RESUMO
Advanced heart failure (HF) is associated with the extensive use of acute care services, especially at the end of life, often in stark contrast to the wishes of most HF patients to remain at home for as long as possible. The current Canadian model of hospital-centric care is not only inconsistent with patient goals, but also unsustainable in the setting of the current hospital-bed availability crisis across the country. Given this context, we present a narrative to discuss factors necessary for the avoidance of hospitalization in advanced HF patients. First, patients eligible for alternatives to hospitalization should be identified through comprehensive, values-based, goals-of-care discussions, including involvement of both patients and caregivers, and assessment of caregiver burnout. Second, we present pharmaceutical interventions that have shown promise in reducing HF hospitalizations. Such interventions include strategies to combat diuretic resistance, as well as nondiuretic treatments of dyspnea, and the continuation of guideline-directed medical therapies. Finally, to successfully care for advanced HF patients at home, care models, such as transitional care, telehealth, collaborative home-based palliative care programs, and home hospitals, must be robust. Care must be individualized and coordinated through an integrated care model, such as the spoke-hub-and-node model. Although barriers exist to the implementation of these models and strategies, they should not prevent clinicians from striving to provide individualized person-centred care. Doing so will not only alleviate strain on the healthcare system, but also prioritize patient goals, which is of the utmost importance.
L'insuffisance cardiaque avancée est associée à une utilisation considérable des services de soins de courte durée, surtout en fin de vie et souvent en contradiction totale avec les désirs de la plupart des patients, qui sont de rester à la maison le plus longtemps possible. Le modèle canadien actuel, centré sur les soins hospitaliers, n'est pas seulement incompatible avec les objectifs des patients, mais il est n'est pas viable vu le manque criant de lits constaté dans des hôpitaux de partout au pays. En tenant compte de ce contexte, nous présentons une perspective permettant de discuter des facteurs nécessaires pour éviter l'hospitalisation des patients atteints d'insuffisance cardiaque avancée. Il faut d'abord identifier les patients admissibles à des soins non hospitaliers en menant des discussions exhaustives sur les objectifs de soins qui se fondent sur les valeurs et qui portent notamment sur la participation du patient et de ses aidants et sur l'évaluation de l'épuisement des aidants. Nous présentons ici les interventions pharmaceutiques qui se sont révélées prometteuses dans la réduction des hospitalisations pour cause d'insuffisance cardiaque. Il s'agit de stratégies visant à lutter contre la résistance aux diurétiques et de traitements non diurétiques de la dyspnée, ainsi que de la poursuite des traitements médicaux indiqués par les lignes directrices. Enfin, pour bien soigner les patients atteints d'insuffisance cardiaque avancée à domicile, les modèles de soins, comme les soins de transition, la télémédecine, les programmes collaboratifs de soins palliatifs à domicile et les programmes d'hospitalisation à domicile, doivent être robustes. Les soins doivent être personnalisés et coordonnés par un modèle de soins intégré, comme le modèle en étoile (spoke-hub-and-node). Bien qu'il existe des obstacles à l'instauration de ces modèles et stratégies, ceux-ci ne devraient pas empêcher les médecins de s'employer à offrir des soins adaptés axés sur la personne. Cette pratique libérera le système de santé d'un poids et permettra de mettre de l'avant les objectifs des patients, qui sont de la plus grande importance.
RESUMO
BACKGROUND: Peripartum cardiomyopathy (PPCM) is a heterogeneous condition characterized by heart failure and left ventricular dysfunction (left ventricular ejection fraction [LVEF] < 45%) in the absence of an alternative cause and a previous diagnosis of cardiomyopathy. The Aboriginal population (Inuit, First Nations, Metis) of Canada often has barriers to health care, which can lead to delays in diagnosis and treatment. Our objectives are to describe PPCM in a Canadian population, and to determine if Canadian Aboriginal women have worse clinical outcomes than non-Aboriginal women. METHODS: A retrospective study was performed at a single tertiary care centre, between 2008 and 2014. Demographic characteristics, symptoms at presentation, medical history, discharge medications, blood work, echocardiographic parameters, and follow-up information were collected. RESULTS: A total of 177 women were screened, and 23 were included in the study (52% were Aboriginal). Aboriginal women were found to have higher rates of gravidity and parity, and higher incidence of tobacco smoking than non-Aboriginal women, and were more likely to be discharged with diuretic medications. At diagnosis, Aboriginal women were more likely to have a lower LVEF (20% [interquartile range (IQR), 15%-23%] vs 40% [IQR, 30%-42%]; P = 0.02) and a more dilated left ventricle (left ventricular end-diastolic diameter, 64 mm [IQR, 57-74 mm] vs 54 mm [IQR, 50-57mm]; P < 0.01). Recovery rate, defined as LVEF > 50%, was similar (46% in Aboriginal patients and 60% in non-Aboriginal patients). CONCLUSIONS: Our findings support that Aboriginal women with PPCM are more likely to present with lower LVEF and a more dilated left ventricle, as well, require more symptomatic management. To our knowledge, this is the first description and contrast of PPCM between Aboriginal and non-Aboriginal Canadians.