Clinician-to-Clinician Update Clinician-to-Clinician Update

Outpatient Program Returns Patient to Independent Lifestyle

February 2017

Contributed by Eric R. Ernst, MD

Chronic heart failure (CHF) sends patients over age 65 back to the hospital more often than any other medical condition.1 To improve these outcomes, outpatient clinics for heart failure are increasing their focus on a patient’s overall well-being and providing supports for care.2

Patient

A 62-year-old male patient with a prior anterior wall myocardial infarction presented and was hospitalized with a myocardial infarction, this time affecting the lateral wall. He was placed on a ventilator due to respiratory failure caused by congestive heart failure (CHF). He was first seen by a C.O.R.E. Clinic cardiologist while recovering in the intensive care unit. Subsequent reperfusion therapy was unsuccessful. Gradually the patient was weaned off of the ventilator and allowed to return home after a brief stay in a transitional care unit where the staff had been trained by C.O.R.E clinicians. The patient indicated that planned out-of-state trips with his wife were a clear priority.

Management

The patient began outpatient treatment within the C.O.R.E. Clinic, where he continued to learn about his condition and how to stay feeling well. He took daily notes on his energy level, weight, blood pressure, heart rate, sodium intake, and medications. He was given access to a telemanagement system that allowed him to call and report these conditionrelated measures, and he called the C.O.R.E. Clinic when he had questions for his advanced practice providers. When his ejection fraction reached about 25%, he received an implantable cardioverter defibrillator to ward off arrhythmias.

Heart-Care-Consult-Feb-2017-Case-Study-248309 case-study TPF1402 4C
— Clinicians at the C.O.R.E. Clinic monitor each patient’s reported health data.

After several months in the outpatient program, he returned from a trip with aching legs and labored breathing. A coronary angiogram revealed that his one remaining coronary artery had become narrowed. The team cardiologists were able to open the remaining coronary artery using an advanced angioplasty procedure. The patient returned home, began walking again, and decreased some of his medications. When his symptoms worsened again the following year, his defibrillator was upgraded to a cardiac resynchronization device. With the new device, he reported feeling strong once again.

Ten years after enrolling in the C.O.R.E. Clinic, the patient has never been hospitalized primarily for CHF. He has never wavered in his dedication to his diet, exercise, and medication plan. He still enjoys traveling out of state each winter to walk on the beach with his wife. She is starting to complain that he is walking too fast.

Discussion

Outpatient programs for heart failure that combine medical care and rehabilitation with lessons in self-care serve to increase quality of life, with the added benefit of keeping patients from being readmitted.3 In this case, a patient with complex heart failure was taught to stay motivated and take control of his care, key factors that have kept him living independently and out of the hospital.

References

  1. Desai AS, Stevenson LW. Rehospitalization for heart failure. Circulation. 2012;126:501-506.
  2. Howlett JG. Specialist heart failure clinics must evolve to stay relevant. Can J Cardiol. 2014;30(3):276-280.
  3. Ades PA, Keteyian SJ, Balady GJ, et al. Cardiac rehabilitation exercise and self-care for chronic heart failure. J Am Coll Cardiol. 2013;1(6):540-547.
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