Heart Failure Patients

Management and discharge considerations

8/5/09

Heart Failure – which kind?

• Heart Failure (HF) or Congestive heart failure (CHF) are inadequate descriptors

• Systolic HF, Diastolic HF, or not HF• must know EF• don’t call edema/effusion HF if you have

an alternate diagnosis eg. Cancer, dialysis

What is EF?

• Every patient needs the actual Ejection Fraction noted. (normal: 50%-70%)

• Systolic HF: EF below 40%

• Accept an EF measurement within 3-6 months, unless there has been a change in medical events or symptoms.

Heart Failure – why?

• What is the etiology of the HF? – Ischemic – 50% of patients– Non-ischemic – hypertension in 30%

consider: drugs, alcohol, arrhythmias such as atrial fibrillation, valve disease especially mitral regurgitation, infection such as HIV, viral etc.

Heart Failure – functional status

• What is the patient’s baseline functional status? Ask specific questions

New York Heart Association (NYHA)• I – no limitations• II – mild limitations • III – moderate limitations (hard to do ADL)• IV – severe limitations (rest, nocturnal)

Heart Failure - timeline

• Were symptoms gradually building up? eg. Weight gain, shortness of breath, edema(patients report abrupt symptoms but data suggest 21 days of fluid accumulation before clinical presentation)

• Has this occurred before?

• When was the last time patient felt well?

example

• 64 y/o man with ischemic CM, baseline EF 25%, normally NYHA Class II, who presented in pulmonary edema (Class IV). In retrospect, he acknowledged more shortness of breath for the last two weeks. The night before coming to the hospital, he slept in the chair.

Comments on this patient

• Description says it all – etiology, EF, baselines, mode of presentation

• History, in retrospect, provides insight into this patient’s ability to recognize and self manage a chronic condition

• Our task: treat the acute symptoms but then figure out how to prevent the same scenario

HF Medications

• ALL CARDIOVASCULAR patients:• aspirin (or warfarin; Plavix if stent)• beta blocker• ACE inhibitor or Angiotensin Receptor

Blocker (ARB)• cholesterol management if ischemic• aldosterone inhibitor

Medications, con’t• Beta Blockers SAVE lives!!!

– Don’t stop, if already on them– BB don’t cause decompensation in most pts– Up titrate at every opportunity– Try to use same meds as home meds– Target: carvedilol 25-50 mg BID– metoprolol SUCCINATE (long acting) 200-400

mg a day– bisoprolol 10-20 mg a day– nebivolol – HTN indication, HF in Europe

Medication con’t again

• ACE inhibitors are first line for HF– “class effect” and generic– Try to use same meds as home meds– Creatinine will go up 0.3-0.5 mg/dl for the first

3 days; do NOT stop unless hyperK, angioedema

– May use in all patients (it saves kidney function)

– If cough: assess HF. If creatinine rises: decrease diuretics.

One more medication slide

• Aldosterone inhibitors – Spironolactone, Eplerenone– Spironolactone: NYHA Class III-IV– Diastolic HF: Topcat Study (x4641)– Eplerenone: post MI, EF below 40%

– NB: 15% will develop hyper K (Rales, study) check labs after starting these drugs

Medications: AA

• AA HF Study:– Hydralazine and Isosorbide added to ACEI

and BB, “maximal medical therapy”– Survival benefit

– Note dosing: both are TID and isosorbide is the dinitrate (“isordil), not mononitrate (Imdur)

– Target: hydralazine 75 mg TID– Target: isosorbide 40 mg TID

Education• Cardiac Rehab can help – needs a consult request. (M-

F). You will need to educate on weekends and holidays. Become familiar with educational materials, resources.

• Please record in chart, teach patient and reiterate at discharge:

• salt restriction• EF (“know your numbers”)• each medication category – if the medication is

contraindicated, it must be written (including both ACE-I and ARB as separate entries)

A few comments

• Reason for decompensation:• try and understand why • anemia, atrial fibrillation – top causes• troponins are up a little, not always

considered an “MI”

• Don’t blame the patient

A few comments #2

• Ascertain barriers to care:• these must be addressed or the patient

will return.

• CMS: “never events” and readmissions may mean no payment and quality citations

A few comments #3

• Ascertain what is this patient’s “normal” blood pressure.

• If EF is poor, BP will be below 100mmHg.• Do NOT hold/stop cardiac medications!!!• rebound HF, death, MI etc. etc.• Write orders so nurses give meds….

Sudden Cardiac Death

• ALL patients with EF below 35%

• THINK about ICD (defibrillator) – document, ask advice, or state why the patient is not a candidate. (They are supposed to live a year or two to benefit from ICD. No ICD if not on medication, if NYHA IV)

Discharge Process

• EF – documented• Medications – prescribed, or documented

why not : 1) BB, 2)ACE/ARB• ICD addressed• Education completed• Follow-up arranged• Dictated. (Please include consultant’s

names, rather than “cardiology saw pt”.)