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Outpatient Management of Heart Failure in Primary Care

National Nurse Practitioner Symposium July 2020

Nicole Dellise, DNP, FNP-BC, CHFN K. Melissa Hayes, DNP, ANP-BC, CHFN

Heart Failure in Primary Care Nicole Dellise, DNP, FNP-BC, CHFN K. Melissa Hayes, DNP, ANP-BC, CHFN Q1

1

Disclosures

Dr. Dellise has no disclosures.

Dr. Hayes had no disclosures.


2

Objectives

DISCUSS implications of heart failure management strategies highlighting key considerations for primary care.

IDENTIFY challenges of optimization of guideline-directed medical therapy in heart failure patients.

REVIEW the appropriate adjustment of heart failure medications according to the volume status of the patient.


3

Presentation Outline

~Background and significance

~Definitions; HFpEF vs HFrEF

~Cases_HFpEF ~Hospital to Home

~Cases_HFrEF ~Resources


4

AHA 2017 Heart Disease & Stroke Statistics Update, Heart Disease and Stroke Statistics—2010 Update: A Report From the American Heart Association Circulation, Feb 2010; 121: e46 - e215.

The number of adults living with heart failure has increased from about 5.7 million (2009-2012) to about 6.5 million (2011-2014).

One in 5 Americans will be >65 years of age by 2050.

HF incidence increases with age, rising from approximately 20 per 1000 individuals 65 to 69 years of age; to >80 per 1000 individuals among those ≥85 years of age.

960,000 new cases annually.

Hospital admissions rates have increased approximately 150% over the past 2 decades.

Half of the hospital admissions are patients with HFpEF.

Half of the hospital admissions are patients with HFrEF.

Heart Failure Facts


5

The number of Americans with HF is expected to significantly worsen in the future.

(Yancy, et al., 2013)

Getty Images / tiero


6

Definitions


7

Heart Failure

A complex clinical syndrome resulting from any structural or functional cardiac disorder that impairs

the ability of the ventricle to FILL with blood or EJECT blood. (Yancy, et al., 2013)


8

HFpEF vs HFrEF

Diastolic Failure - Heart Failure with Preserved Ejection Fraction (HFpEF) result of the inability of the heart to relax and FILL with blood (EF ≥ 45%)

Systolic Failure - Heart Failure with Reduced Ejection Fraction (HFrEF) result of the inability of the heart to EJECT blood (EF ≤ 40%)


9

Heart Failure Mid-Range EF (HFmEF)

Grey area with LVEF > 40 but no quite 50-55% HFmEF

Group treated based on symptomatology, etiology and usually end up being treated as LVEF HFrEF.


10

Yancy CW, et al. Circulation. 2013;128:e240-e327.Image Source: Jessup M, Brozena SA. New Engl J Med. 2003; 348:2007-2018.

Reduced EF (HFrEF)

Normal Heart Preserved EF (HFpEF)

Heart Failure – Ejection Fraction (EF)


11

Classifications of Heart Failure

Circulation 2013;128:e240-327.

Classification Ejection Fraction (EF)

Heart failure with reduced ejection fraction (HFrEF)• Formerly referred to as systolic heart failure

< 40%

Heart failure with preserved ejection fraction (HFpEF)• Formerly referred to as diastolic heart failure

> 50%

HFmEF borderline 41-49%

HFrEF improved - patients with a history of HFrEF > 40%


12

Brief Pathophysiology Review


13

RAS, renin-angiotensin system; SNS, sympathetic nervous system.

Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease)

Morbidity and mortalityArrhythmiasPump failure

Peripheral vasoconstriction/Increased filling pressures

Heart failure symptoms

Remodeling and progressiveworsening of LV function

Initial fall in LV performance, wall stress

Activation of RAAS and SNS

Fibrosis, apoptosis,hypertrophy,

cellular/molecular

alterations,myotoxicity

FatigueActivity altered Chest congestionEdemaShortness of breath

Neurohormonal Activation in Heart Failure


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Altered gene expression Apoptosis

Remodeling

Pathogenesis of Heart Failure

Myocardial Insult

Myocardial Dysfunction

Renin-Angiotensin-Aldosterone Activation

Sympathetic Activation

Reduced Organ Perfusion


15

Pathophysiologic Progression of HF

Injury Adaptation Remodeling

Normal

Dilated and fibrotic

Compensatory hypertrophy

Architecturaldistortion

Normal

Courtesy of A. Agocha, MD.


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HFpEF


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ACC/AHA HF Stage vs NYHA Class

ACC/AHA HF Stage

High risk for developing heart failure (HF) No structural disease

Structural heart diseaseNo HF symptoms

Structural heart diseasePrior or current HF symptoms

Refractory end-stage HFrequiring special interventions

Jessup M et al. N Engl J Med. 2003;348:2007-2018. New York Heart Association/Little Brown and Company, 1964. Adapted from Farrell et al. JAMA. 2002;287:890-897.

A

B

C

D

NYHAFunctional Class

Asymptomatic

Symptomatic with moderate exertion

Symptomatic with minimal exertion

Symptomatic at rest

Class I

Class II

Class IV

Class III


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HFpEF HFrEF


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Etiology HFpEF HFrEF

HTN ++ +

Ischemic heart disease + +++

Obesity + +

Valve disease + +

Arrhythmias (ie a-fib, tachycardia) + +

Sleep disordered breathing ++ -

Myocarditis (ie viral, SLE, Chagas, AIDs) - +

Diabetes + +

Older age ++ -

Anemia - +

Toxic (ie ETOH, Chemo, nutritional deficiency, amphetamines)

- +

Pregnancy - +

Thyroid disease - +

Idiopathic dilated - +

Stress (Takotsubo) - +

Amyloidosis ? -

Sarcordosis ? -


20

Diagnostics HFpEF HFrEF

Signs and Symptoms of HF

+ +

Diagnosis of Exclusion + -

B-Type Nauturtic Peptide - or + ↓ ↑ + ↑↑

Chest X-Ray + +

ECG + +

Transthoracic Echocardiogram

+ +

Right heart Catherization + +

Stress testing + +

Left heart catherization + +


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SymptomsHFpEF HFrEF

Dyspnea + +

Orthopnea + +

Paroxysmal nocturnal dyspnea

+ +

Fatigue + +

Reduced exercise capacity + +

Cough or Wheezing + +

Confusion/Delirium + +

GI Symptoms: early satiety, nausea, vomiting, abdominal discomfort

+ +

Sudden weight gain more than 2 pounds in one day or 5 pounds in 1 week

+ +

Chest pain + +


22

Physical ExamHFpEF HFrEF

Rales ++ ++

Peripheral edema + ++

Jugular venous distension + ++

S3 + ++

S4 ++ +

Displaced point of maximal impulse - ++

Mitral regurgitation murmur + ++

Hepatomegaly and/or ascites + ++

Cool extremities + ++

Narrow pulse pressure + ++

Hypotension + ++

Tachycardia + ++

Hypertension ++ +


23


24

Measuring JVP


25

Goals

HFpEF HFrEF

Reduce Symptoms + +

Improve Quality of Life + +

Decrease hospitalizations + +

Reduce Mortality + +

Identification and treatment of co-morbidities

+ +


26

Guideline Directed Medical Therapy

HFpEF HFrEFDiuretics ++ ↓ symptoms ++ ↓symptoms

ACE Inhibitor, ARB, or ARNI - ++ ↓ morbidity & mortality

Beta Blocker - ++ ↓ morbidity & mortality

Aldosterone Antagonist + (?) ++ ↓ morbidity & mortality

Hydralazine/isosorbide dinitrate - ++ ↓ morbidity & mortality for AA

Corlanor - ++ ↓ hospitalization

Digoxin - ++ ↓ hospitalization


27

Interventions

HFpEF HFrEF

ICD Therapy - Recommended for primary prevention of SCD

CRT - Indicated for HFrEF with LBBB

Heart Transplant - Indicated for HFrEF who meet criteria

Permanent Mechanical Circulatory Support

- Indicated for HFrEF who meet criteria

Chronic Inotropes - Indicated for HFrEF who meet criteria


28

Case Study

Heart Failure with Preserved Ejection

Fraction

Image Source: Jessup M, Brozena SA. New Engl J Med. 2003; 348:2007-2018.


29

Case Study HFpEF: Mr. Jones

55 year old Caucasian male

Past Medical History

HFpEF

Obstructive Sleep Apnea

Hypertension

Chronic Kidney Disease, Stage 3

Uncontrolled Diabetes Type 2

TIA

Hyperlipidemia


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Aspirin 81mg Lipitor (Atorvastatin) 40mg QHS Bumex (Bumetanide) 4mg BID Aldactone (Spironolactone)

25mg daily Cymbalta (Duloxetine) 30mg

daily Lyrica (Pregablin) 200mg TID Cozaar (Losartan) 25mg QHS

MEDICATIONS


31


EKG 3/2020

Sinus Rhythm

Boarder line left axis deviation

Cardiac Stress Test 9/2018

Indication: Shortness of breath and Chest pain

No evidence of ischemia or infarct

LVEF greater than 70%


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Case Study HFpEF: Mr. Jones Echocardiogram 10/2019

Normal left ventricular size with mild to moderate hypertrophy.

Normal systolic function.

Stage II diastolic dysfunction.

Normal right ventricular size and function.

No significant valvular disease.

PA systolic pressure estimated at 37mmHg plus RA pressure.


33


Heart Failure Hospitalization # 1

• Presented with progressive dyspnea on exertion. Walking 10 feet causes severe dyspnea. ADLs cause dyspnea.

• Noted gradual weight gain over 2 months (252 pounds to 288 pounds). • Not responding to Lasix 80 mg BID. • Admission vital signs: BP 187/90, HR 77, RR 22, oxygen 98 % RA • Admission Labs: Sodium 136, Potassium 4.9, BUN 76, Creatinine 2.6, BNP 78 • Reports he does not monitor fluid or sodium intake. •Established with heart failure clinic• Lasix (Furosemide) 80 mg BID•Aldactone (Spironolactone) 25 mg Qday•Cozaar (Losartan) increased 50 mg QHS•Advised patient to keep blood pressure log

October


34



• Admitted following right heart catheterization demonstrating significant volume overload.• RA = 27 mean • PA = 40/31 mean = 34• PCW = a wave = 31 v wave = 33 mean = 28• SVR 23 Wood Units• PVR 1.3 Wood Units

• Admission vital signs: BP 125/82, HR 82, RR 18, oxygen 97 % RA• Admission weight 278 pounds• Admission labs: Sodium 138, potassium 4.5, BUN 66, Creatinine 2.4, BNP 67

• Lasix (Furosemide) 80 mg BID• Aldactone (Spironolactone) 25 mg daily• Cozaar (Losartan) 50 mg QHS• HF teaching and reinforcement

November


35



• Admitted from clinic with volume overload• Symptoms: Abdominal dissension, LE edema, JVD elevated 16 cm, orthopnea.• Admission vital signs: BP 133/72, HR 72, RR 20, oxygen 97 % RA• Admission weight 282 pounds• Admission labs: Sodium 140, potassium 4.6, BUN 68, Creatinine 2.6, BNP 88

• Diuretic switched to Bumex (Bumetanide) 6 mg BID• Aldactone (Spironolactone) 25 mg Qday• Cozzar (Losartan) 50 mg QHS• HF teaching and reinforcement• Comorbidities Contributing?

• Diabetes Seen by endocrinology for uncontrolled diabetes type 2• OSA compliant w/ CPAP• HTN controlled• CKD, stage 3 kidney function stable • Medication review: ? Lyrica• Socioeconomic factors?

February


36


FOLLOW UP:

Seen in clinic for post hospital follow

up 7 days after discharge.

SUBJECTIVE:

Able to walk from home to mailbox

without limitations. Denies orthopnea.

Limiting sodium and fluid intake. Wearing CPAP nightly. Blood

glucose average 200s

EXAM:

JVD 7 cm. Trace LE edema

VITALS:

BP 126/89, HR 78, RR 16, oxygen saturation 98%

WEIGHT:

270 pounds

LABS:

Sodium 139, potassium 4.8,

BUN 58, creatinine 2.2, bnp 66


37

HFpEF Clinical Pearls

Management of hypertension

Management of fluid

Management of Co-Morbidities

Assess Socioeconomic

Factors

Labs:

BNP NOT always elevated w/ HFpEF

and or Obesity


38

Transitioning from Hospital to Home

Follow up phone call with 72 hours of hospital discharge

• Improves outcomes• Billable via Transitional

Care Management Services CPT code

2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure

Steven M. Hollenberg, Lynne Warner Stevenson, Tariq Ahmad, Vaibhav J. Amin, Biykem Bozkurt, Javed Butler, Leslie L. Davis, Mark H. Drazner, James N. Kirkpatrick, Pamela N. Peterson, Brent N. Reed, Christopher L. Roy, Alan B. StorrowJ Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011

Image source: Hollenberg, Stevenson, Ahmad, Bozkkurt, Butler, Davis, et al. J Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011


39

First post-discharge visit checklist

• History• Exam• Testing• Medication• Therapy Considerations• Patient Education• Consultations


Image source: Hollenberg, Stevenson, Ahmad, Bozkkurt, Butler, Davis, et al. J Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011


40


Transitional Care Management Services

CPT Code 99495: Moderate Complexity

Communication within 2 business days of discharge

Moderate complexity medical decision making

Face to face visit within 14 days of discharge

CPT Code 99496: High Complexity

Communication within 2 business days of discharge

High complexity medical decision making

Face to face visit within 7 days of discharge

Getty Images / fcscafeine


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Co-Managing Heart Failure in Primary Care


42

Co-Managing Heart Failure in Primary Care

Partner with local heart specialist or cardiologist.

Get to know the hospitalists team that takes care of the HF pts in local hospital.

Connect with community resources such as home health, medication delivery services.

Communicate any medications changes to the cardiologist or concerns for disease progression.

Knowing when to refer for advanced care.


43

Case Study

Heart Failure with Reduced Ejection Fraction

Image Source: Jessup M, Brozena SA. New Engl J Med. 2003; 348:2007-2018.


44

Case Study HFrEF: Mrs. Smith

HPI: Mrs. Smith is a 51 yo AA female with history of HFrEF 2/2 to hypertensive heart disease with LVEF of 20-25%. Presents today for follow up after recent hospitalization.

Current symptoms include: DOE with walking around in home and ADLs, No DOE at rest, + PND about 2 nights a week, + 2 pillow orthopnea, LE edema, and early satiety.


45


PMH:

Hospitalization for new onset HF symptoms

Hypertension x 20 years (non-adherent)

Type 2 DM x 10 years

Obesity

Family History:

Father with Cardiomyopathy

Social:

Stopped all ETOH 2 years ago

No illicit drugs, non-smoker

Divorced, lives with mom and son


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Case Study HFrEF: Mrs Smith

Glucophage (Metformin) 500mg BID Lasix (Furosemide) 80mg once a day Coreg (Carvedilol) 12.5mg once a day Lopressor (Metoprolol) 25mg once a day Prinivil (Lisinopril)10mg once a day KDUR (Potassium chloride) 10meq QD

MEDICATIONS


47

VS: Weight 245# , b/p 155/80, HR 78, o2 sat 98%, rr 16, Temp 98.6

Gen: AA female well developed, well nourished in NAD

HEENT: EOMs intact bilaterally, PERRLA bilaterally, oropharynx benign, neck supple, no carotid bruits

CV: regular rate and rhythm, S1S1, +S4 no S3, soft II/VI systolic apical murmur, PMI slightly laterally displaced. JVD 8-10 cmh20 noted pt sitting 90 degrees, no HJR

Pul: Bilat CTA

Ab: normoactive BS, non-tender, non-distended, no HJR, no heptosplenomegaly

Extremities: Bilateral LE 2+ edema to knees, 2+ bilateral LE pulses



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Most RecentTesting:

ECHO: Severe depressed LV systolic function with severe global hypokinesis with LVEF est at 20-25%.

Impaired relaxation (Stage I diastolic dysfunction).

Normal right ventricular size and function.

No significant valvular disease.

RA pressure estimated at 8

Cardiac Cath: No significant coronary artery disease

LABS: Glucose 204, KCL 4.3, CL 102, Co2 28, BUN 16, Creat1.2, CA 9.6 ; BNP= 1194



49

Diagnosis:

HFrEF Class C, NYHA class IIIb, etiology likely hypertensive heart disease.

WET VS DRY?

Case Study HFrEF: Mrs Smith


50

Plan:

WET - Needs increased diuresis (what ss = ? WET)

Has increased B/P - Good time to increase after load reduction by changing over to ARNI (STOP Prinivil (Lisinopril) x 36 hrs)

Beta blocker optimization?? (on 2 different ones) point to only be on one…which one? Coreg (Carvedilol)12.5mg increase to BID after increased diuretics for a few days.

STOP Lopressor (Metoprolol )

Add Aldactone (Spironolactone) 25mg QD

Consider adding Digitex (Digoxin) 0.125mcg

Increase diuretic to 80mg BID to lose 1-2 pounds a day….

Increase KCL to 10meq BID (KCL is on the low side)



51

Once optimized:

Consider Adding isosorbide/hydralazine (bidil ) slow increase to 1 tab BID-TID

Repeat ECHO and if LVEF remains < 30 % will need referral to EP for ICD for primary prevention



52

Follow up visit:

HOW SOON?

WHAT NEXT?



53

What would plan be if patient was DRY on exam?



54

HFrEF Clinical Pearls

When Dry increase Beta

blocker (if HR & B/P allow)

When Wet increase ACE/ARB/ARNI

( if B/P & Lab allow)

36 hour wash out changing from ACE

to ARNI

Higher Creatine Higher Diuretic

Dose

Lasix (Furosemide) 80mg = Demadex (Torsemide) 20mg = Bumex

(Bumetanide) 2mg


55

Patient Teaching


56

Patient Teaching: Key Points

Medication Review

Activity Level

Dietary and Sodium restrictions (no added salt)

Fluid restrictions (1500-2000ml/day)

Daily weight monitoring

Assessment of peripheral edema

Substance use counseling if appropriate

List of warning signs of decompensation

Bring list of medications and daily weights to each outpatient visit

Who to call for worsening symptoms or ICD discharge

Smoking Cessation


57

Same time

Same scale

Notify provider for weight gain > 2 lbs. above baseline

Daily Weights

Getty Images / TerryJ


58

MEDS TO AVOID

NO NSAIDS for pain

Watch for the TZDs: Actos( Pioglitzxone), Avandia (Rosiglitazone) etc)

Worsening renal function (all diabetic meds)

Calcium Channel Blockers in LVEF <40%


59

When to refer?


60

Slow The Slide


61

I-NEED-HELP

I: IV inotropes

N: NYHA IIIB/IV or persistently elevated natriuretic peptides

E: End-organ dysfunction

E: Ejection fraction < 35%

H: Hospitalized > 1

E: Edema despite escalating diuretics

L: Low blood pressure, High heart rate

P: Prognostic medication-progressive intolerance or down-titration of GDMT

(Yancy, et al., 2018)


62


63

Stages, Phenotypes and Treatment of HF

or ARNI

(Yancy, et al, 2013)


64

Clinician and Patient Resources American Association of Heart Failure Nurses

https://www.aahfn.org/

Heart Failure Society of America

https://hfsa.org/

American Heart Association

https://www.heart.org/en/health-topics/heart-failure

2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized with Heart Failure http://www.onlinejacc.org/content/74/15/1966?rss=1

2013 ACCF/AHA Guideline for Management of Heart Failure https://www.ahajournals.org/doi/full/10.1161/cir.0b013e31829e8776

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for Management of Heart Failure https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000509


65

On the Horizon


66

On the Horizon for HF

SGLT2 inhibitors significantly improve HF related outcomes, decreasing the frequency of HF

related hospitalizations as well as CV related Death

The FDA has approved Farxiga (dapagliflozin) due to the reduction of risk for CV death and HF hospitalization in people with chronic HFrEF Class II-IV (McMurray et al., 2019; Petrie, 2020)

COVID-19 Impact (unknown)

CardioMems_Remote Hemodynamic monitoring

(Guide-HF)

Wojcik & Warden (2019) Curr Cardiol Rep. Sep 14;21(10):130. doi: 10.1007/s11886-019-1219-4.Mechanisms and Evidence for Heart Failure Benefits from SGLT2 Inhibitors.


67

SUMMARY

HFpEF vs HFrEF: Goals are the same but treatment is vastly different.

Management of Co-Morbid conditions is essential for reducing Heart Failure exacerbations.

Primary Care providers are essential in co-management of the Heart Failure patient.

Collaboration and resources are readily available.


68

Questions? Email Us! [email protected]

[email protected]


69

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DeWalt, D. A., Malone, R. M., Bryant, M. E., Kosnar, M. C., Corr, K. E., Rothman, R. L., . . . Pignone, M. P. (2006). A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Services Research, 6, 30. doi: 10.1186/1472-6963-6-30

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Steven M. Hollenberg, Lynne Warner Stevenson, Tariq Ahmad, Vaibhav J. Amin, Biykem Bozkurt, Javed Butler, Leslie L. Davis, Mark H. Drazner, James N. Kirkpatrick, Pamela N. Peterson, Brent N. Reed, Christopher L. Roy, Alan B. Storrow

J Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011

Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. [Research Support, Non-U.S. Gov't]. N Engl J Med, 360(14), 1418-1428. doi: 10.1056/NEJMsa0803563

Jessup, M. et al. (2016) 2016 ESC and ACC/AHA/HFSA heart failure guideline update — what is new and why is it important? Nat. Rev. Cardiol. doi:10.1038/nrcardio.2016.134

Krumholz, H. M., Merrill, A.R., Schone, E.M., Schreiner, G.C., Jersey, C., Bradley, E.H., …Drye, E.E. (2009). Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circulation: Cardiovascular Quality and Outcomes, Journal of the American Heart Association, 2, 407-413.doi: 10.1161/CIRCOUTCOMES.109.883256

Lindenfeld, J., Albert, N. M., Boehmer, J. P., Collins, S. P., Ezekowitz, J. A., Givertz, M. M., . . . Walsh, M. N. (2010). HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail, 16(6), e1-194. doi: 10.1016/j.cardfail.2010.04.004


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30-Day Mortality, and 30-Day Readmission Rates in Medicare Patients With Heart Failure and With Reduced Versus Preserved Ejection Fraction. Am J Cardiol. doi: 10.1016/j.amjcard.2016.04.015

Murray, M. D., Tu, W., Wu, J., Morrow, D., Smith, F., & Brater, D. C. (2009). Factors associated with exacerbation of heart failure include treatment adherence and health literacy skills. Clin Pharmacol Ther, 85(6), 651-658. doi: 10.1038/clpt.2009.7

McMurray, J. et al DAPA-HF Trial Committees and Investigators (2019).Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. The New England journal of medicine, 381(21), 1995–2008. https://doi-org.proxy.library.vanderbilt.edu/10.1056/NEJMoa1911303

Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., . . . Turner, M. B. 2015). Heart Disease and Stroke Statistics—2015 Update: A Report From the American Heart Association. Circulation, 131(4), e29-e322. doi: 10.1161/cir.0000000000000152

Philbin, E. F., Dec, G. W., Jenkins, P. L., & DiSalvo, T. G. (2001). Socioeconomic status as an.independent risk factor for hospital readmission for heart failure. Am J Cardiol, 87(12), 1367-1371. doi: http://dx.doi.org/10.1016/S0002-9149(01)01554-5

Petrie, M. C.… McMurray, J. (2020). Effect of Dapagliflozin on Worsening Heart Failure and Cardiovascular Death in Patients With Heart Failure With and Without Diabetes. JAMA, 323(14), 1353–1368. Advance online publication. https://doi-org.proxy.library.vanderbilt.edu/10.1001/jama.2020.1906

Roger, V.L., Go, A.S., Lloyd-Jones, D.M., Adams, R.J., Berry, J.D., Brown, T.M., …Wylie-Rosett, J. (2011 ). Heart disease and stroke statistics-2011 update: A report from the American Heart Association. Circulation: Journal of the American Heart Association, 123, e18-e209. doi: 10.1161/CIR.0b013e3182009701

US Department of Health and Human Services, Centers for Disease Control and Prevention. (2010). Heart Failure Fact Sheet . Retrieved from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm.

Wojcik & Warden (2019) Curr Cardiol Rep. Sep 14;21(10):130. doi: 10.1007/s11886-019-1219-4.Mechanisms and Evidence for Heart Failure Benefits from SGLT2 Inhibitors.

Yancy, C. W., Januzzi, J. L., Jr., Allen, L. A., Butler, J., Davis, L. L., Fonarow, G. C., . . . Wasserman, A. (2018). 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol, 71(2), 201-230. doi: 10.1016/j.jacc.2017.11.025

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., . . . Wilkoff, B. L. (2013). 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 128(16), e240-e327. doi: 10.1161/CIR.0b013e31829e8776


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Q1 - Heart Failure in Primary Care · K. Melissa Hayes, DNP, ANP-BC, CHFN Q1 1 'LVFORVXUHV 'U 'HOOLVHKDV QR GLVFORVXUHV 'U +D\HV KDG QR GLVFORVXUHV Heart Failure in Primary Care Nicole