Il Database dellItalian Network on Congestive Heart Failure INCHF: Risultati e Prospettive Proposte

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Baby Boomers Estimated Increase of elderly
population in the next 50 years
Font NIH 2000
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Hospital admissions for HF in Italy by sex and
age(2001)

3
Aging Population Evolution of health care
demand and available resources

• Progressive increase of frail elderly HF
  patients
• Inadequacy of traditional routine care for
  these pts
• vs
• Control care expenditures (hospital admissions)
• Need of new strategies for disease management.
• a combination of patient education, provider
  use of practice guidelines, appropriate
  consultation, and supplies of drugs and ancillary
  services.

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The aging failing heart
Cardiac disease
Comorbidities and Age related impairments
Normal aging CV Changes
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Normal aging changes in the cardiovascular system

• Increased arterial stiffness and aortic impedance
• LV and myocyte hypertrophy. Loss of myocyte.
  Increased fibrosis. Switching from alpha- to beta
  myosyn heavy chain
• Preserved contractile force at end-systole.
  Prolonged contractile activation.
• Normal systolic function at rest. Reduced
  functional reserve (HR and LVEF) during stress.
• Reduced early diastolic filling rate
• Decreased (postsynaptic) responsiveness of
  myocardium, pacemaker cells and arterial
  vasculature to beta-adrenergic stimulation.
  Reduced baroreceptor sensitivity.

Lakatta EG , Circulation 199387631-6.
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CHARM CV death or hospitalisation for CHF
Candesartanevent/n
Placeboevent/n
Test for interaction
Age lt65 384/1614 413/1642(yrs) gt65 lt75
416/1337 476/1270 gt75 350/852 421/884 LVEF lt40
817/2287 944/2292 gt40 333/1516 366/1504 Gender
Male 813/2617 917/2582 Female 337/1186 393/1214
NYHA II 359/1730 415/1686 III/IV 791/2073 895/211
0 Overall 1150/3803 1310/3796
p0.26
p0.40
p0.93
p0.63
0.6
0.8
1.0
1.2
1.4
candesartan better
Hazard ratio
placebo better
7
Bring-up 2 ß-blockers in elderly pts
ß-BLOCKER IMPLEMENTATION
Baseline 1518 elderly patients 1013 not treated
60 without contraindication
40 for contraindication
BRING UP 2
464/607 (76) started carvedilol
8
IN-CHF Registry Prescription of beta-blockers by
year and age17553 pazienti
Del Sindaco et al. Ital Heart J 2002
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HF Admission and Survival for Older People
Receiving Beta-Blockers after MIRochon PA et al,
Lancet 2000 356 639-44
10
Comorbidities in Medicare CHF patients
(n122,630 65 years)
Hypertension 55 Diabetes 31 COPD
26 Ocular disorders 24 Hypercholesterolemia
21
Braunstein JB et al, JACC 2003 42 1226-33
Depression 11-56
Turvey CL et al, JAGS 2002 50 2003-8 De Geest S
et al, Eur J HF 2003 5 57-67
Mental impairment Musculoskeletal
problems Incontinence Renal failure CVA Anemia
Braunstein JB, JACC 2003 42 1226-33
Lien CT et al, Eur J HF 2002 4 91-8 Krum H
Gilbert RE, Lancet 2003 362 147-58
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Comorbidities and CHF in elderly

• HF can be the result of the presence of poorly
  managed CV risk factor
• HF can be the result of the existence of poorly
  managed comorbidities
• Comorbidities may influence the progression of HF
  and the response to therapy
• Comorbidities with other age-related impairments
  may complicate the course of the disease

12
Polypharmacy and Drug interactions in elderly
patients

• CHF, COPD and diabetes usually associated with
  polypharmacy
• 11-25 of older persons use 5 or more meds
  simultaneously
• Multiple physicians, multiple drugs
• Errors in self-administration caused by age
  related impairments, complexity of medication
  regimen, duration of treatment
• SAE more common because they take more drugs
• More than 20 of adverse drug reactions in the
  elderly are due to drug interactions (Drug-drug /
  -nutrient /-alcohol)
• Altered physiology in the elderly affects
  medications
• Multiple organ system changes (CV, GI, liver,
  kidney)
• Pharmacodynamics /Pharmacokinetics

13
Am J Med 2001 110 438-441
CONCLUSION A combination of ACE-inhibitors and
spironolactone should be considered with caution
and monitored closely in patients with renal
insufficiency, diabetes, older age, worsening
heart failure, a risk for dehydration. A daily
spironolactone dose of 25 mg should not be
exceded.
14
CHF and age related impairments(common reasons
for nonadherence and lack of
self-management)

• Visual and hearing impairment (20-50)
• Cognitive impairment (26-78 dementia,
  depression, etc)
• Possibly related to cerebral hypoperfusion and
  CVA
• ADL/IADL aging and chronic conditions limit
  functional capabilities
• Lack of social support social isolation marital
  functioning vs living alone
• Health illiteracy (25) difficulties to
  understand written and oral informations
  concerning their illness and treatment
• do you understand what I have told you? is not
  enough

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Take-home message

• Elderly patients are different from trial
  patients
• The aging of the heart may influence the response
  to drugs
• A proportion of elderly patients may tolerate and
  improve with EB drugs but they are usually
  undertreated
• Comorbidities, polypharmacy and age related
  impairments (including social problems) may
  greatly complicate the disease management of HF

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Heart Failure Readmissions

• 50 at 6 months
• gt 50 preventable hospitalizations
• Causes
• Failure of pts adherence to treatments
• Failure to seek treatment for escalating symptoms
• Poor discharge planning
• Failure of social support system
• Failure to address pts charcteristics
  disability, cognitive impairment, low income,
  depression, multiple comorbidities

Moser D. Circulation 2002
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Implementation of a Disease Management Program
for elderly with HFKey elements 5A

• Assess (valuta),
• Advice (consiglia),
• Agree (concorda),
• Assist (assisti e cura),
• Arrange (organizza).

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Integrating the geriatric and gerontological care
paradigm

• The key principles of care
• Continuity and Coordination of Care (including
  discharge and follow-up plans)
• Enhancing patients education and self management
• Multidisciplinary Intervention (physician,
  nurses, dieticians, social workers,
  physiotherapists, psychologist, etc)
• Integrated Network of Healthcare Services
  (hospitals, hospice, Clinics, Home-care)
• Multidimensional Evaluation (including
  behavioural and psycosocial aspects and economic
  condition)

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The Local NHS
Hospital Multidisciplinary HF Clinics
Pazients
GPs Cardiologists Nurses
Home Care Services
The model should be very flexible according to
the complexity and phase of the disease of the
disease, non pharmacologic options, organization
and other local issues
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Multidisciplinary Team in HF Management
GPs
Nurses
Cardiologist
Dieticians
Physiotherapist
Social Workers
Psychologist
21
Integrating the geriatric and gerontological care
paradigm

• The goals are to
• Maximize functional independence and autonomy
• Prevent further decline
• Stabilize or improve QOL
• Prolong survival
• Containing costs

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• The care of elderly with HF is a typical example
  of our need to move from hi-tech to hi-touch
  medical and social strategy to provide the best
  intervention to prevent hospitalisation and
  improve quality of life