital. You have a bit more time to make changes in their home regimen and hopefully prevent a rehospitalization.”
Rehospitalization is bad both for patients, whose risk of mortality increases every time they are hospitalized, and for hospitals being penalized by Medicare for potentially avoidable heart failure readmissions. Nationwide, about one-quarter of patients hospitalized for heart failure are readmitted within 30 days. Patients also have a 30% chance of being either readmitted or dying within 90 days after being discharged from a hospital.
In addition to discharging still “wet” patients from the hospital too soon, Dr. Tedford said another common mistake he sees is failing to recognize that a patient has congestion in the first place.
It is important to pick up on signs of congestion, said Dr. Tedford, not only to know how to treat hospitalized heart failure patients “the treatment for “dry” patients is different “but also to know how long and aggressively to treat them.
Hospitalists need to know that “fluid can hide in a number of places.” This is particularly true for patients lying in bed all day, and Dr. Tedford reminded hospitalists to examine patients’ thighs and backs for signs of edema.
Too, “the lack of edema doesn’t necessarily mean that there is no congestion,” Dr. Tedford said. Some patients with advanced heart failure “have gotten acclimated to higher pressures and can very quickly clear excess fluid from their legs and lungs.”
As a result, doctors should not “be fooled by the lack of pulmonary rales or the lack of congestion on X-ray,” he added. Listening for crackles is “not a physical exam tool that I pay too much attention to in my heart failure patients.”
Instead, measuring the jugular venous pressure (JVP) to diagnose jugular venous distension is a much better physical exam tool. It does take practice to do well, Dr. Tedford said, but “it’s important to get good at it.”
Finding out that a heart failure patient is experiencing orthopnea is also a good predictor of congestion. To discern orthopnea, however, doctors have to ask the right questions. “Don’t ask ‘How many pillows do you sleep with?’ ” he said. “Instead ask, ‘What happens when you actually lie flat? Do you sleep upright because of back pain or because you feel short of breath?’ Go a little deeper into those questions.”
The goal: euvolemia
Tracking a person’s weight is also key to determining if she is becoming congested. But Dr. Tedford cautioned that weight, as a surrogate for fluid buildup, “is not perfect.” Patients can lose weight so “their dry weight is lower than we think it is, or they might gain weight from eating more or from their insulin.” That’s why heart failure specialists were eagerly awaiting FDA approval “which came in May “of the new, implantable CardioMEMS monitors that can continuously send readings on patients’ pulmonary pressures.
The goal, he stressed, should be to get patients to a state of euvolemia. “We want to get all the fluid off of them,” said Dr. Tedford. “It decreases stress on the right side of the heart, decreases mitral regurgitation, and allows their oral medications and kidneys to work better.” It also helps keep patients from returning to the hospital by giving them more leeway with diet, fluid intake and medication doses.
Unfortunately, he said, inpatient providers are being “pressed to discharge these people early.” In addition, hospitalists sometimes misinterpret a patient’s rise in creatinine as evidence that diuretics worked and that “patients must be dry, even when other signs and symptoms are saying they are not.”
Instead, Dr. Tedford said, a creatinine rise may “be due to too aggressive fluid removal.” While diuresis should go slower, the goal should still be the same: “Achieve and maintain euvolemia.”
As for taking water off these patients, there is no one best strategy. As Dr. Tedford explained, the 2011 DOSE trial published in the March 3, 2011, New England Journal of Medicine (NEJM) found that neither a bolus nor a continuous Lasix drip strategy worked better than the other “and that both high-dose and low-dose drips worked without significant differences in renal function.
The Heart Failure Society of America guidelines published in the June 2010 Journal of Cardiac Failure call for using loop diuretics, not thiazide-type diuretics. The guidelines also recommend administering loop diuretics two or three times a day, rather than as single large doses. For patients already on loop diuretic therapy at home, their initial IV dose should be equal to or exceed their chronic oral daily dose.
With furosemide, said Dr. Tedford, keep in mind that while the effective life is about six hours, the peak effect occurs in between 30 and 60 minutes.
So if you give patients a diuretic dose of furosemide but then find that their urine output isn’t adequate an hour later, “that dose was not enough,” he said. “You should double it.” If you check after another hour and find that the double dose isn’t working as well as it should, “you need to double it again “or you need a different strategy.”
Dr. Tedford recommended that busy hospitalists set up standing orders, instructing nurses to notify you if patients aren’t producing a certain amount of urine in the first hour. “We can waste a lot of time when we are treating these people,” he said.
According to Dr. Tedford, the excitement over using ultrafiltration instead of IV diuretics for acute decompensated congestive heart failure has died down a bit. That’s because a study published in the Dec. 13, 2012, issue of NEJM concluded that ultrafiltration was associated with more serious adverse events, even with similar weight loss. Dr. Tedford now opts for ultrafiltration only in refractory cases “if I think the kidneys are more of a problem than the heart.”
Meanwhile, the idea of tracking levels of brain natriuretic peptide (BNP) or N-terminal pro-brain natriuretic peptide (NT-proBNP) and using that information to guide therapy “is not quite ready for prime time,” he said. That was the conclusion of a study published in the Jan. 28, 2009, issue of the Journal of the American Medical Association (JAMA).
The research found that the people who improved the most were also those most likely to be taking other heart failure medications like ACE inhibitors and beta-blockers. “If we are treating our patients with evidence-based therapy, tracking BNP or ProBNP levels may not be necessary,” Dr. Tedford said.
ACE inhibitors, ARBs and beta-blockers
Hospitalized heart failure patients who are “warm and wet,” with stable renal function, should stay on their ACE inhibitors, ARBs and beta-blockers. If they are newly diagnosed with heart failure, however, hospitalists should wait to start new beta-blockers until patients are compensated and euvolemic, and doctors should prescribe only carvediolol, metoprolol XL or bisoprolol to patients with heart failure.
Meanwhile, the timing of ACE inhibitor or ARB initiation is more controversial. “There is no urgency to add ACE inhibitors immediately in newly diagnosed heart failure patients,” Dr. Tedford said. (He does sometimes, “if I don’t think it’s going to cloud the rest of my evaluation.”) He noted, however, that these medications should be started by the time patients are discharged.
Keep in mind that patients who are truly “cold and dry” are rare. “If you are diagnosing a lot of people as cold and dry, you are probably misdiagnosing people who are actually cold and wet,” Dr. Tedford said. That is the category of patients with the worst prognosis.
He also warned hospitalists to be careful when they see younger heart failure patients (those under age 40 or 50). Younger patients can feel “warm” on exam and yet have very low cardiac output. Symptoms to watch for are abdominal pain, anorexia and nausea, as well as tachycardia.
“They can fool you and may not fit in this cold/wet category, but they are just as sick,” Dr. Tedford said. A paper explaining the categorization system based on congestion and perfusion at rest was published in the Feb. 6, 2002, issue of JAMA.
Another mistake that Dr. Tedford sometimes encounters: Doctors may correctly focus on getting rid of the patient’s congestion, but they then fail to take the next step to figure out why heart failure patients decompensated so much that they needed to be hospitalized.
“Was it because of the progression of their heart failure, or is it because they were noncompliant either with fluid restrictions or diuretics?” he asked. “That’s when you find out they can’t afford their medications because they were put on all brand names.” Or patients may be taking medications contraindicated in heart failure like calcium channel blockers for A-fib or NSAIDs for arthritis.
“Do they have thyroid dysfunction or arrhythmias? We sometimes fall into the trap that this is simply progression of their heart failure, but that’s not always the case,” Dr. Tedford said. “There are reversible causes that can be corrected.”
For example, Dr. Tedford recently saw a patient who had refractory volume overload. “Since we switched her Celebrex to Tylenol for her arthritis, her volume status has been much easier to maintain,” he noted. “In fact, we cut her diuretics in half.”
Some noncardiologists are also not aware that heart failure can develop in patients with preserved ejection fraction.
HFpEF (heart failure with preserved ejection fraction, previously called diastolic heart failure) is as common in North America as HFrEF (heart failure with reduced ejection fraction). “If you are not seeing this as frequently as you are seeing HFrEF, then perhaps you are missing the diagnosis,” Dr. Tedford said. When heart failure is a new diagnosis, patients need an echocardiogram to determine if they have HFpEF or HFrEF because outpatient treatment will differ.
Putting more effort in the discharge process can pay off. The most recent heart failure treatment guidelines published online by the American Heart Association in Circulation in 2013 devote a whole section to discharge recommendations.
Among the most important steps: making sure patients have a follow-up appointment scheduled within a week. A phone call earlier than that is helpful too.
“I instruct patients to weigh themselves every day,” Dr. Tedford said. “If they gain more than three to four pounds, they are on the phone with me asking what to do with their diuretics.” Many drug errors are caught at follow-up appointments, and it is not easy to know the perfect oral diuretic dose for heart failure patients upon discharge. (See “Transitioning out of the hospital,” below.)
And if hospitalists find that the heart failure is progressing, that should prompt action. That may involve discussing advanced heart failure therapy options like left ventricular assist devices, heart transplantation or palliative care.
“We know recurrent hospitalization increases the risk of dying, and we see people with end-stage heart failure recurrently hospitalized,” Dr. Tedford said. “If we could avoid those, it’s good for both the patient and the community.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Transitioning out of the hospital
FOR JUST OVER TWO YEARS NOW, all patients with an admitting diagnosis of heart failure who are discharged by Ryan J. Tedford, MD, from Baltimore’s Johns Hopkins Hospital leave with an appointment within a week. That appointment is at a nurse practitioner-run Heart Failure Bridge Clinic.
As a result, said Dr. Tedford at a cardiology precourse before this spring’s Society of Hospital Medicine conference, those patients’ 30-day readmission rate is now under 20% “a 10% reduction.
In addition to reviewing all medications and stressing the importance of adhering to diet and drug regimens, the nurses often pick up things like worsening renal function or developing hyperkalemia. They also frequently adjust the dose of diuretics that patients are sent home on. That’s because it can be “very difficult,” Dr. Tedford said, to select the perfect oral dose after a patient has been on IV diuretics in the hospital.
“We catch a fair amount of errors in discharge medications or in the lack of understanding on the part of the patient,” Dr. Tedford said. “Adequate follow-up is essential, and that’s not follow-up with a cardiologist in three months. That doesn’t work for heart failure.”