Spare Ronnie from Drowning: Reducing Heart Failure Symptoms in Hospice Patients Utilizing a New Guideline-Directed Medical Therapy Algorithm (TH371C)

Abstract

•Differentiate the various etiologies of congestive heart failure, and describe how this understanding impacts treatment.•Utilizing a newly introduced, vital sign-driven, heart failure treatment algorithm, the attendee will have the capacity to devise an anti-congestive medication strategy tailored to each hospice patient, and to any point in that patient's life trajectory.•Following the patient's response to the treatment algorithm, each attendee will have an improved capacity to prognosticate life expectancy for each heart failure patient. Guideline Directed Medical Therapy (GDMT) is the foundation of current heart failure treatment. However, in end-stage disease, upon hospice enrollment, these medications are often either abandoned, or simply cut-and-pasted into the patient's new drug regimen without scrutiny. Neither approach serves the hospice patient well. Optimal treatment entails first defining the etiology of each patient's congestive failure, (preserved or reduced ejection fraction, and the presence or absence of concomitant valvular heart disease and/or atrial fibrillation). Application then of a streamlined, tiered algorithm of GDMT, specifically adapted to the hospice setting, best achieves, and preserves, optimal symptom management. The algorithm is vital sign qualified; each different tier of therapy requires a different level of systolic blood pressure and/or heart rate to permit medication administration. This dynamic automatically establishes a hierarchy of importance for the different medication groups, assists with formulating a rational initial medication regimen tailored to each patient, and prevents drug administration when, because of either relative hypotension or bradycardia, the agent could be deleterious. It also aids prognostication, and the eventual transitioning of patients off GDMT to only comfort medications (opioids and benzodiazepines) at the immediate end of life. Comparing statistics drawn from a 12-month chart review of heart failure patients admitted to our in-patient hospice facility prior to implementation of this algorithm, to an ongoing data analysis of current patients with the same primary diagnosis. Statistics reveal a 31% improvement in BORG scale, and a 28% improvement in PPS. The live discharge rate to home* has risen by 39%, with patients living (comfortably) weeks longer. Improved symptom management of hospice-enrolled patients with a primary diagnosis of heart failure underpin this treatment algorithm, with ongoing patient review. *“home” may include assisted or skilled nursing facility