心脏衰竭的表现课件.ppt

1、1,Multi-Disciplinary Heart Failure Management,Connie Keibler, MSN, ARNP Western Washington Medical Group, Cardiology,2,3,Heart Failure Outlook,5 million Americans have Heart Failure 1/2 million new diagnosis of HF annually $27 Billion annual health care burden 250,000 deaths from HF annually Leading

2、 cause of hospitalization for those over 65 years old,4,Heart Failure Hospitalization,$14 Billion spent annually for those admitted to the hospital in Acute Decompensated Heart Failure 3.5 million hospitalizations annually 1/3 of those admitted for ADHF are re-admitted within 90 days A hospital visi

3、t for ADHF results in 60 day mortality rates between 8 and 20% Increased mortality risk persists for 6 mos.,5,Heart Failure Future,6,Heart Failure Mortality,250, 000 deaths annually 1/2 of those diagnosed with Heart Failure die within 5 years,7,8,Heart Failure Risk,Common Causes Ischemic heart Disea

4、se Diabetes Hypertension Valvular Heart Disease ETOH Abuse Obesity Cigarette Smoking Hyperlipidemia Physical Inactivity Sleep Apnea,Less Common Causes Familial Hypertrophic CM Postpartum CM Thyroid Abnormality Connective Tissue Disorders Toxin Exposure Myocarditis Sarcoidosis Hemochromatosis Medicat

5、ion Exposure,9,Heart Failure-A Syndrome,Heart failure is a constellation of symptoms and signs produced by a complex circulatory and neuro-hormonal response to cardiac dysfunction Heart failure is a complex clinical syndrome that can results from any structural or functional cardiac disorder that im

6、pairs the ability of the ventricle to fill with or eject blood.,10,Clinical Classifications,Backward Inability of the ventricle to eject its contents, resulting in elevated filling pressures Forward decreased cardiac output and inadequate tissue perfusion,11,Clinical Classifications,Left-Sided Left

7、Ventricle is weakened or overloaded Results in pulmonary congestion Right-Sided Right Ventricle is impaired Results in systemic venous overload May occur independently from conditions affecting the right ventricle only Left-Sided failure usually is the cause of right-sided failure,12,Clinical Classi

8、fications,Systolic: Impaired ability of the heart to contract Weakened muscle, enlarged heart size Inability of heart to empty Left ventricular ejection fraction (LVEF) 4045% Diastolic: inability of the heart to relax is impaired Stiff, thickened myocardial wall but normal size Inability of heart to

9、 fill LVEF 45%,13,Clinical Classifications,Acute sudden onset with associated signs and symptoms Chronic secondary to slow structural changes occurring in the stressed myocardium Acute Decompensated sudden exacerbation or onset of symptoms in chronic heart failure,14,Clinical Classifications,Heart F

10、ailure is a Symptomatic Disorder New York Heart Association-Functional Classification Class I: No abnormal symptoms with activity Class II: Symptoms with normal activity Class III: Marked limitation due to symptoms with less than ordinary activity Class IV: Symptoms at rest and severe limitations in

11、 functional activity,15,Clinical Classifications,Heart Failure is a Progressive Disorder ACC/AHA Stages of HF Stage A-Presence of risk factors for heart failure Stage B-Presence of structural heart disease but no Symptoms Stage C-Presence of structural heart disease along with signs and symptoms Sta

12、ge D-Presence of structural heart diseases and advanced signs and symptoms,16,ACC/AHA 2005 Guidelines,17,18,HF Hospitalization,1/3 of those admitted for ADHF are re-admitted within 90 days 1/2 of all HF Hospital Re-Admissions are Avoidable A hospital visit for ADHF results in 60 day mortality rates

13、between 8 and 20%,19,Clinical Predictors,A Multivariate Analysis using the ADHERE Data Identified the Following Most Significant Predictors of Mortality: Bun Systolic BP HR Age,20,Seattle Heart Failure Model,Age Gender Ischemic Etiology NYHA Ejection Fraction Systolic BP Cholesterol Hemoglobin,% Lym

14、phocyte Count Uric Acid Sodium Use of K-Sparing Diuretic Statin Allupurinol Diuretic,Multivariate risk model using the following Predictors of Survival at Baseline and after Interventions,21,Reasons for Re-Admission,Compliance with Medication Compliance with Diet, Specifically Sodium Delays in Seeki

15、ng Medical Attention,22,JACHO Quality of Care Indicators,DC Instructions Assessment of LV Function ACEI or ARB at Discharge Smoking Cessation Advice/Counseling,23,JACHO Quality of Care Indicators,Education better absorbed when the patient is stable and adapted to living with HF OPTIMIZE-HF found tha

16、t DC Instructions did not have an effect on Mortality or Re-hospitalization 60-90 days. Missing continuity of Care in the Community Home Care Heart Failure Clinics Primary Care,24,Barrier to HF Management,Cognitive Impairment Complex Self Care Management Lack of Motivation Poor Physical Capacity Dep

17、ression Anxiety,Multiple Co-Morbidities Psychosocial/Financial Concerns Physical Limitations Multiple Heath Care Providers and Lack of Shared Communication,25,26,Heart Failure Management,Improve Access to Appropriate Cost-Effective Health Care Prevent Hospitalization Improve QOL Improved Survival Co

18、ntrol Health Care Costs,Goals,27,Multi-Disciplinary HF MGMT,Fluid Management Education Intensity of Care Access,Characteristics,Strategy must outline and follow clinical rationale based on practice guidelines that define target care patterns for patients.,28,Systematic Review,Literature Review 74 Tr

19、ials and 30 Meta-Analysis Shared Key Elements One to One Patient Education Symptom Monitoring and Strategies for Self-Management,29,Self-Management of HF,Compliance with evidence based medications Adopt a low-sodium diet Reduce fat and cholesterol in diet Restrict fluid intake if indicated Stop smok

20、ing Eliminate alcohol consumption Increase activity/exercise Monitor daily weight,30,Self-Management of HF,AND Notify health care provider of signs and symptoms of worsening heart failure pain in jaw, neck, or chest increased SOB increased fatigue dizziness of syncope swelling in feet, ankles, legs,

21、 or abdomen palpitations tachycardia weight gain decreased exercise capacity,31,Deventer-Alkmaar HF Study,Physician and Nurse Directed HF Clinic vs. Usual Care 1 year intervention 9 scheduled visits 3 telephone 6 office 1 week after discharge Verbal and written education Optimized Rx Easy Access Adv

22、ice for self-care,32,Deventer-Alkmaar HF Study,51% risk reduction in Primary End-Point Hospitalization for worsened HF and/or All Cause Mortality NNT - 5 Improved EF at 1 Year Improved NYHA Class Significant Improvement in QOL Scores,33,Multi-Disciplinary Management,Quick and sustained improvements

23、6 wk intervention Cost savings of $67,804,Comprehensive inpatient education, discharge planning, and outpatient support vs. usual care*,Multi-Disciplinary Team Physician Champion Advanced Practice Nurse or PA Nurse Educator Home Health Nurse Dietician Physical Therapy Social Services Pharmacist,34,3

24、5,Nursing,Nursing is a profession focused on assisting individuals, families, and communities in attaining, maintaining, and recovering optimal health and functioning. Modern definitions of nursing define it as a science and an art that focuses on promoting quality of life as defined by persons and

25、families, throughout their life experiences from birth to care at the end of life.,36,Collaborative practice is intended to combine the knowledge and skills of several health professionals to maximize the efficiency of both the clinicians and the health care system. Collaborative practice brings tog

26、ether health care professionals with different and complimentary knowledge and skills to increase the scope of and access to patient services.,Collaborative Practice,Shared responsibility and outcomes,37,Collaborative Practice,Correct and accurate transfer of vital patient information Effective team

27、 collaboration that produces positive patient care outcomes Behaviors that aid and encourage respect, trust and credibility among team members,Expected Outcomes,38,39,Just One Day,40,Just One Day,41,Cardiac Rhythm Management,Small improvements in hemodynamics =significant improvements in HF symptoms symptoms. Optimizing hemodynami