Heart Failure Certification Review Course Part 2 - Oregon · 6/1/2015 1 Heart Failure Certification Review Course Part 2 Connie M. Lewis MSN, ACNP-C, NP-C, CCRN, CHFN Objectives ♥Recognize

6/1/2015

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Heart Failure Certification Review Course

Part 2

Connie M. LewisMSN, ACNP-C, NP-C, CCRN, CHFN

Objectives

♥ Recognize heart failure symptoms

♥ Discuss HF guidelines related to medications, ICD, CRT, exercise, sodium restriction

♥ Discuss palliative care indications

Case Study 1CAD, HF sx, CPX, AF, Peripheral Vascular Disease,

E ECHO, Palliative care, Beta Blockers, ACE-I, ICD, CRT-D

64 YO female transferred from OSH July 2009 with biventricular failure.

“Her overall long-term prognosis is poor. I have discussed

the critical nature of the patient's illness with her family and they

acknowledge understanding. They would like everything done for her for now. The

patient is too drowsy and obtunded at present to communicate her wishes.”

History of present illness:

Severe ischemic CMP that had been refractory to therapy, complicated by atrial fibrillation, renal failure over the past month.

HF symptoms:

Weight gain, fatigue, shortness of breath at rest, PND, orthopnea, increased abdominal girth, early satiety

NYHA class IV

AHA stage C

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What are the HF Symptoms?

♥ Fatigue or tiredness

♥ Rapid weight gain, 3 lbs overnight or 5 lbs in 2

days

♥ Shortness of breath

♥ Use more pillows to sleep (orthopnea)

♥ Wake up short of breath at night (PND)

♥ Sleeps in recliner

♥ Frequent coughing

♥ Increased abdominal girth

♥ Early satiety, lack of appetite and/or nausea

♥ LE edema, swollen ankles, legs, and/or abdomen

♥ Decreased exercise tolerance

♥ Increased heart rate

Case Study 17/2009

Past medical history:

� CAD (age 45), CABG 1989, h/o PCI LAD graft 2001, anterior MI in 2003- medically managed. Not a repeat surgical candidate

� CKD with left renal atrophy� COPD, 2ppd for 20 years� HTN� PVD

� Hyperlipidemia� Atrial fibrillation

� DVT� GoutFamily history: Multiple family members on paternal side with early CAD

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Ten Most Common

Co-Morbidities Among Medicare Beneficiaries

with HF >65 and <65

Hypertension80.7-84.2%

Ischemic heart disease64-71.9%

Hyperlipidemia56.9-60%

Anemia49.7-50.3%

Atrial fibrillation28.5-% in >65 years

2013 ACC/AHA Clinical Guidelines

Arthritis35.3-43.5%

Diabetes46.3-59.2%

Chronic kidney disease42.3-45%

COPD30-33.4%

Alzheimer's disease/dementia27.6% in >65 years

Asthma15.5% in <65 years

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Peripheral Artery Disease (PAD)

• Associated with a 2-fold increase in the prevalence of HF

• Concomitant PAD associated with an increased risk for hospitalization and mortality

• PAD is not a contraindication to beta-blocker treatment in HF

• Case Study 1: PAD increased

risk of transplant complications,

as does CKD

Chronic Kidney Disease• Risk factor for development of HF

• Independent risk factor for morbidity and mortality

• Cardiorenal syndrome – describes concomitant cardiac and renal dysfunction.

GFR (ml/min/1.73m2) Stage of Kidney Disease

>90 1

>60-89 2

30-59 3

15-29 4

<15 5

Nephrology consult if:1. GFG<60ml/min to identify the cause of the kidney disease and

management of the disease2. All potential dialysis patients with GFR<30ml/min

Core Curriculum

Atrial Fibrillation

ACCF/AHA Guidelines for the Management of Heart Failure. Circulation.2013

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Antiarrhythmic Agents

♥ Amiodarone and dofetilide are the only antiarrhythmic agents to have neutral effects on mortality in clinical trials of patients with HF

♥ Sototolol, dronedarone, propafenone, flecainide, quinidine should be avoided in HF due to their pro-arrhythmic and negative inotropic effects in the setting of decreased LV function.


Antiarrhythmic Agents

Amiodarone is not felt to cause worsening LV dysfunction or HF symptoms

♥ Not recommended for primary prevention of sudden death in patients with HF

♥ May be considered to reduce occurrence of recurrent symptomatic arrhythmias and subsequent ICD shocks

♥ When amiodarone is initiated, potential for drug interactions with concomitant therapies must be reviewed

♥ The maintenance doses of digoxin, warfarin and some statinsshould be reduced and then monitored closely

♥ Monitor liver and thyroid function at baseline and every 6 months

♥ Pulmonary function test at baseline and as needed based on symptoms

♥ PA and lateral chest x-ray recommended at baseline and annually.

Case Study 17/2009

�Admitted to CCU

�Swan Ganz, milrinone, furosemide drip, creatinine 3.9 on admission, atrial fibrillation

�Diuresed 30 lbs over 2 weeks

�Discharged after 2 weeks

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Recommendations for Noninvasive

Cardiac Testing

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Yancy C et al. Circulation 2013;128:e240-e327

Chest X-Ray

• Establish baseline

• Assess the following:

- Cardiac shape/size

- Pulmonary vasculature

- Pulmonary

infiltrates/congestion

- Pleural effusion

- Device and lead positionCardiothoracic ratio greater than 1:2 (50%) is abnormal

Echocardiogram

ECHO:

• Atrial size, ventricular size and function

• Ejection fraction

• Wall and septal thickness

• Wall motion

• Valve function and severity of valve insufficiency

• Doppler of valve flow to measure pressures

• Congenital heart defect

• Non-compaction syndrome

• Effusion

• Thrombus

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• Left heart catheterization ̶ Direct measurement of left heart

pressures ̶ Valvular function and surface area ̶ Coronary angiography to assess

for coronary artery obstruction and determine if surgical revascularization is possible

• Right heart catheterization ̶ Hemodynamics̶ Right heart pressures̶ Pulmonary arterial

pressures̶ Pulmonary capillary

wedge pressure ̶ Cardiac output and

index• Thermodilution• Fick Method

Catheterization: LHC and RHC

Electrocardiogram

(12 Lead ECG)

• To assess:

– Ischemic changes, arrhythmias, left ventricular hypertrophy

– Monitoring for drug side effects or electrolyte imbalances

– Conduction abnormalities

– Bundle branch block

– QT interval related to drug levels

– Identify appropriate candidates for biventricular pacemaker insertion

Case Study 17/2009

ECHO 7/2009

� LVEF 20-30%

� LVIDd 5.6 cm

� Four chamber enlargement with evidence for anteroapical MI with severely depressed LV systolic function and moderately depressed RV systolic function

� Moderate to severe mitral regurgitation

� Moderate tricuspid regurgitation

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Case Study 17/2009

Cardiac MRI 7/22/2009

� LVEF 20%

� Ischemic heart disease

� Severely depressed global left ventricular systolic function; dilated

left ventricle

� Dilated and moderately hypokinetic right ventricle

� Transmural myocardial infarction in the proximal-mid left anteriordescending coronary artery territory

� No MRI evidence for LV apical thrombus

� Small right-sided pleural effusion

� Mild mitral regurgitation

� Moderate biatrial enlargement

� Dilated IVC and hepatic venous congestion consistent with right atrialhypertension

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Case Study 1

�What treatment would you expect?

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Case Study 17/2009

Discharge medications:� Lisinopril 2.5 mg daily� Metoprolol extended release 100 mg daily� Furosemide 80 mg bid� warfarin 4mg tablet, by mouth daily� Allopurinol 100 mg daily� Aspirin 81mg by daily� Diazepam 5 mg three times daily as needed� ProAir HFA 3 puffs every 4 hours as needed for wheezing� Fluoxetine 20 mg daily at bedtime� Simvastatin 20 mg daily at bedtime� Spironolactone 25 mg daily

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ACE-IBeta blockerDiureticAldosterone Antagonist

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Drugs Commonly Used for HFrEF

(Stage C HF)

Drug Initial Daily Dose(s) Maximum Doses(s)Mean Doses Achieved in

Clinical Trials

ACE Inhibitors

Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/d (421)

Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg/d (412)

Fosinopril 5 to 10 mg once 40 mg once ---------

Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg/d (444)

Perindopril 2 mg once 8 to 16 mg once ---------

Quinapril 5 mg twice 20 mg twice ---------

Ramipril 1.25 to 2.5 mg once 10 mg once ---------

Trandolapril 1 mg once 4 mg once ---------

ARBs

Candesartan 4 to 8 mg once 32 mg once 24 mg/d (419)

Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/d (420)

Valsartan 20 to 40 mg twice 160 mg twice 254 mg/d (109)

Aldosterone Antagonists

Spironolactone 12.5 to 25 mg once 25 mg once or twice 26 mg/d (424)

Eplerenone 25 mg once 50 mg once 42.6 mg/d (445)


Practice Guideline:

ACE- inhibitors (ACE-I)

Considerations for use of ACEI:

♥ Inhibit the renin-angiotensin-aldosterone system (RAAS) by inhibiting the conversion of angiotensin I to angiotensin II

♥ Promote afterload reduction and vasodilation

♥ Promote reverse remodeling of left ventricle

♥ Recommended if LVEF <40%

♥ Do not automatically withhold for renal insufficiency

♥ Monitor electrolytes and renal function

♥ May cause cough and angioedema

Drugs Commonly Used for HFrEF

(Stage C HF) (cont.)

Drug Initial Daily Dose(s) Maximum Doses(s)Mean Doses Achieved in

Clinical Trials

Beta Blockers

Bisoprolol 1.25 mg once 10 mg once 8.6 mg/d (118)

Carvedilol 3.125 mg twice 50 mg twice 37 mg/d (446)

Carvedilol CR 10 mg once 80 mg once ---------

Metoprolol succinate

extended release

(metoprolol CR/XL)

12.5 to 25 mg once 200 mg once 159 mg/d (447)

Hydralazine & Isosorbide Dinitrate

Fixed dose combination

(423)

37.5 mg hydralazine/

20 mg isosorbide

dinitrate 3 times daily

75 mg hydralazine/

40 mg isosorbide

dinitrate 3 times daily

~175 mg hydralazine/90 mg

isosorbide dinitrate daily

Hydralazine and

isosorbide dinitrate (448)

Hydralazine: 25 to 50

mg, 3 or 4 times daily

and isorsorbide

dinitrate:

20 to 30 mg

3 or 4 times daily

Hydralazine: 300 mg

daily in divided doses

and isosorbide dinitrate

120 mg daily in

divided doses

---------


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Guideline-Directed Medical Therapy(GDMT)

Strategies for Achieving Optimal GDMT

1. Uptitrate in small increments

2. Certain patients (e.g., the elderly, patients with chronic kidney disease) may require more frequent visits and laboratorymonitoring during dose titration and more gradual dose changes.

3. Monitor vital signs closely

4. Alternate adjustments of different medication classes

5. Monitor renal function and electrolytes for rising creatinine and hyperkalemia, recognizing that an initial rise in creatinine may be expected and does not necessarily require discontinuation of therapy

6. Patients may complain of symptoms of fatigue and weakness with dosage increases

7. Discourage sudden spontaneous discontinuation of GDMT medications by the patient and/or other clinicians without discussion with managing clinicians.

8. Carefully review doses of other medications for HF symptom control (e.g., diuretics, nitrates) during uptitration

9. Consider temporary adjustments in dosages of GDMT during acute episodes of noncardiac illnesses (e.g., respiratory infections, risk of dehydration, etc.).

10. Educate patients, family members, and other clinicians about the expected benefits of achieving GDMT,

VanderbiltHeart.com


Case Study 110/2009

October 2009

�Laparoscopic cholecystectomy

�ECHO: LVEF 15-25%. Severe Dilated CM with 4-chamber dilatation with severe LV systolic/diastolic dysfunction; moderate reduction in RV systolic function with moderate MR and mild pulmonary HTN

�Consider ICD, CRT-D

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Implantable Cardioverter

Defibrillators (ICD)

• Primary prevention of sudden cardiac death (SCD) is indicated for those at greatest risk for SCD but have not had arrhythmias.

• Secondary prevention dictates the implantation of ICDs in HF patients who have had life threatening arrhythmias.

• Poor Cardiac Output leads to increase catecholamine release thereby potentiating arrhythmia

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Primary Prevention in HFrEF

• Ischemic (at least 40 days post MI) or selected with nonischemic

• Do not have a prior history of arrhythmias or syncope

• HFrEF

� LVEF < 35%

� NYHA Class II or III on chronic after 3-6 months of GDMT

� Expected to live >I year


ICD Today

♥ Extended Multiprogrammable tiered

therapy

♥ Longevity (> 5-7 yrs)

♥ Endocardial lead systems

♥ Smaller, thinner

♥ Pectoral implant

♥ Advanced rhythm discrimination

♥ State-of-the-art pacing therapies

♥ Powerful diagnostics

♥ Atrial therapies

Ventricular Tachycardia Sinus Rhythm

A

V

A

V

ICD activated

ICD Therapy Delivery and Effects

Tachycardia Normal rhythm

restored

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Secondary Prevention ICD

• Current or prior HF

• Reduced EF

• With a history of cardiac arrest, VF, or destabilizing VT

Cardiac Resynchronization Therapy (CRT)

Biventricular Pacing (Bi-V)

• CRT Coordinates activation of the ventricles and septum

• Indicated for patients with:

� Symptomatic NYHA class II, III, or ambulatory IV symptoms on GDMT

� EF < or equal to 35%

� QRS > 150 ms or greater

• Improves hemodynamic performance by forcing the left ventricle to complete contraction and begin relaxation earlier, allowing an increase in ventricular filling time

• Associated with improvement in:

� Functional class

� Quality of life

� Survival


Biventricular Pacing:

Cardiac Resynchronization Therapy (CRT)

♥ Transvenous Approach

♥ Standard pacing lead in right atrium

♥ Standard pacing or defibrillation lead in right ventricle

♥ Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus

♥ Back-up epicardial approach

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Device Therapy for Stage C HFrEF

Recommendations COR LOE

ICD therapy is recommended for primary prevention of SCD in selected

patients with HFrEF at least 40 days post-MI with LVEF ≤35%, and NYHA

class II or III symptoms on chronic GDMT, who are expected to live ≥1 year*I A

CRT is indicated for patients who have LVEF ≤35%, sinus rhythm, LBBB with

a QRS ≥150 msI

A (NYHA class

III/IV)

B (NYHA class

II)

ICD therapy is recommended for primary prevention of SCD in selected

patients with HFrEF at least 40 days post-MI with LVEF ≤30%, and NYHA

class I symptoms while receiving GDMT, who are expected to live ≥1 year*I B

CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, a non-

LBBB pattern with a QRS ≥150 ms, and NYHA class III/ambulatory class IV

symptoms on GDMT.

IIa A

CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, LBBB

with a QRS 120 to 149 ms, and NYHA class II, III or ambulatory IV symptoms

on GDMT

IIaB

CRT can be useful in patients with AF and LVEF ≤35% on GDMT if a) the

patient requires ventricular pacing or otherwise meets CRT criteria and b) AV

nodal ablation or rate control allows near 100% ventricular pacing with CRT

IIa B


Case Study 12010

January 2010

� CRT-D, cardiac resynchronization therapy with implantable cardioverter-defibrillator

June 2010 ECHO

� LVEF 25-35%, LVIDd 5.7 cm (3.5-5.6 CM)

� LA and RA moderately dilated

� Mildly depressed RV, RVIDd 3.8 cm (2.7-3.3 cm)

� Mild-moderate MR, trace TR

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Case Study 12/2011

February 2011

�Admitted with atypical chest pain

�Successful intervention to left main and proximal LCX with a 3.0 x 26mm Integrity bare metal stent

�Hospital stay: 2 days

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Case Study18/2011

Increase in HF symptoms:

Fatigue, shortness of breath with minimal exertion, increasing dosages of diuretics

08/19/11 15:07 1340*

08/02/11 06:00 747.2*07/05/11 06:00 956.106/06/11 14:37 1256*05/06/11 14:23 1097*

03/14/11 06:00 643.5*

ECHO

� LVEF 15-25%, LVIDd 5.7 cm (3.5-5.6 CM)

� LA and RA severely dilated

� Mildly depressed RV, RVIDd 3.1 cm (2.7-3.3 cm)

� Moderate to severs MR, moderate TR

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More aggressive diuresis

Recommendation for Biomarkers

2013 ACCF/AHA Heart Failure Guidelines

B-type natriuretic peptide (BNP)/NT-proBNP

• Increased level correlates with excess intravascular volume and increased filling pressures, causing ventricular stretch and releasing BNP

• Levels tend to be lower in obese patients and HFpEF; levels elevated with MI and acute pulmonary embolism; also affected by age, gender, and renal function.

• Helpful in determining if dyspnea is related to cardiac or non-cardiac cause.

• Should be used in conjunction with other assessment tools to identify HF.

– BNP level <100 pg/ml = normal

– BNP 100-300 pg/ml suggest possible HF, but is not definitive

– BNP >300 pg/ml = mild heart failure

– BNP >600 pg/ml = moderate heart failure

– BNP levels >900 pg/ml = severe heart failure.

• NT-proBNP levels are substantially greater than BNP levels in patients with HF due to increased stability (half-life) of NT-proBNP in circulation; results from the two tests are not interchangeable; NT-proBNP concentrations are approximately four-fold higher than BNP concentrations

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Causes for Elevated Natriuretic

Peptide LevelsCardiac Noncardiac

• Heart failure, including RV

syndromes

• Acute coronary syndrome

• Heart muscle disease,

including LVH

• Valvular heart disease

• Pericardial disease

• Atrial fibrillation

• Myocarditis

• Cardiac surgery

• Cardioversion

• Advancing age

• Anemia

• Renal failure

• Pulmonary causes: obstructive

sleep apnea, severe

pneumonia, pulmonary

hypertension

• Critical illness

• Bacterial sepsis

• Severe burns

• Toxic-metabolic insults,

including cancer

chemotherapy and

envenomation

Cardiopulmonary Exercise Testing

The ability to perform physical exercise is critically related to:

♥ Pulmonary system’s ability to permit oxygen uptake and carbon dioxide elimination and

♥ Cardiovascular system’s capacity to supply oxygen to exercising muscles.

*Determine whether symptom limitation is related to cardiac

or pulmonary cause, or deconditioning*

Cardiopulmonary Exercise Testing

*Directly measures VO2, VCO2, and air flow (minute ventilation,tidal volume, and respiratory rate)CO2

*Criteria for advanced heart failure:

Peak VO2 <12 to 14 mL/kg/min

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Case Study 1

Outpatient Testing

Cardiopulmonary Testing

� VO2 6.3 ml/kg/min

� RQ 1.13

Right Heart Catheterization

� RA 8

� PA 42/21

� PCWP 15

� PA sat 58%

� CO 4.46

� CI 2.3

BNP 1340Na 139BUN 37Creatinine 1.65 K 5.0BP 90/50

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Normal Results• Right atrial pressure (RA) is -1 to 6 mmHg• Pulmonary artery systolic pressure (PAS) 15 to 30

millimeters of mercury (mmHg)• Pulmonary diastolic pressure (PAD) is 4 to 12 mmHg• Pulmonary capillary wedge pressure(PCWP) is 6 to15

mmHg• Cardiac output (CO) 4-8 L/min• Cardiac index (CI) 2.8-4.2 liters per minute per

square meter (of body surface area)• SVO2 >60%

Stages, Phenotypes and Treatment of HF


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1. Severe symptoms of HF with dyspnea and/or fatigue at rest or with minimal exertion NYHA class III or IV

2. Episodes of fluid retention (pulmonary and/or systemic congestion, peripheral edema) and/orreduced cardiac output at rest (peripheral hypoperfusion)

3. Objective evidence of severe cardiac dysfunction shown by at least 1 of the following: a. LVEF <30% b. Pseudonormal or restrictive mitral inflow pattern c. Mean PCWP >16 mm Hg and/or RAP >12 mm Hg by PA catheterization d. High BNP or NT-proBNP plasma levels in the absence of noncardiac causes

4. Severe impairment of functional capacity shown by one of the following: a. Inability to exercise b. 6-Minute walk distance ≤ 300 m (984 feet)c. Peak VO2 <12 to 14 mL/kg/min

5. History of ≥ 1 HF hospitalization in past 6 mo

6. Presence of all the previous features despite “attempts to optimize” therapy, including diureticsand GDMT,* unless these are poorly tolerated or contraindicated, and CRT when indicated


*GDMT: Guideline Directed Medical Therapy

Advanced HF Clinical Events and Findings

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Transplantation?

The benefit of transplantation is clear if a person requires continuous intravenous medications in the hospital. In unhospitalized patients, the following requirements have been recommended for consideration for cardiac transplantation:

♥ A history of repeated hospitalizations for heart failure

♥ Need for ventricular assist device or artificial heart to support circulation

♥ Increasing types, dosages, and complexity of medications

♥ A reproducible VO2 of less than 14 mL/kg per minute

Patients are stratified into low, medium, and high risk of death without transplant. The final decision about listing a patient for transplant is determined by an established cardiac transplant center.

Case Study 1Advanced Therapies

♥ Evaluated for heart transplant and denied listing due to age and comorbidities

♥ Referred for consideration for DestinationTherapy LVAD

♥ She declined

Case Study 1Palliative Care: When

� Palliative care begins at the time of diagnosis and continues through the trajectory of the disease

� Assessing emotional readiness of patient and family is vital for effective communication

� Annually the provider should review and discuss options of current and potential therapies

Clinical Practice Guidelines for Quality Palliative Care 2009Allen LA. Decision making in advanced heart failure. Circulation 2012Yancey CW. 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation 2013

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Palliative Care

• Palliative care is an interdisciplinary medical specialty that focuses on the care of patients with serious illness.

Can be delivered concurrently with life-prolonging care or

as the main focus of care

Clinical Practice Guidelines for Quality Palliative Care 2009

Palliative Care in Heart Failure

• 600,000 newly diagnosed HF patients every year

• $33.2 billion annual cost (direct and indirect costs)

• One in five patients die within one year of diagnosis

• Higher mortality rates found in

a. Advanced age

b. Multiple comorbidities

c. Frailty

d. Advanced HF (stage D)

• Five year survival rate worse than most types of cancer

Clinical Practice Guidelines for Quality Palliative Care 2009

Heart Failure Disease Trajectory

• Loss of functional abilities during progression from Class I to Class IV

• Repeated exacerbations and hospitalizations during progression from Class III to Class IV

• Sudden death more common during Class II to Class III

• Class IV deaths mostly occur from prolonged deterioration caused by chronic pump failure

Goodlin SJ. Journal of Cardiac Failure 2004;10(3):200-209

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Triggers for Specialist Palliative

Care Referral

Is the patient having more distressing physical or psychological symptoms?

Are there social or spiritual concerns that are distressing and

impacting the patient’s/family’s daily life?

Is there poor understanding of current health concerns, prognosis,

and options for treatment?

Is there inadequate identification of patient and family goals of care?

Is there concern about the safety and sustainability of post-discharge plan of

care?

Comprehensive Palliative Care

• Establishing goals of care that are in keeping with the patient’s values and preferences

• Consistent and sustained communication between the patient and all those involved in his or her care

• Psychosocial, spiritual, and practical support both to patients and their family caregivers

• Coordination across all sites of care• Prevent and relieve suffering• Support the best possible quality of life for patient and their families

regardless of the stage of the disease or the need for other therapies.

Shared Decision Making

� Institute of Medicine identified “patient-centered care” as 1 of the 6 pillars of quality

� Shared decision making is the process through which clinicians and patients share information with each other and work toward decisions about treatment options that are aligned with the patients’ values, goals, and preferences

� Prognosis is not just about survival, but about outcomes relevant

to the individual including:

Quality of life

Costs and burdens of treatments

a. Caregiver burden

b. Self-care burden

c. Uncertainty

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Shared Decision Making

Review all conditions when having honest discussion of prognosis:

1. Other serious illnesses eg. CKD, COPD

2. Coexisting conditions

3. Dementia

4. Frailty

a. Weight loss: Unintentional loss >10 pounds of

dry weight in past year

b. Weakness, poor grip strength

c. Poor endurance, exhaustion

d. Slowing of movements, ambulation

e. Low activity and energy expenditure

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Case Study 1The Rest of the Story

• 6 years later, continue end of life discussions

and goals of care 1-2 times a year

Case Study 2O Outpatient Sodium, Fluid, Exercise Recommendations

47 year old single father with history of ischemic cardiomyopathy, HFrEF, and hypertension referred to HFDM clinic for medication titration

NYHA class II, AHA stage C


NYHA Functional

Classification

ACCF/AHA Stages of

HF

II: Slight limitation of

physical activity.

Comfortable at rest,

but ordinary physical

activity results in

symptoms of HF

C: Structural heart

disease with prior or

current symptoms of

HF

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Case study 2: NYHA class II, AHA stage C

Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms

♥ Clinicians should consider some degree (e.g., <3g) of sodium restriction in patients with stage C and D HF for symptom improvement



♥ Exercise training or regular physical activity is recommended as safe and effective for patients with HF who are able to participate to improve functional status

♥ Fluid restriction (1.5-2L/day) is reasonable in stage D, especially in patients with hyponatremia, to reduce congestive symptoms


Conclusion

♥ Look to the guidelines – they will guide you in the knowledge of heart failure and patient management

Documents

Heart Failure Certification Review Course Part 2 - Oregon · 6/1/2015 1 Heart Failure Certification Review Course Part 2 Connie M. Lewis MSN, ACNP-C, NP-C, CCRN, CHFN Objectives ♥Recognize