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The Team Approach
to
Heart Failure
Mariell Jessup MD FACC, FAHA
Professor of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania
Disclosure: No relevant relationships.
Frank Netter Montage of Heart Failure
Heart Failure in the United States:
Estimated Total Costs
American Heart Association. Heart Disease and Stroke Statistics—2004 Update.
Lowery et al. Lippincott’s Case Management. 2004;9:S1-S15.
Physicians/Other Professionals
$1.8 Billion
Total cost = $28.8 billion
Drugs/
Medical Durables
$2.7 Billion
Home
Healthcare
$2.1 Billion
Lost Productivity/
Mortality
$2.1 Billion
Hospital/
Nursing Home
$17 Billion
Normal
Systolic
Heart
Failure
Diastolic
Heart Failure
Aurigemma, Zile, Gaasch
Circulation 2005
What else needs to happen?
What else needs to happen?
• Medication reconciliation
• Continue evidenced-based therapy
• Start evidenced-based therapy
• Written discharge instructions
• Post-discharge systems of care
What else needs to happen?
ADHERE® CART: Predictors of Mortality
SYS BP 115 n=24,933
SYS BP 115 n=7,150
6.41%
n=5,102
15.28%
N=2,048
21.94%
n=620 12.42%
n=1,425
5.49%
n=4,099
2.14%
n=20,834
BUN 43 N=33,324
Greater than Less than
2.68%
n=25,122
8.98%
n=7,202
Cr 2.75 2,045
Highest to Lowest Risk Cohort
OR 12.9 (95% CI 10.4-15.9)
Fonarow GC, et al. Risk stratification for in-hospital mortality in heart failure using classification and regression tree
(CART) methodology. JAMA. 2005;293:572-580.
33,324 patients!
Revised August 2005 from Jessup M, Brozena S. NEJM 2003;348:2003
Risk factor reduction, patient and family education
Treat HTN, DM, CAD, dyslipidemia. ACEI or ARB
ACEI, BB in all. Is patient candidate for surgery?
Sodium restriction, diuretics
Aldosterone antagonists
Digoxin
Inotrope, nesiritide
VAD, TX
Stage A
High risk
with no
symptoms
CRT, ICD if applicable
Stage B
Structural
heart
disease,
no
symptoms
Stage C
Structural
disease,
prior or
current
symptoms
Stage D
Refractory
symptoms
requiring
special
intervention
Stages & steps:
treatment of systolic
HF
Hospice
Brief inotrope or nesiritide
ACEI, ARB’s if intolerant of ACEI, BB if MI or low LVEF
Annals of Internal Medicine 2008; volume 148.
2010
Who Manages CHF?
IM43%
FP/GP 29%
CARD
17%Other
11%
Who and how we will take care
of the heart failure patients?
• 2007 HF hospital discharges: 990,000
• 2007 HF office visits: 3,434,000 – 83% hospitalized once
– 43% hospitalized at least 4 times
• 2010 internists, and generalists: 50,070
• 2010 Physicians and surgeons: 293,740
• 2010 cardiologists: 20,000
Clark et al. BMJ 2007; 337:942
All cause hospitalization
Clark et al. BMJ 2007; 337:942 All cause mortality
World Health Organization
Heart failure as a model of
chronic care.