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Multidisciplinary Care for End-Stage HF. How to Improve Care?
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The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
palliative measure or until eligible for advanced therapies). Continuous inotrope infusion exposes patients to increased risk of arrhythmias and mortality. It is unknown whether such patients can be weaned off inotropic support in an outpatient setting. Methods: In a single-center observational study of patients admitted with ADHF between 2016-2018, we studied demographics, clinical history, physical exam data, and laboratory data. We determined functional status and compliance with medical therapies of patients who were successfully weaned off inotropes. Creatinine, electrolytes, vital signs, and physical exam findings were followed weekly/biweekly during weaning and followed post-wean for ≥60 days. Results: 9 patients (mean age 49 y; 5 males) were successfully weaned off inotropes in an outpatient setting. All had been discharged home on milrinone or dobutamine infusion. Only 1 patient had ischemic cardiomyopathy; 2 had required mechanical support during hospitalization. Median length of stay after inotrope initiation was 8 days with median 78 days on inotropes prior to weaning. 6 patients were started on sacubitril/valsartan, which was uptitrated during weaning, of whom 3 tolerated the maximum dose. The other patients were uptitrated on angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARB). 60 days post-wean, all 9 patients reported doing well with NYHA Class IIIa (n=5), Class IV (n=1), and Class II (n=3) symptoms. On longitudinal follow-up, 1 patient was hospitalized 1year post-wean, was subsequently restarted on inotropes and required heart transplantation. Conclusion: With close monitoring and gentle uptitration of afterloadreducing agents, it is feasible to wean patients with ADHF off inotropes in an outpatient setting.
Figure 1. During a mean follow-up of 4§2 months, 7 patients (30%) were admitted (4 patients for CV problems and 3 for non-CV). 16 patients died (14 CV deaths and 2 non-CV). Of those, twelve patients (75%) died at home or in long-stay centers Conclusion: The multidisciplinary care for end-stage HF was feasible and well accepted for the patients and their relatives. The majority of the patientes knew the severity of the disease and the poor prognosis and received treatments for non-CVsymptoms. A high percentage of patients died outside the hospital. The high short-term mortality probably suggests that palliative care should be considered earlier in endstage HF.
963 Multidisciplinary Care for End-Stage HF. How to Improve Care? S. Mirabet,1 A. Pascual,2 P. Fluvia,3 M. Pirla,1 N. Mesado,1 I. Lumillo,1 E. Villegas,4 M. Llauger,5 and E. Roig.1 1Cardiology, Hospital Sant Pau, Barcelona, Spain; 2Palliative Care, Hospital Sant Pau, Barcelona, Spain; 3Cardiology, Hospital Josep Trueta, Girona, Spain; 4 Intern Medicine, Creu Roja, Barcelona, Spain; and the 5Primary Care, Sant Pau, Barcelona, Spain. Purpose: Palliative care in advanced heart failure (HF) patients is not standardized. Our aim was to assess the feasibility of a multidisciplinary team in patients with advanced HF. Methods: Observational, prospective, single-center study performed in outpatients with advanced HF excluded for heart transplantation or LVAD. The multidisciplinary team includes a cardiologist and nurse specialized in advanced HF, a palliative care physician, case manager nurses and primary care physicians. Patients were identified as palliative according to the clinical clues reported in 2013 ACC/AHA guidelines. All patients and their relatives accepted to be included in the program. We evaluated the level of knowledge of the end-stage phase of the disease, the main non-cardiovascular symptoms and treatments, number of hospital admissions, time to death and place of death. Results: From October 2016 to March 2018, 23 patients were included. Age 77 § 5 years, 92% men;they had high comorbidity (Barthel 78.6 § 15) and dependency (Charlson 6 § 1.1). Ten patients had HFpEF.All patients knew the severity of their illness and 65% considered the possibility of dying soon. More than 70% of the patients had non cardiovascular (CV) symptoms. Main symptoms and palliative treatments are shown in
964 Chloride Homeostasis in End Stage Heart Failure and LVAD Recipients K. Stawiarski,1 O. Agboola,2 D. Jacoby,2 L. Bellumkonda,2 T. Ahmad,2 L. Sugeng,2 M. Chen,2 G. McCloskey,2 A. Geirsson,2 M. Anwar,2 and P. Bonde.2 1Yale New Haven Health Bridgeport Hospital, New Haven, CT; and the 2Yale School of Medicine, New Haven, CT. Purpose: Abnormal chloride homeostasis is associated with worse survival in patients with chronic heart failure. Maladaptive neurohormonal
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
palliative measure or until eligible for advanced therapies). Continuous inotrope infusion exposes patients to increased risk of arrhythmias and mortality. It is unknown whether such patients can be weaned off inotropic support in an outpatient setting. Methods: In a single-center observational study of patients admitted with ADHF between 2016-2018, we studied demographics, clinical history, physical exam data, and laboratory data. We determined functional status and compliance with medical therapies of patients who were successfully weaned off inotropes. Creatinine, electrolytes, vital signs, and physical exam findings were followed weekly/biweekly during weaning and followed post-wean for ≥60 days. Results: 9 patients (mean age 49 y; 5 males) were successfully weaned off inotropes in an outpatient setting. All had been discharged home on milrinone or dobutamine infusion. Only 1 patient had ischemic cardiomyopathy; 2 had required mechanical support during hospitalization. Median length of stay after inotrope initiation was 8 days with median 78 days on inotropes prior to weaning. 6 patients were started on sacubitril/valsartan, which was uptitrated during weaning, of whom 3 tolerated the maximum dose. The other patients were uptitrated on angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARB). 60 days post-wean, all 9 patients reported doing well with NYHA Class IIIa (n=5), Class IV (n=1), and Class II (n=3) symptoms. On longitudinal follow-up, 1 patient was hospitalized 1year post-wean, was subsequently restarted on inotropes and required heart transplantation. Conclusion: With close monitoring and gentle uptitration of afterloadreducing agents, it is feasible to wean patients with ADHF off inotropes in an outpatient setting.
Figure 1. During a mean follow-up of 4§2 months, 7 patients (30%) were admitted (4 patients for CV problems and 3 for non-CV). 16 patients died (14 CV deaths and 2 non-CV). Of those, twelve patients (75%) died at home or in long-stay centers Conclusion: The multidisciplinary care for end-stage HF was feasible and well accepted for the patients and their relatives. The majority of the patientes knew the severity of the disease and the poor prognosis and received treatments for non-CVsymptoms. A high percentage of patients died outside the hospital. The high short-term mortality probably suggests that palliative care should be considered earlier in endstage HF.
963 Multidisciplinary Care for End-Stage HF. How to Improve Care? S. Mirabet,1 A. Pascual,2 P. Fluvia,3 M. Pirla,1 N. Mesado,1 I. Lumillo,1 E. Villegas,4 M. Llauger,5 and E. Roig.1 1Cardiology, Hospital Sant Pau, Barcelona, Spain; 2Palliative Care, Hospital Sant Pau, Barcelona, Spain; 3Cardiology, Hospital Josep Trueta, Girona, Spain; 4 Intern Medicine, Creu Roja, Barcelona, Spain; and the 5Primary Care, Sant Pau, Barcelona, Spain. Purpose: Palliative care in advanced heart failure (HF) patients is not standardized. Our aim was to assess the feasibility of a multidisciplinary team in patients with advanced HF. Methods: Observational, prospective, single-center study performed in outpatients with advanced HF excluded for heart transplantation or LVAD. The multidisciplinary team includes a cardiologist and nurse specialized in advanced HF, a palliative care physician, case manager nurses and primary care physicians. Patients were identified as palliative according to the clinical clues reported in 2013 ACC/AHA guidelines. All patients and their relatives accepted to be included in the program. We evaluated the level of knowledge of the end-stage phase of the disease, the main non-cardiovascular symptoms and treatments, number of hospital admissions, time to death and place of death. Results: From October 2016 to March 2018, 23 patients were included. Age 77 § 5 years, 92% men;they had high comorbidity (Barthel 78.6 § 15) and dependency (Charlson 6 § 1.1). Ten patients had HFpEF.All patients knew the severity of their illness and 65% considered the possibility of dying soon. More than 70% of the patients had non cardiovascular (CV) symptoms. Main symptoms and palliative treatments are shown in
964 Chloride Homeostasis in End Stage Heart Failure and LVAD Recipients K. Stawiarski,1 O. Agboola,2 D. Jacoby,2 L. Bellumkonda,2 T. Ahmad,2 L. Sugeng,2 M. Chen,2 G. McCloskey,2 A. Geirsson,2 M. Anwar,2 and P. Bonde.2 1Yale New Haven Health Bridgeport Hospital, New Haven, CT; and the 2Yale School of Medicine, New Haven, CT. Purpose: Abnormal chloride homeostasis is associated with worse survival in patients with chronic heart failure. Maladaptive neurohormonal