Management of Heart Failure Across the Continuum
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Objectives:At the end of this course, you will be able to:
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1. Describe the different types of Heart Failure (Systolic versus Diastolic )
2. Describe both, the ACC stages and NYHA classes of Heart Failure
3. Identify recommended therapies for treatment of Heart Failure
4. Explain the different medication classes and their uses for the treatment of Heart Failure
5. Identify differences between ambulatory, inpatient and transitional Heart Failure patient treatment goals
6. Explain the differences between ambulatory, inpatient and transitional monitoring
7. Describe potential causes for readmission of a heart failure patient
Heart Failure Across the Continuum – Table of Contents1. What is Heart Failure
Types of Heart FailureSystolic vs. DiastolicACC StagesNYHA ClassesVentricular RemodelingPathophysiology
4 – 13
2. HF in Ambulatory CareHistory and PhysicalRecommended Therapies: Considering ACC StageMedications overview
• ACE / ARB / B-Blocker• Diuretics• Others
Transition to inpatient care
14 – 20
21 – 32
3. Hospitalized Patient (Inpatient Care)Goals of ED and IP Care Treatment / acute presentationClinical features / causes of acute clinical changeSpecial concerns and Key tests (BNP, ECHO, ECG, CXR)Principles of treatment Indications for Invasive TherapyDocumentation for improved codingTransition to ambulatory care
33 – 54
4. Transitional CareTransition support Causes of readmission for HFRemote Monitoring and Readmission Risk AssessmentPalliative Care
55 – 59
5. Conclusions 60
6. Appendix and References 61 – 70
Post test with answers 71 – 72
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• A clinical syndrome resulting from any structural or functional cardiac defect limiting ventricular filling, a syndrome is described by specific symptoms and signs
• Around 5.8 million people in the United States have heart failure. • About one in five people who have heart failure die within one year from diagnosis.• HF ranks as the most frequent cause of hospitalization and re-hospitalization
among older Americans.1,2
• In 2010, heart failure will cost the United States $39.2 billion.3 This total includes the cost of health care services, medications, and lost productivity.
• The most common causes of heart failure are coronary artery disease, high blood pressure, and diabetes.
• HF is diagnosed on the presence of characteristic signs and symptoms and not on the basis of any diagnostic tests
– Tests such as echocardiograms and cardiac stress testing establish thepathophysiologic cause but do not define whether heart failure is present or not
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What is Heart Failure?
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1 Wier LM, Levit K, Stranges E, et al. HCUP Facts and Figures: statistics on hospital-based care in the United States, 2008: exhibit 2.3, most frequent principal diagnoses by age. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports.jsp. 2 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. 3 Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics—2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee . Circulation. 2010;121:e1-e170.
Types of Heart Failure
• There are several ways to clinically classify heart failure: – By type
• Systolic versus diastolic– By stages or classes
• American College of Cardiology (ACC)/American Heart Association (AHA), Stages A, B, C and D
• New York Heart Association classes I - IV– By underlying cause
• Ischemic, due to radiation therapy, etc.– By anatomical location
• Right versus left
• Coding classifications and definitions focus primarily on systolic versus diastolic (or both) and acute versus chronic (or both). Specific documentation is necessary to help coding accurately reflect severity of illness and risk of mortality
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Systolic Versus Diastolic Heart Failure
• In 1994, the Agency for Healthcare Research and Quality (AHRQ) in association with the American Heart Association and the American College of Cardiology, developed guidelines to distinguish systolic and diastolic dysfunction.
• It is important to distinguish between the two as their long-term treatments are different.
• Patients may also have combined systolic and diastolic heart failure.
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• Systolic heart failure is characterized by inability of heart muscle to contract vigorously – Results in inadequate amount of blood
and oxygen to body– Failure to contract adequately causes
fluid backup into the lungs causing pulmonary congestion
• Evidenced by:– Ejection Fraction usually less than
40%– Confusion – Shortness of breath – Diaphoresis – Fatigue– Pulmonary edema
• Common patient populations include:– Men aged 50-70; patients with CAD,
Hx MI, or certain cardiomyopathies
• Diastolic heart failure occurs when the heart has a problem relaxing between contractions (diastole) to allow enough blood to enter the ventricles.
– Results in systemic fluid accumulation– Some patients may also have pulmonary
congestion • Evidenced by:– Ejection fraction >50%– Jugular vein distension (JVD)– Peripheral edema (especially in legs,
ankles and feet)– Ascites/Anasarca– Hepatomegaly– Pulmonary Hypertension• Common populations include:– Older women; patients with obesity,
hypertension and chronic lung conditions
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Systolic Versus Diastolic Heart Failure (continued)
ACC/AHA Stages for Heart Failure (cont.)
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At Risk for Heart Failure:STAGE A High risk for developing HF
STAGE B Asymptomatic LV dysfunction
• Designed to emphasize preventability of HF
Heart Failure:STAGE C Past or current symptoms of HF
STAGE D End-stage HF
• Designed to recognize the progressive nature of LV dysfunction
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ACC/AHA Stages for Heart Failure (cont.)
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Complement, but do not replace NYHA classes
• NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)
• ACC Stages - progress in one direction due to cardiac remodeling
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NYHA Classes for Heart Failure
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Patients with:─Previous MI─LV remodeling including LVH and Low EF─Asymptomatic valvular disease
ACC/AHA Stages for Heart Failure
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Stage AAt high risk for HF
but without structural
heart disease or symptoms of HF
Stage BStructural heart disease but without
symptoms of HF
Stage CStructural heart disease with
prior or current symptoms of HF
Stage DRefractory HF requiring specialized interventions
Patients with:─Hypertension─Atherosclerosisdisease
─Diabetes─Metabolic syndrome
Or
Patients─Using cardiotoxins─With HFx CM
Patients with:Known structural heart disease
And
Shortness of breath and fatigue, reduced exercise tolerance
Patients:Who have marked symptoms at rest despite maximal medical therapy (e.g. those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions
At Risk for Heart Failure Heart Failure
Ventricular Remodeling - Illustration
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Ventricular remodeling ‐ Cross‐sectional view of left and right ventricles:a, normal; b, concentric hypertrophy; and c, eccentric hypertrophy.Abbreviations: LV, left ventricle; RV, right ventricle. Produced and printed with permission from The Cleveland Clinic Foundation; Cleveland, Ohio.
a b c
RV LV RV LV RVLV
Source: CRITICALCARENURSE Vol 24, No. 6, DECEMBER 2004 , pg 18
Consequences of Ventricular Remodeling:High Pressure (wall stress) heightens myocardial oxygen consumption, which promotes further hypertrophy and activatesneurohormonal systems –resulting in reduction of ejection fraction, ventricular performance, morbidity and mortality.
Goals for Understanding Ventricular Remodeling: Promote regression and prevent progression of LV enlargement to decrease disease progression and improve survival
↑ MVO2
↑Heart Rate
↑Ischemia
↑Wall stress
Afterload mismatch↓Cardiac
output ↓ LV contractility ↑Vasoconstriction InflammatoryNeurohormonal
activation
Hypoperfusion/Hypotension
↑Wall stress↑Diastolic
dysfunction Volumeredistribution
End organdysfunction
Inflammatory/Neurohormonal
activation
↑Left atrial andPulmonary
Venous pressure
Alveolar-Capillary leak
Renal dysfunction(fluid and salt retention)
Blood volumeexpansion
Pulmonaryedema
Hypoxia
Pathophysiology of Acute HF
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AMBULATORY CAREHeart Failure in
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Heart Failure in Ambulatory CarePatient History & Physical for identification of potential HF
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Presenting Symptoms
Past Medical History
Family, Social and Dietary History
Physical Exam
• Cough/sputum production
• Dyspnea on exertion• Paroxysmal nocturnal
dyspnea• Orthopnea• Chest pain• Palpitations• Edema• Fever or viral illness• Fatigue• Recent weight gain• Decrease exercise
intolerance• Blood loss
• History of HF• History of MI• Cardiac risk factors• HTN/smoking/DM/^lip
ids• RF/Endocarditis• Thyroid dysfunction• Thromboembolic
disease• Postpartum• Blunt chest trauma• HIV
• Ischemic heart disease• HF• Congenital heart
disease• Risk factors for ASCAD• Salt and fluid intake• Tobacco use / abuse• Alcohol use / abuse• Drug abuse• Other Toxins
(Chemotherapy, Stimulants, TCA, COX-1 and COX-2 inhibitors,Glitazones,glucocorticoids)
• Vital signs (including height and weight)
• Cyanosis, pallor, jaundice• Diaphoresis• Labored breathing, rales >
25%, lung sound that do not clear with cough
• Tachycardia, bradycardia, arrhythmias
• Left lateral displacement of point of maximal impulse
• S3, S4, or murmur• Elevated jugular venous
pressure, + hepato-jugular reflux
• ABD, large, pulseatile, or tender liver
• Decreased peripheral pulses• LE edema
Heart Failure in Ambulatory CareRecommended Therapies; Reduce Risk: Patients in Stage A
• Treating known risk factors (hypertension, diabetes, etc.) with therapy consistent with contemporary guidelines
• Avoiding behaviors increasing risk (i.e., smoking, excessive consumption of alcohol, illicit drug use)
• Periodic evaluation for signs and symptoms of HF
• Ventricular rate control or sinus rhythm restoration
• Noninvasive evaluation of LV function
• Drug therapy– Angiotensin Converting Enzyme Inhibitors (ACEI)– Angiotensin Receptor Blockers (ARBs)
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Heart Failure in Ambulatory CareRecommended Therapies: Patients in Stage B
• General Measures as advised for Stage A
• Drug therapy for all patients– ACEI or ARBs– Beta-Blockers
• ICDs in appropriate patients
• Coronary revascularization in appropriate patients
• Valve replacement or repair in appropriate patients
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Heart Failure in Ambulatory CarePatients in Stage C with Reduced LVEF with Symptoms
• General measures as advised for Stages A and B• Drug therapy for all patients
– Diuretics to reduce fluid retention– ACEi– Beta-blockers (reduces mortality)– Avoid NSAIDS, most anti-arrhythmics and most Ca2+ channel blockers
• Drug therapy for selected patients– Aldosterone Antagonists (moderately severe symptoms, and easy to monitor)– ARBs (for those ACEi intolerant)– Digitalis (reduces hospitalizations)– Hydralazine/nitrates (ACEi / ARB intolerance; hypotension or renal
insufficiency• ICDs in appropriate patients (primary prevention of SCD and secondary
prevention prolong survival)• Cardiac resynchronization in appropriate patients• Exercise Testing and Training
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Heart Failure in Ambulatory CarePatients in Stage C with Normal LVEF with Symptoms
• Treating known risk factor (hypertension) with therapy consistent with contemporary guidelines
• Ventricular rate and sinus rhythm control for all patients• Restoration/maintenance of sinus rhythm in appropriate patients• Drugs for all patients
– Diuretics (control pulmonary congestion and peripheral edema)• Drugs for appropriate patients
– ACEI– ARBs– Beta-Blockers
• Coronary revascularization in patients with CAD in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function
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Might be effective in symptom control, with controlled hypertension
• Patients are now symptomatic at rest despite optimal medical therapy – requiring close monitoring:– Close management of fluid retention and other symptoms– Refer for transplant if potentially eligible– Refer to a HF program with expertise in refractory HF– Discuss End of Life care
• May include AICD deactivation
• For selected patients consider the following:– LVAD (Left Ventricular Assist Device)– PA (Pulmonary Artery) catheter placement – Continuous IV infusion of a positive inotrope (palliation)
Heart Failure in Ambulatory CarePatients in Stage D (Refractory Heart Failure)
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MEDICATIONSHeart Failure
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Heart Failure in Ambulatory CareMedication Overview:
• ACEi if– Current/prior symptoms of HF– Reduced LVEF
• ARB’s• Β-Blockers• Diuretics and Salt
Restriction if– Current/prior sx of HF– Reduced LVEF– Fluid Retention
• Aldosterone Antagonists• Hydralazine and long
acting nitrites• Digoxin
• Rx to avoid– NSAIDs– Most anti-arrhythmics– Most Ca2+ channel blockers
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ACE Inhibitors
Selection Exclusions Monitoring•SBP> 85 mmHg•Minimal volume overload
•Dose increased at intervals determined by BP and renal function
•Patients with borderline renal titration should be slower
•ACE allergy•Moderate severe AS•Cardiogenic shock•BP <80 mmHg•Hyperkalemia•Serum Creatinine>3•Bilateral Renal arterystenosis
•Pregnancy•Any in patient requiring IV pressors
•Cough• Increase fatigue•Dizziness•SBP <80•Renal function•Lowest diuretic possible
•Stagger ACE and B-Blockers
•Avoid NSAID’s
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ACE Agents
Agent Initiation Steps Target
Captopril 6.25mg tid 12.5-25mg tid 50mg tidEnalapril 2.5mg bid 5mg bid 2.5-20mg bidLisinopril 5mg daily 5, 10mg daily 5-40mg dailyRamipril 2.5mg bid 2.5mg bid 5mg bidQuinapril 5mg bid 10mg bid 10-20mg bidFosinopril 10 mg daily 5-10-20mg daily 20-40mg daily
ACC Guidelines:•ACEIs and Beta-blockers should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF. •ACEI should be used in patients with a reduced EF and no symptoms of HF, even if they have not experienced MI. •ACEI or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF.
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ARB’s
Selection Exclusions Monitoring•May be used if ACE’scannot be tolerated
•SBP > 85 mmHG•Minimal fluid overload•Dose increase determined by BP and renal function
•Patients with border line renal function should betitrated slower
•Only Valsartan andCandesartan are approved for use in patients with HF
•Allergy•Cardiogenic shock•Hypoperfusion•SBP<80 mmHg•Pregnancy•Any patient on IVpressors
•Severe renal arterystenosis
•Potassium > 5.5
• Increase fatigue•Dizziness•SBP < 80 mmHg•Renal function•Not be used with ACE and B-Blocker
•Avoid NSAID’s
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ARB Agents
Agent Initiation Titration Target
Candesartan 4mg daily 8-16-32mg daily
32mg daily
Losartan 25mg daily 50-100mg daily 100mg daily
Valsartan 40mg bid 80mg bid 160mg bid
ACC Guideline:• For older patients – “start low and go slow”•An ARB should be administered to post-MI patients without HF who are intolerant of ACEIs and have a low LVEF.•ACEIs or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF.•ARBs can be beneficial in patients with low EF and no symptoms of HF who are intolerant of ACEIs.
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B-Blockers
Selection Exclusions Monitoring•SBP >85 mmHg•Not requiring IVpressors
•No longer significantly volume overload
•Used with ACE inhibitors
•When only one drug can be initiated for HF, B-Blockers are preferred
•Cardiogenic shock•Hypoperfusion•SBP<80 mmHG•Symptomaticbradycardia
•Significant volume overload
•Hold if SBP<80 mmHg•Hold HR < 55 bpm•Monitor daily weights•May cause increase fatigue, weight gain, dizziness, and or heart block
•Prescribe lowest diuretic possible
•Stagger B-blocker and ACE dosing
•Avoid NSAID’s•An ARB should NOT be given with ACE and B-blocker
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B-Blockers Agents
Agent Initiation Titration Target
Carvedilol 3.125mg bid 6.25-12.5mg bid 6.25-25mg bid
Metoprolol 6.25-25mg QD 25, 50 100mg daily 200 mg dailyBisoprolol 1.25mg daily 2.5-5mg daily 10mg daily
Titration Recommendations:• Start while in hospital and D/C on that dose if tolerating• Increase at 2-4 week intervals until target dose is reached or patient becomes
symptomatic
ACC Guidelines:• Beta-blockers and ACEIs should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF.
• Beta-blockers are indicated in all patients without a history of MI who have a reduced LVEF with no HF symptoms.
• Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated.
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Diuretic Agents
Agent Initiation Titration Target
Furosemide 40mg daily 80-160mg daily 160-200mg daily
Bumetanide 1 mg daily 2,4 mg daily 8 mg daily
Torsemide 10mg daily 25,50, 100mg daily 200mg daily
HCTZ 25mg daily 25-50mg daily 50 mg daily
ACC Guidelines:•Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluidretention.•Monitoring - Smallest dose possible: avoid: hypokalemia;hypomagnesemia; prerenal azotemia; orthostatic hypotension
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Aldosterone Antagonists
Agent Initiation TargetSpironolactone 12.5mg daily 25 mg dailyEplerenone 50 mg daily 50 mg daily
ACC Guidelines:• Addition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be less than or equal to 2.5 mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium should be less than 5.0 mEq/L. Under circumstances where monitoring forhyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists.
• Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF.
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Long Acting Nitrates
Agent Initiation Target
Hydralazine 25mg 4 X/d 50mg 4 X /day
Isosorbide dinitrate 30 mg tid 40 mg tid
• Selection– Use with African-Americans who may be
ACE/ARB intolerant, or may not respond to optimal management
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Digoxin
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TRANSITIONS TO INPATIENTHeart Failure
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Heart Failure Care Transitions Ambulatory to Hospital
Goals: Primary Care in the ambulatory setting must coordinate patients returning to the hospital– Ensure patient history and care plan is available for emergency and
or hospital physicians (as necessary or appropriate)– Help patient understand the reasons they will need hospitalization
and what they can do to help avoid these circumstances• Primary care is integral to coordination of patient care; Key concepts: well
coordinated care between providers, across settings and equal coordination of care across providers and settings
• Evidence based care1 means better care for the individual, better health for the population and reduced costs for the health system
• Patient experience should be at the forefront of care– leverage the latest clinical advances and health information technology to ensure
patients receive the most timely, efficient and safest care possible.– latest evidence-based clinical data helps clinicians make the most informed
decisions, when and where they need it.
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1 - ACC/AHA Task Force on Practice Guidelines. Manual for ACC/AHA Guideline Writing Committees: Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines. 2006. Available at: http://www.acc.org/qualityandscience/clinical/manual/pdfs/methodology.pdf and http://circ.ahajournals.org/manual/ . Accessed January 30, 2008.
Goals of Emergency / Inpatient Treatment
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• Treat life-threatening conditions• Establish the diagnosis
• Review signs and symptoms• Adequacy of systemic perfusion• Volume status• Get input from PCP or other physicians treating the patient
• Contribution from precipitant or co-morbid factors• Assess and treat any other cardiac and non-cardiac conditions
• Evaluate the Cardiac Status• Evaluate the stage/class; systolic/diastolic• Identify and treat precipitant(s)• Monitor and reassess frequently
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Acute Decompensated Heart Failure Presentation
1. Volume overload
Pulmonary and/or systemic congestion frequently precipitated by acute increase in chronic hypertension.
2. Profound depression of cardiac output
Hypotension, renal insufficiency, and/or a shock syndrome.
3. Combination of 1 and 2
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Heart Failure - Clinical Features
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Cardiac Fluid/Electrolytes Respiratory• Hypotension/Hypertension• Tachycardia (heart rate
>100 bmp)• New arrhythmias or
uncontrolled chronic arrhythmias
• Elevated BNP levels • Ejection fraction may be
impaired or normal depending on type of failure
• Cardiogenic shock
• Weight gain of 2‐3 or more pounds in 1 day
• Jugular vein distention (JVD)
• Edema• Low Sodium and
Chloride levels
• SOB/ Dyspnea/Orthopnea
• Coughing clear, white or pink sputum
• Tachypnea (respirations >24)
• Altered lung sounds: crackles
• Hypoxia/ABG’s with PO2 <70
• Oxygen requirement or need for increasing amounts including BiPap
• CXR noting: “CHF”/Pulmonary edema/Pleural effusion
• Acute respiratory failure
The Hospitalized Patient
Common causes for the acute clinical change:– Non-compliance with Drug therapy or diet– AMI – Acute Myocardial Infarction– Uncorrected high blood pressure– Atrial fibrillation or other arrhythmia– Recent addition of negative inotropic drugs (verapamil, nifedipine,
diltiazem, beta blockers)– Pulmonary Embolism– NSAID, EtOH, or illicit drug use– Endocrine abnormalities (Diabetes, thyroid disease)– Concurrent infection (Pneumonia, viral illnesses)
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The Hospitalized Patient
• Special concerns during the H&P– Establish the diagnosis (symptoms and signs of HF)
• Class/Stage– Adequacy of systemic perfusion– Volume status– Contribution from precipitant or co-morbid factors
• Key tests:– Electrocardiogram (ECG)– Chest radiography (CXR)– B-type natriuretic peptide; N-terminal pro b-type natriuretic– Echocardiography
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Electrocardiogram: Common Abnormalities in Heart Failure
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Abnormality Causes Clinical implications
Sinus tachycardia Decompensated HF; anemia; fever; hyperthyroidism Clinical assessment; Laboratory investigation
Sinus bradycardia b-Blockade; Digoxin; Anti-arrhythmics; Hypothyroidism; Sick sinus syndrome Evaluate drug therapy; Laboratory investigation
Atrial tachycardia/flutter/fibrillation
Hyperthyroidism; infection; mitral valve diseases;Decompensated HF; myocardial infarction
Slow AV conduction; medical conversion;electroversion; catheter ablation; anticoagulation
Ventricular arrhythmias Ischemia; infarction; cardiomyopathy; myocarditis;hypokalemia, hypomagnesaemia; Digitalis overdose
Laboratory investigation; Exercise test; perfusion studies; coronary angiography,electrophysiology testing; ICD
Ischemia/Infarction Coronary artery disease Echo; troponins; coronary angiography;revascularization
Q waves Infarction; hypertrophic cardiomyopathy; LBBB, pre-excitation Echo; coronary angiography
LV hypertrophy Hypertension; aortic valve disease; hypertrophic cardiomyopathy Echo/Doppler
AV block Infarction; drug toxicity; myocarditis; sarcoidosis;Lyme disease
Evaluate drug therapy; pacemaker; systemic disease
Microvoltage Obesity; emphysema; pericardial effusion;amyloidosis Echo; chest X-ray
QRS length > 120 ms of LBBB morphology Electrical and mechanical dysynchrony Echo; CRT-P; CRT-D
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Source: European Journal of Heart Failure (2008), 933-989 doi:10.1016/j.ejheart.2008.08.005
Chest Radiography: Common Abnormalities in Heart Failure
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Abnormality Causes Clinical Implications
Cardiomegaly Dilated LV, RV, atria; Pericardial effusion Echo/Doppler
Ventricular hypertrophy
Hypertension, aortic stenosis, hypertrophic cardiomyopathy Echo/Doppler
Normal pulmonary findings Pulmonary congestion unlikely
Reconsider diagnosis (if untreated); Serious lung disease unlikely
Pulmonary venous congestion Elevated LV filling pressure Left heart failure confirmed
Interstitial edema Elevated LV filling pressure Left heart failure confirmed
Pleural effusions
Elevated filling pressures; HF likely if bilateral; Pulmonary infection, surgery, or malignant effusion
Consider non-cardiac etiology if abundant; If abundant, consider diagnostic or therapeutic centers
Kerley B lines Increased lymphatic pressures Mitral stenosis or chronic HF
Hyperlucent lung fields Emphysema or pulmonary embolism Spiral CT, spirometry, Echo
Pulmonary infectionPneumonia may be secondary to pulmonary congestion Treat both infection and HF
Pulmonary infiltration Systemic disease Diagnostic work-up
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Source: European Journal of Heart Failure (2008), 933-989 doi:10.1016/j.ejheart.2008.08.005
Pro-BNP, BNP and NT-pro-BNPWhen the heart is stressed, it produces a precursor, pro-BNP, which is separated to release the active hormone BNP and an inactive fragment, NT-proBNP
Both BNP and NT-proBNP are produced mainly in the heart’s left ventricle, and released as a natural response to heart failure,hypotension, angina, hypertrophy (when the left ventricle has been “stretched” too much from the accumulation of blood and fluid), or when overworked (i.e. rapid heart rate)
Elevations of BNP are dependent on overall patient condition (including presence and type of co-morbid conditions) and the stage and type of heart failure.
BNP levels should be correlated with other clinical indicators
B-Type Natriuretic Peptide (BNP)
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Conditions that Influence BNP Concentrations
Increased BNP:• Age (older)• Sex (female)• Ethnicity (black)• Renal dysfunction• Myocardial infarction/acute coronary
syndromes• Right-sided heart failure (cor
pulmonale, acute pulmonary embolus)• High output failure (cirrhosis, septic
shock)
Decreased BNP:• Obesity
• Early acute heart failure (less than 1 hour)
• Acute mitral regurgitation
• Mitral stenosis (in the absence of right ventricular failure)
• Stable NYHA Class I patients with decreased LV ejection fraction
BNP Values*:• <100 pg/ml = no systolic or diastolic heart failure• 100-200 pg/ml = normal or chronic CHF • 200-400 pg/ml = could be indicative of LV or RV CHF, PE, LVH, ESRD, AMI• >400 pg/ml = overt CHF
*Normal levels and clinical significance of values vary between hospitals and physicians
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Echocardiography – Helps Identify the Etiology of Heart Failure
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Measurement Abnormality Clinical implicationsLV ejection fraction Reduced (45 - 50%) Systolic dysfunction
LV function; global and focal Akinesis; hypokinesis; dyskinesis Myocardial infarction/ischemia; Cardiomyopathy; myocarditis
End-diastolic diameter Increased (.55 - 60 mm) Volume overload; HF likely
End-systolic diameter Increased (.45 mm) Volume overload; HF likely
Fractional shortening Reduced (25%) Systolic dysfunction
Left ventricular thickness Hypertrophy (.11 - 12 mm) Hypertension; aortic stenosis; hypertrophic cardiomyopathy
Left atrial size Increased (.40 mm) Increased filling pressures; Mitral valve dysfunction; Atrialfibrillation
Valvular structure and function
Valvular stenosis or regurgitation (especially aortic stenosis and mitralinsufficiency)
May be primary cause of HF or complicating factor; Assess gradients and regurgitant fraction; Assess hemodynamicconsequences; Consider surgery
Mitral diastolic flow profile Abnormalities of the early and late diastolic filling patterns
Indicates diastolic dysfunction and suggests mechanism
Tricuspid regurgitation peak velocity
Increased (.3 m/s) Increased right ventricular systolic pressure Suspect pulmonary hypertension
Aortic outflow velocity time integral
Reduced (15 cm) Reduced low stroke volume
Inferior vena cava Dilated Retrograde flow Increased right atrial pressures; Right ventricular dysfunction Hepatic congestion
Pericardium Effusion; hemopericardium; thickening
Consider tamponade; uremia; malignancy; systemic disease; acute or chronic pericarditis; constrictive pericarditis
Source: European Journal of Heart Failure (2008), 933-989 doi:10.1016/j.ejheart.2008.08.005
The Hospitalized Patient – Principles of Treatment
• Stabilize systemic perfusion if necessary
• If fluid overloaded, IV loop diuretics– Initially equal or greater than oral outpatient dose– Later guide by urine output and signs / symptoms
• Increase dose?• Continuous IV diuretic infusion• Add 2nd medication (metolazone, spironolactone)
– While on IV diuretics or changing HF meds, daily basic metabolicpanels
• Monitor I/Os, vital signs, body weight daily
• Check signs and symptoms of perfusion and congestion both supine and standing
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The Hospitalized Patient – Principles of Drug Therapy
• Continue home meds as appropriate
• If not on a BB, start while inpatient– Start at a low dose– If not on a BB during admission:
• Start at low dose• Monitor for orthostatic hypotension
• Vasodilators only if– Severely symptomatic volume overload– Inadequate response to diuretics after escalation– No systemic hypotension
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The Hospitalized Patient – Other Therapy Options
• Progressive deterioration of renal function BUN >80 mg/dl and Cr>3 mg/dl or hyperkalemia may necessitate discontinuation of ACE inhibitors and spironolactone
• Use of further vasodilators, either oral or intravenous, should be considered
• Intravenous inotropic therapy can improve renal function and allow effective diuresis
• Invasive hemodynamic monitoring– For refractory symptoms and signs
• Ultrafiltration or hemodialysis may be necessary
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Initial Management of Acute Heart Failure
Target Therapeutic example
Mechanism of action Side effects
Alleviate congestion
IV furosemide Water and sodium excretion
Electrolyte abnormalities
Reduce elevated LV filling pressures
IV nitrates Direct relaxation of vascular smooth muscle cells through various mechanisms
Hypotension, decreased coronary perfusion pressure
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Target Therapeutic example
Mechanism of action Side-effects
Poor cardiac function
Inotropes Activate Cyclic adenosinemonophosphate (cAMP) or calcium sensitization, resulting in improved contractility andvasodilation (with increased sympathetic tone)
Hypotension, arrhythmias, myocardial damage, association with increased morbid events
Tachycardiaand increased systemic blood pressure (i.e. in cases of excessive sympathetic tone)
Beta-blockers: IV esmolol may be used when HF is related to AF with RVR and/or severe hypertension
Blockade of beta-1 and beta-2 receptors
Bradycardia,hypotension, negative inotropy; however given short half-lifeesmolol, these side-effects should be short-lived
Initial Management of Acute Heart Failure (cont.)
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Use of Diuretics
• Helpful in relieving congestion and decreasing volume overload: consider loop diuretics as first choice
• Multiple divided doses versus continuous infusion
• High-dose versus low-dose loop diuretics
• Consider combination of diuretics.
• Precipitation of metabolic abnormalities
• May predispose to arrhythmias
• Worsening of renal function
• Lower the dose as tolerated once euvolemic state is achieved.
Appropriate Adverse Effects
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• Diuretics are useful in relieving the symptoms of congestion andcorrecting the volume overload, but excessive diuresis can cause metabolic abnormalities and adversely effect the neurohormonalbalance.
• Vasodilator therapy should be aggressively pursued for controlling thehemodynamic abnormalities and relief of symptoms in acutedecompensated heart failure.
• Beta blockers should be continued through hospitalization when admitted with ADHF unless contraindicated. Beta blockers should be part of discharge medication regimen unless contraindicated.
• ACEi/ARB should be continued through hospitalization in spite of modest deterioration in renal function and should be optimized prior to discharge, unless contraindicated.
• Aldosterone antagonists should be considered for patients in Class III and Class IV CHF, unless contraindicated.
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Additional Medication Considerations
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Indications for Invasive TherapyImplantable Cardioverter Defibrillator
• Nonischemic cardiomyopathy or ischemic heart disease at least 40 days post MI with ejection fraction of <35% with NYHA Class II or III symptoms on maximum chronic optimal medical therapy and reasonable expectation of survival of more than 1 year with goodfunctional status.
Indications for Cardiac Resynchronization Therapy
• Sinus rhythm
• QRS duration >0.12 msec
• LVEF <35%
• Typically NYHA functional Class II or III, but any patient regardless of NHYA class can be considered (new addition to ACC in 2009)
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Major Scenarios for Consideration ofImplantable Cardiac Defibrillators in HF
Scenario 1• Current/prior symptoms of HF• Reduced LVEF with history of cardiac arrest, ventricular
fibrillation, or hemodynamically destablizing ventriculartachycardia
Scenario 2• Nonischemic Cardiomyopathy or Ischemic disease, 40
days post myocardial infarction and a LVEF < 35%• NYHA Class II or III on optimal therapy• Expected survival > 1yr
Scenario 3• LVEF < 35%• Sinus rhythm or Atrial fibrillation• NYHA Class III or Class IV on optimal therapy• Cardiac dyssynchrony (QRS >= 0.12 seconds)
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Secondary prevention to
prolong survival
Primary prevention of sudden cardiac
death
Consider for that are severely symptomatic –also consider AICD with Resynchronization Therapy
Heart Failure Documentation Improvement Key Concepts
For acute care, documentation should indicate severity of the patients illness or condition, key terms that indicate severity and / or specify the patient's condition:
• Document the etiology of the cardiomyopathy – such as hypertensive heart disease, ischemic heart disease, valvular and which valve(s), viral, alcoholic, etc.). This documentation reflects a higher level of evaluation.
• Document the known results of cardiac function studies and state whether they reflect failure due to left ventricular systolic dysfunction, left ventricular diastolic function or both.
• Clarify the patient’s heart failure status (due to chronic left ventricular systolic or diastolic dysfunction) and whether the current episode reflects acutedecompensation.
• Document whether the patient had an acute MI within eight weeks of this episode and whether the acute MI was the cause of this episode ofdecompensation.
• Name/document the relationship if this is a CKD patient and volume overload or non-cardiac pulmonary edema led to the decompensation.
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TRANSITIONS TO AMBULATORYHeart Failure
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Heart Failure Care Transitions Hospital to Ambulatory
Goals: Coordination with Primary Care
• Help patients understand the importance of avoiding readmission by reinforcing the following:– Take medication as prescribed (understanding purpose of meds)– Keep appointments with your doctors (primary care and other providers)– Keep track of daily weights and nutrition (especially salt and fluids restriction)
and bring health records to doctor visits– Get daily physical activity– Know the warning signs and what do to for increasing symptoms of HF– Maintain a healthy lifestyle to improve overall well being
• Primary care providers should understand readmission risk scores and how their patients would benefit from remote monitoring
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Heart Failure Care TransitionsCauses of Hospital Readmission for CHF
HFSA Research 2000
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Heart Failure Care TransitionsRemote Monitoring and Readmission Risk
Remote Monitoring (Tele-health) – Studies have shown that monitoring HF patients through telephone or other device monitoring can reduce HF Readmissions
Readmission Risk – Several tools are publically available and include LACE; Modified LACE; Yale New Haven Readmission Risk Tool
Risk Assessment can help clinicians understand a HF patient’s individual needs for management across care settings (Transitions or Health Coach; Home Care; Remote Monitoring i.e. Tele-monitoring; or Palliative Care)
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• Initiate Palliative Care at the diagnosis
• Intended for people with serious illnesses
• Focus is on providing patients with relief from their symptoms and the stress of a having a serious illness and improving quality of life — no matter the diagnosis
• Appropriate at any age and at any stage of an illness, and it can be provided along with treatments that are meant to cure.
Heart Failure Care Transitions Palliative Care Integrative Model
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Newer
Figure 1. Palliative Care Integrative Model Figure 2. Disease-Directed Palliative Care Model
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Conclusions
• Manage HF better by using evidence-based guidelines more consistently– Early recognition of HF and prompt action in outpatient and inpatient
settings– Careful, anticipatory, collaborative care especially at transitions
ambulatory ↔ acute care– Patient and caregiver education
• Prevent readmissions– Ambulatory monitoring– Discharge planning– Invasive, restorative or palliative care
• Learn from best practices– From peers– From Trinity organizations
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Appendix
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• ACC Guideline Drug Tables pgs 62 – 64
• ACC Stages and Treatments Options pgs 65 – 66
• Clinical Profiles of Acute Heart Failure pg 67
• Heart Failure ICD-9 Codes pg 68
• Ventricular Remodeling Definition pg 69
Drug Stage A Stage B Stage C
Ace Inhibitors
Benazepril (Lotensin) H
Capropril (Capoten) H, DN Post MI HF
Enalapril (Vasotec, Renitec) H, DN Asymptomatic LVSD HF
Fosinopril (Monopril) H HF
Lisinopril (Prinivil, Zestril) H, DN Post MI HF
Moexipril (Univasc) H
Perindopril (Aceon) H, CV Risk
Quinapril (Accupril) H HF
Ramipril (Altace) H, CV Risk Post MI Post MI
Trandolspril (Mavek) H Post MI Post MI
Angiotensin Receptor Blockers
Candesartan (Atacand) H HF
Eprosartan (Teveten) H
Irbesartan (Avapro) H, DN
Losatan (Cozaar) H, DN CV Risk
Olmesartan (Benicar) H
Telmisartan (Micardis) H
Valsartan (Diovan) H, DN Post MI Post MI, HF
Cardiovascular Medications Useful for Treatment of Various Stages of Heart Failure
CV Risk –Reduction in future cardio-vascular risk
DN –Diabetic Nephropathy
H – Hypertension
HF - Heart Failure
LVSD – Left ventricular systolic dysfunction
2005 ACC / AHA Guidelines for Diagnosis and Management of Heart Failure in Adults
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Drug Stage A Stage B Stage C
Aldosterone Blockers
Eplerenone (Inspra) H Post MI Post MI
Spironolactone (Aldactone) H HF
Beta-Blockers
Acebutolol (Sectral) H
Atenolol (Senormin, Tenormin) H Post MI
Betaxolol (Kerlone) H
Bisoprolol (Zebeta) H HF
Carteolol (Cartrol) H
Carvedilol (Coreg) H Post MI HF, Post MI
Labetalol (Trandate, Normodyne) H
Metoprolol succinate (Toprol XL) H HF
Metroprolol tartrate (Lopressor) H Post MI
Nadolol (Cargard) H
Penbutolol (Levatol) H
Pindolol (Visken) H
Propranolol (Inderal) H Post MI
Timolol (Betimol, Istalol) Post MI
Digoxin HF
CV Risk –Reduction in future cardio-vascular risk
DN –Diabetic Nephropathy
H – Hypertension
HF - Heart Failure
LVSD – Left ventricular systolic dysfunction
Cardiovascular Medications Useful for Treatment of Various Stages of Heart Failure
2005 ACC / AHA Guidelines for Diagnosis and Management of Heart Failure in Adults
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Drug Initial Daily Dose (s) Max Total Daily Dose Duration of ActionsLoop Diuretics
Bumetanide (Bumex) 0.5 to 1.0 mg once or twice 10 mg 4 to 6 hours
Furosemide (Lasix) 20 to 40 mg once or twice 600 mg 6 to 8 hours
Torsemide (Demadex) 10 to 20 mg once 200mg 12 to 16 hours
Thiazide Diuretics
Chlorothiazide (Chlotride, Diuril) 250 to 500 mg once or twice 1000 mg 6 to 12 hours
Chlorthalidones (Thalitone) 12.5 to 25 mg once 100 mg 24 to 72 hours
Hydrochlorothiazide (HydroDIURIL) 25 mg once or twice 200 mg 6 to 12 hours
Indapamide (Lozol) 2.5 mg once 5 mg 36 hours
Metolazone (Mykrox, Zaroxolyn) 2.5 mg once 20 mg 12 to 24 hours
Potassium-Sparing Diuretics
Amiloride (Midamor) 5 mg 20 mg 24 hours
Spironolactone (Aldactone) 12.5 to 25 mg once 50 mg 2 to 3 days
Triamterene (Dyrenium) 50 to 75 mg twice 200 mg 7 to 9 hours
Sequential Nephron Blockade
Metolazone (Mykrox, Zaroxolyn) 2.5 to 10 mg once plus loop diuretic
Hydrochlorothiazide (HydroDIURIL) 25 to 100 mg once or twice plus loop diuretic
Chlorothiazide (Chlotride, Diuril) (IV) 500 to 1000 mg once plus loop diuretic
Oral Diuretics Recommended for Use in the Treatment of Fluid Retention in Chronic HF
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Jessup M. and Brozena S. N Engl J Med 2003;348:2007-2018
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ACC/AHA Stages and Treatment for Heart Failure
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Clinical Profiles of Acute Heart Failure
(Dickstein et al)
67
Hypertensive AHF
AcutelyDecompensated
Chronic HFPulmonaryEdema
ACS and HF
CardiogenicShock
Right HF
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Heart Failure ICD-9 CM Codes
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ICD-CM-9 Codes for Heart Failure428 Heart failure – heart failure due to hypertension list first a hypertension code, using the following (402.0-402.9, with fifth-digit 1 or 404.0-404.9 with fifth-digit 1 or 3) as appropriate; Excludes: rheumatic (398.91)428.0 Congestive heart failure, unspecified; Congestive heart disease; Right heart failure (secondary to left heart failure)Excludes: fluid overload NOS (276.6)
428.2xSystolic heart failure (see specific 5th
digit below)
428.3x Diastolic heart failure (see specific 5th digit below)
428.4x Combined Systolic/Diastolic heart failure (see specific 5th digit below)
428.1 Left heart failure - Acute edema of lung with heart disease NOS or heart failure; Acute pulmonary edema with heart disease NOS or heart failure; Cardiac asthma; Left ventricular failure
428.20 Unspecified
428.30 Unspecified
428.40 Unspecified
428.21 Acute 428.31 Acute 428.41 Acute428.9 Heart failure, unspecifiedCardiac failure NOS; Heart failure NOS; Myocardial failure NOS; Weak heart 428.22
Chronic428.32 Chronic 428.42 Chronic
428.23 Acute on chronic
428.33 Acute on chronic
428.43 Acute on chronic
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Table 1: Ventricular remodeling: definition and consequences Definition: A cascade of changes in genome expression, cells, molecules, and interstitiumthat alters the size, shape, and function of the left ventricle after injury. Alterations in heart size and shape (volume) that are not associated with preload-mediated increase in myocytelength.
Hallmarks leading to change in shape of left ventricle from a V to a U include a Combination of:
• Dilatation (myocyte lengthening and cell slippage)• Cell loss/death (apoptosis) • Interstitial fibrosis• Heart failure after myocardial infarction: formation of a discrete collagen scar• Nonischemic heart failure: isolated fibrosis• Hypertrophy (see Figure 1b and c) Initially concentric (thickening of myocytes); Then
becomes eccentric (thinning of the left ventricular walls)
Consequences:• High pressure (wall stress) in the ventricle during systole and diastole heightens
myocardial oxygen consumption, a situation that promotes further hypertrophy andactivates neurohormonal systems
• Reduction in ejection fraction; Reduced ventricular performance Morbidity and mortality
Source: CRITICALCARENURSE Vol 24, No. 6, DECEMBER 2004 , pg 18
Ventricular Remodeling - Definition
References1. 2005 / 2009 ACC / AHA Guidelines For Diagnosis And Management Of Heart Failure In Adults
2. Wier LM, Levit K, Stranges E, et al. HCUP Facts and Figures: statistics on hospital-based care in the United States, 2008: exhibit 2.3, most frequent principal diagnoses by age. Agency for Healthcare Research and Quality. http://www.hcup-us.ahrq.gov/reports.jsp.
3. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
4. Lloyd-Jones D, Adams RJ, Brown TM, Et Al. Heart Disease And Stroke Statistics—2010 Update. A Report From The American Heart Association Statistics Committee And Stroke Statistics Subcommittee . Circulation. 2010;121:e1-e170.
5. Heart Failure Society Of America 2010 Guideline Executive Summary. Journal Of Cardiac Failure 2010;16:476-506.
6. Dickstein et al. European Journal Of Heart Failure (2008), 933-989 Doi:10.1016/J.Ejheart.2008.08.005
7. Eric D. Adler, MD; Judith Z. Goldfinger, MD; Jill Kalman, MD; Michelle E. Park, BA; Diane E. Meier, MD, Palliative Care In The Treatment Of Advanced Heart Failure Http://Circ.Ahajournals.Org/Content/120/25/2597
8. CRITICALCARENURSE Vol 24, No. 6, December 2004 , Pg 18
9. Jessup M. And Brozena S. N Engl J Med 2003;348:2007-2018
10. HFSA Research 2000
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Post Test:Questions and Answers
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1. True or False: Heart Failure is diagnosed on the basis of diagnostic testsFalse: HF is diagnosed on the presence of characteristic signs and symptoms and not on the basis of any diagnostic
tests2. ______ heart failure is characterized by: an inability of heart muscle to contract vigorously;
results in inadequate amount of blood and oxygen to body; and is evidenced by Ejection Fraction usually less than 40%
a. Systolic Heart Failureb. Diastolic Heart Failurec. Both Systolic and Diastolic Heart Failured. Neither Systolic or Diastolic heart Failure
3. What stage and class is a person in end stage Heart Failure?a. Stage A/Class Ib. Stage D/Class IVc. Stage B/Class IId. Stage C/Class III
4. True or False: When treating older patients with ARBs, one should: “start low and go slow”True
5. These are goals for what setting of Heart Failure treatment: Establish the diagnosis; Review signs and symptoms; Identify adequacy of systemic perfusion and volume status
a. Ambulatory goalsb. Transitional goalsc. Emergency and Inpatient goalsd. These are not goals for any setting of Heart Failure treatment
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Post Test Cont.:Questions and Answers
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6. Which of the tests listed below if not a key test for hospital management of Heat Failure:a. ECGb. Chest radiographyc. ProBNP or NT-proBNPd. These are all key tests
7. True or False: Excessive diuresis will not cause metabolic abnormalities or adversely effect the neurohormonal balance
False: Diuretics are useful in relieving the symptoms of congestion and correcting the volume overload, but excessivediuresis can cause metabolic abnormalities and adversely effect the neurohormonal balance
8. What is Acute Decompensated Heart Failure Presentation?a. Volume overloadb. Profound depression of cardiac outputc. Combination of A and Bd. All of the above
9. True or False: Patient and caregiver education will assist in the patient’s Heart Failure management
True
10. What of the below options are potential causes for readmission:a. Failure to see careb. Prescription non-adherence c. Diet non-adherence d. All of the above