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Heart Failure Guideline Stages CHEST Protocol A B Classes 1. 2. 3. 4. Types Symptoms of HF High risk , no Sx C Sx No structural defects Structural Defects High Risk, No Sx D Refractory Structural defects Cardiac Disease without limitations of activities Cardiac Disease with slight limitations. Ordinary activies result in fatigue, palpitations, Dyspnea, or Angina Cardiac Disease with marked limitations. Less than ordinary activites result in symptoms. Cardiac Disease with the inability to perform normal activities without discomfort. Symptoms present even at rest. 1. Systolic (Low EF <40%) 2. Diastolic (norm EF) 1. Dyspnea 2. Cyanosis in Acute CHF 3. Orthopnea 4. Paroxysmal Nocturnal Dyspnea (PND) 5. Cardiac Asthma 6. Fatigue 7. Bilateral Edema 8. Pulmonary Rales (Crackles due to Pulmonary Edema) 9. Pleural Effusion 10. Abdominal Symptoms o Hepatomegaly (Severe Cases) o o o Pharmacological Treatments Goals of Tx Monitoring Patient Education Anorexia Nausea Ascites (Fluid in the abdominal Cavity) 1. ACEI & BB 2. ARB, BiDil (CI D HF) 3. Diuretics a. Loop b. Spironolactone 4. Verapamil (CI in S HF) 1. 2. 3. 4. Relieve uncomfortable sx Reduce Remodeling Improve exercise tolerance Reduce complications Weight Monitoring for SE Hypertension Guidelines JNC-7 NICE (National Institute of Health and Clinical Excellence) Canadian Hypertension Education Program Elevated Blood Pressure Target Organ Damage Stages Symptoms o Kidney Damage o Vision Disturbances o Angina o TIA Etiology 1. Kidney Disease Most common cause of Secondary Hypertension Aortic Coarctation o 2. 3. Aldosteronism Hypersecretion of Aldosterone 4. Hyperthyroidism/Parathyroid disease 5. Cushing's Syndrome 6. Pheochromocytoma 7. Sleep Apnea 8. Increase Intracranial Pressure 9. Lifestyle 10. Medications o Stimulants o Steroids o Psychoactive Drugs o NSAIDs o Thyroid Replacement o Goals TLC Dependent upon comorbidities 1. Diabetes 2. Complicated HF 3. Uncomplicated HF Prevent Target Organ damage 1. Cardiac 2. Cerebrovascular 3. PVD 4. Kidney 5. Retinopathy 1. Diet (DASH) 2. Weight Loss (BMI<25 or 10kg) 3. Exercise 4. Quit Smoking 5. Limited EtOh Pharmacological Tx 1. 2. 3. 4. Thiazide Diuretics ACE Inhibitors/ARBs Calcium Channel Blockers Beta Blockers Monitoring Patient Education BP HR Chem 7 o Potassium with Thiazides & ACEI o BUN/SCr for Kidney Damage Side Effects o Direct o Masking (e.g. Thiazides and Hyperglycemia) Self Testing o BP o HR Hyperlipidemia Guidelines Etiology Staging/Risk Factors Goals Signs & Sx Pharmacological Tx TLC Level (LDL/TLC Initiation/ Rx initiation) Very High (70/100/130) ACS CHD + o Diabetes o Metabolic syndrome o Smoking o HTN CHD/CHD Equiv(100/100/130) MI Angina PVD Stroke Diabetes Framingham Risk factors 1. Age>45 2. Smoking 3. HTN 4. FH CHD 5. HDL< 40 2+ FRF 10-20% (130/130/130) 2+ FRF 0-10% (130/130/160) 1 FRF (160/160/190) LDL driven by risk factors LDL-c > Target TG >150 TG > 500 Hypertriglyceridemia 1. Statins 40% (RASLPF 5:20:40:80:80:160) 2. Fibric Acid Derivatives (+/-) 3. Anionic Resins (15-30) 4. Niacin (5-25%) 5. Ezetimibe (15%) 6. Sitosterol 7. Omega 3 Fatty Acids Diet Exercise Smoking Weight Loss Monitoring Patient Education Myalgia 4 wks LDL 6-8 wks LFT 6-12 wks CK DI 3A4 o Lovastatin o Simvastatin o Atorvastatin 2C9 o Fluvastatin Renal o Rosuvastatin Myalgia Diabetes Guidelines Etiology Staging Goals Signs & Sx ADA Guidelines 1. type 1 2. Type 2 a. Hyperglycemia i. Drug induced ii. Diet induced iii. Poor compliance b. Hypoglycemia i. Drug Induced None FBG < 100 Post Pradial <180 A1C < 7.0% or 6.5% if patient can tolerate 1. Hypoglycemia a. Altered Mental Status i. Irritability ii. Confusion b. Sweating c. Shaking d. Tachycardia e. HA f. Hunger 2. Hyperglycemia a. Polydipsia b. Polyurea c. Polyphagia d. Weight Loss e. Ketoacidosis f. Gastroparesis 3. Ketoacidosis a. Tachycardia b. Hypotension c. Dehydration d. Kussmal Sign e. Altered Mental Status f. Ketotic Breath 4. Lactic Acidosis a. Dyspnea b. Muscle Aches c. Altered Mental Status d. Palpitations Pharmacological Tx TLC Monitoring Patient Education Compliance Diet Exercise FBG QD PPBG TID A1C Q 3 months SE Hypoglycemia Sx Tx Hyperglycemia Sx Tx General Notes Points to Know for each Disease State 1. 2. 3. 4. 5. 6. 7. 8. Guidelines Etiology Staging Signs & Sx Pharmacological Tx TLC Monitoring Patient Education Points to know for each drug 1. 2. 3. 4. Dosing Schedule Therapeutic Range Titration Push Dose before switching until a. Max effective dose b. Intolerance c. Excessive Risk 5. Side Effects & Monitoring of SE Presentation 1. Introduction a. Who am I b. What disease state am I presenting 2. Subjective a. Chief complaint b. HPI c. PMH d. SH/FH e. Allergies 3. Objective a. Medication list b. Labs c. PE 4. Prioritized Problem List 5. Assessment a. According to the S & O of X and Y, this patient has… i. Stage/Severity ii. Etiology b. According to Guidelines they can be treated with i. TLC ii. 2+ medication options Pros and Cons c. Goals of Treatment are… 6. Plan a. Start… b. Stop… c. Continue… d. Drug, Dose, Route, Schedule 7. Monitoring a. Clinic b. Self Monitoring 8. Patient Education a. Monitoring instructions b. Specific Sx to watch for c. “Patient Verbalized understanding of…”