Clinical Pearls - Option Care of Arizona

February 2005

This publication was designed by Option Care with you in mind and will serve as your one source for "hot" topics in home infusion today.

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Heart Failure Options

According to American Heart Association statistics, almost five million Americans have been diagnosed with Heart Failure and nearly 500,000 new cases are diagnosed annually. Ten out of every 1,000 people 65 years of age or older are affected. Heart Failure is the number one discharge diagnosis in patients over 65 and the largest single expense annually for Medicare. These patients have a high readmission rate: 2% at 2 days, up to 50% at six months. With the aging population of baby boomers, these numbers are expected to increase.

Considering the financial burden to the health care system, plus the emotional and physical stress for the patient, an interdisciplinary approach is required to provide the most appropriate care for this patient population. Trends in diagnosis, acute and chronic treatment are continually being evaluated. Digitalis, loop diuretics, ACE inhibitors, calcium channel blockers, beta blockers, and/or vasodilators continue to be the front line, conservative treatment. Use of the blood test BNP (b-type natriuretic peptide), has helped physicians more quickly differentiate heart failure from other, non-cardiac problems. The use of left ventricular assist devices and implanted defibrillators may actually increase length of survival rates beyond the current average of 5 years. The availability of noninvasive hemodynamic monitoring has made it possible for physicians to obtain important hemodynamic data without the use of costly, high risk, invasive procedures, i.e. heart cath or Swan-Ganz monitoring. In addition to the familiar inotropes, dopamine, dobutamine, milrinone, and amrinone, there is now a new class of drug being used to treat heart failure. Nesiritide is a manufactured, chemical copy of the hormone natriuretic peptide which produces both venous and arterial dilation.

Acute patients are frequently treated with inotropic therapy, IV diuretics and/or vasodilators. In most hospitals, inotropic and nesiritide infusions are only done in ICU, CCU or telemetry. Although these drugs have been associated with an increase in mortality, recent innovations have led many physicians to re-evaluate use of inotropic drugs or nesiritide on an out-patient basis in a very select group of patients.

Those are patients with class III or IV NYHC heart failure who are either awaiting cardiac transplant, or patients with chronic, recurrent HF who are not candidates for transplant. Goals for treating these two groups of patients differ. The goal with transplant candidates is to provide hemodynamic support until an appropriate donor heart is available.

In that case, inotropic or nesiritide therapy is considered a “bridge to transplant”. Those patients who cannot be successfully weaned from inotropic therapy have poor prognosis and survival rates if transplant is not an option. In this population, inotropic therapy is considered a terminal therapy, or “bridge to end of life”. The goal is to provide comfort and to decrease the physical, emotional, and financial stress of repeated ER visits and re-hospitalizations, and allow patients choices regarding their final days of life.

Several recent articles promote the idea of inotropic therapy, when used as palliative treatment, as a type of hospice care. In this case, the focus would be on relieving symptoms rather than pain.

ACC/AHA Practice Guidelines 2001 state that “The decision to continue intravenous infusions at home should not be made until all alternative attempts to achieve stability have failed repeatedly, because such an approach can present a major burden to the family and health services and may ultimately increase the risk of death.” Obviously, only a small percentage of patients fall into one of the two categories previously described. In order to achieve the described goals, it is important for the entire health care team to approach these cases with a “disease management” mentality. Successful components of Option Care’s disease management program include a multidisciplinary approach to: patient/family education, clinical monitoring, assessment, telephone contact, and 24 hour availability of clinical staff.

With increasing numbers of heart failure patients on the horizon, physicians will continue to explore opportunities to provide appropriate care in a cost effective manner while providing the patient choices as they wait hopefully for transplant, or plan for the end of life. [NM]

Whether it is anti-infectives. TPN, IVIG, or home chemotherapy, Option Care is the right choice. You may call us 24 hours a day, 7 days a week, for all your home infusion and specialty pharmacy needs.

For Patient Care: 800-531-2469 or 928-708-0025
For Customer Care: Contact Risa Little at 928-899-5774
E-Mail at rlittle@optioncareaz.com

And please, visit us online at www.optioncareaz.com

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