Download When You Have Heart Failure

Initial
Assessment
Signs &
Symptoms
Yes
Confirm Diagnosis
Advance Care
Planning
Diag.
Investigations
This conversation
should happen early
on and if pt
conditions get worse
Labs
Treat all Cardiac Risk
Factors
No
Other
Diagnoses
Consider
once
ready for
teaching
Patient
Resources
Non Pharmaceutical
Treatment
Start Diuretic if
Volume Overload
(use minimum dose
to control overload)
Ver 8.0 – June 2016
HF - Preserved Ejection Fraction
LVEF > 40%
Treat Underlying Causes
(HTN, Atrial Fib, Ischemia)
Consider ARB +/- Beta Blocker
HF – Reduced Ejection Fraction
LVEF < 40%
ACE + Beta Blocker + MRA
Titrate to Max. Dose
(switch to ARB if ACE not tolerated)
Still Symptomatic
Yes – NYHA II - III
Yes – NYHA III - IV
If Indications appropriate
Replace ACE or ARB with
Sacubitril/Valsartan
Consider:
Digoxin, Referral
If Indications appropriate
Replace ACE or ARB with
Sacubitril/Valsartan
Increase or combine diuretics,
Consider: Referral or
admission
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Print Handout
Heart Failure Patient Questionnaire Please take the time to answer the following questions before you see your doctor Appointment Date: __________________ Since your last doctors appointment on_______________
Yes
No
How many times? Yes
No
How far in street blocks? Reason
Did you see a Specialist If yes: which specialist Have you been admitted to a hospital? Have you had to go to a hospital Emergency for treatment?
What are you doing for activity For how long? How many times per week Walking Housework Gardening Anything else Are you participating in a structured exercise program?
How may pillows do you need to use to sleep? (circle) none 1 2 3 4 5 6 7 Yes
Better
Worse
No Comments Has there been a change in your energy level since your last appointment? Has there been an change in your shortness of breath since your last doctors appointment? Has your chest pain changed since your last visit? Do you ever feel your heart racing? Do you wake up at night with shortness of breath? Do you get lightheaded or dizzy? Do you have swelling in your: (circle) feet ankles legs stomach Do you take extra water pills for your swelling? Better Worse Same Comments
Since your last doctors appointment do you feel your condition is?
What fluid restriction do you follow? Over the last two weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things Yes 6‐8 cups
4‐6 cups None
Other
No Feeling down, depressed or hopeless If your patient answers “yes” to either question, go to the PHQ9 questionnaire Feeling anxious, nervous or on edge If your patient answers “yes” to either question, go to Not being able to stop or control worrying the GAD7 questionnaire Questions you would like to ask your nurse or doctor today?
Continued
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Print Handout
Name ________________________________________ Date _________________________________________ Weight Vital Signs Heart Sounds PHYSICAL EXAM
Current Last Visit B/P Lying S1 S2 (circle) Standing S3 Dry HR O2 Sat Murmurs
Grade S4 Waist Circumference (cm) Murmur Location/Radiation
Ascites
Lungs Clear Crackles <1/4 >1/2 (circle) JVP (cm)
Edema +1 +2 (circle) Fluid Volume
(circle one) Euvolemic Dry Activity +3 Type: +4 Overloaded Time/day: _____________ Minutes Days/wk|: 1 2 3 4 5 6 7 NYHA Class I (circle) No Sx II III IV N/A No Sx at rest Comfortable only at rest Sx at Rest EF Date: Echo MIBI MUGA (circle) Chest XRay: Date: Clinical Status Better Same Worse Stable:
Yes No
EDUCATION
Topic: Yes
MD (Directives and/or plan of care)
Disease
Medications
Fluid
Salt
Activity/Exercise
Smoking
Travel
Stress Management
Type: Diuretic:
ACE/ARB:
Beta Blocker:
Other:
Medication:
MEDICATIONS
Notes/Changes:
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Signs and Symptoms of Heart Failure
The diagnosis of HF is difficult because many of the signs and symptoms are neither sensitive nor
specific. This is especially true when HF is in the early stages, when evaluating women, obese
patients, the elderly or those with chronic obstructive pulmonary disease (COPD) and chronic
kidney disease (CKD).
To help identify those patients at-risk for HF, there is a spectrum of co-morbidities that may predict
the future development of HF. These include: hypertension, diabetes, and prior myocardial
infarction. A review of new HF cases in BC suggests that 80% of individuals were previously
diagnosed with hypertension, 40% with diabetes, and 45% with ischemic heart disease. On average,
these co-morbidities were apparent 8, 6 and 4 years before their diagnosis of HF, respectively.
To confirm the diagnosis of HF, conduct a thorough medical history, physical examination and
initial investigations (see Table 3). Use this information to identify potential causes for a patient’s HF,
any relevant co-morbid conditions or precipitating factors, and to serve as a baseline when assessing
the impact of HF therapies.
Signs
Symptoms
Red Flags
 Weight gain
 Fatigue
 Systolic BP < 80
(2 kg (4 lb) in two days or
 Breathlessness
 Sa O2 , < 92%
2.5 kg (5 lb) in 1 week
 Swelling of
lower
extremities
 Decreased exercise
capacity
 paroxysmal
nocturnal
dyspnea
 Swelling and/or
Abdominal bloating
 Peripheral Edema
 Extra heart sounds
 Plural Effusion
 Elevated JVP
 Orthopnea
 Ascites
 Confusion
 Reduced appetite
 Tachycardia > 100
 New onset Cyanosis
Apply O2
Call 911
And/or
Refer to Acute care
Hospital
And /or
Consult a
Cardiologist
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Non-Heart Failure Causes of Shortness of Breath
Cardiac Causes
Non-Cardiac Causes
Ischemic Heart Disease
 Myocardial infarction, ischemia
Supraventricular arrhythmias
 Atrial Fibrillation
Hypertension
Asthma
Valvular heart disease
Interstitial Lung Disease
Restrictive lung disease due to abdominal
obesity
Pulmonary Embolism
Sleep Apnea
Chronic Obstructive Pulmonary Disease
Pneumonia
Renal Insufficiency
Collagen vascular disease
Endocrinologic or metabolic disorders
 Hyperthyroidism, hypothyroidism,
uremia, diabetes mellitus,
acromegaly, thiamine deficiency,
selenium deficiency, carnitine
deficiency, kwashiorkor, carcinoid
Pregnancy
Febrile illnesses
Anemia
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New York Heart Association Functional Class Functional Class I (mild) II (mild) III (moderate) IV (severe) Symptoms None  Can perform ordinary activities without any
limitations
No symptoms at rest  Occasional swelling
 Somewhat limited in ability to exercise or do other
strenuous activities
Comfortable only at rest  Noticeable limitations in ability to exercise or
participate in mildly strenuous activities
Symptoms at rest  Unable to do any physical activity without discomfort
Heart failure is classified on a scale of I‐IV based on the patients symptoms and ability to do activity or exercise. The functional class can get better or worse over time based on how the patient responds to treatment and how severe their symptoms are. Treatment for patient’s heart failure is based on their functional class. Adapted from: The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253‐256 Return to Page 1
Risk Factors
Coronary artery disease
Hypertension
Diabetes Mellitus
Alcohol or substance abuse
Family history of cardiomyopathy or sudden death
Sleep apnea
Valvular heart disease
Atrial fibrillation
Smoking
Cancer treatment including:
o Chemotherapy
o Radiation therapy
Thyroid disease and other endocrinopathies
Age ( > 60 years)
Conditions that may worsen heart failure
Chronic obstructive pulmonary disease
Kidney disease
Moderate to severe sleep apnea
Anemia
Hypertension
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Advance care planning Discussion initiated early in the disease course and particularly when symptoms and/or functional status declines despite maximal medical therapy.  Discussion about natural history of the disease and prognosis in all cases
 Address all precipitating factors: angina, hypertension, sodium and fluid
restriction, adherence to medications, contributory conditions
 Ensure all active therapeutic options have been appropriately considered (ICD,
biventricular pacing, revascularization, transplant)
Once the decision to initiate end‐of‐life care is made, the goal of therapy is to manage all symptoms (including those of comorbid conditions, e.g. chronic pain) and address function and quality of life issues. Subsequent care should be based on the following principles o Support of dying patients and their families
o Control of pain and symptoms ( eg. overload)
 Consider choice and dose of narcotic as renal function is likely impaired –
i.e. Hydromorphone for narcotic naïve, Duragesic patch.
 Consider narcotic use with uncontrolled angina, or as a first‐line for
dyspnea
 Consider home oxygen (See COPD Guideline for indications
http://www.bcguidelines.ca/guideline_copd.html)
 Adequate diuretic use (sometimes more than one agent) is important
 ACE‐I dose may need to be reduced if limited by symptomatic hypotension
and renal impairment (Cr > 250 μmol/L or > 30% from baseline)
o Decisions on the use of life‐sustaining therapies
See End of Life Care
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Heart Failure Diagnostic Tests
Assessment of Left Ventricular Function
(The Canadian standard is to have LVEF measured within 30 days
of a HF diagnosis; however due to waitlists and regional
variations in access, echo assessment of LVEF may not be feasible
in all parts of the province)
2D Echocardiogram – allows assessment of left ventricular
function as well as other cardiac structures
(repeat at end of treatment)
OR
MUGA – most accurate assessment – especially for patients with
COPD or obesity which may affect echo image quality; or in
those who require precise assessment of LVEF for consideration
of advanced HF therapies (e.g. defibrillator or cardiac
resynchronization therapy)
OR
Perfusion Imaging (eg MIBI Scan) – especially in those patients
where ischemia may be the underlying etiology of the HF
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Investigations
Initial investigations to support the diagnosis and guide heart failure management
Imaging
•
Echo: In HF patients, echo is considered the gold standard to measure LVEF and to
assess for structural heart disease and diastolic function.
•
Chest radiograph: May be considered in the context of the patient (e.g., those with comorbid conditions).
Blood
 Natriuretic Peptide (BNP or NT-proBNP): Considered to be the biochemical test of
choice for ruling-in or ruling-out the diagnosis of HF.

Serum creatinine, BUN & electrolytes: Useful to guide selection of pharmacologic
therapy.

Thyroid stimulating hormone (TSH): Useful to recognize a readily reversible cause of
HF.

Complete blood count (CBC): Useful for a number of reasons including diagnosis of
anemia.
Other
•
Electrocardiogram (ECG) standard 12-lead: The results are important for treatment
decisions (e.g., presence of atrial fibrillation, evidence of prior infarction, bundle branch
block). A normal ECG does not rule out a HF diagnosis; however a normal ECG makes HFrEF less likely.
•
Cardiovascular disease risk assessment: Framingham Risk Score or
www.bestsciencemedicine.com/chd/calc2.html. Refer to BCGuidelines.ca - Cardiovascular
Disease – Primary Prevention.
Natriuretic Peptide Testing
BNP and NT-proBNP have similar clinical utility. Either biomarker can be used for diagnostic
purposes, however results from the two assays are not comparable. Both tests have a highsensitivity for the detection of HF. A low result (i.e., <100 for BNP or <300 for NT-proBNP) for
either test is associated with a high negative predictive value for the clinical syndrome of HF, while
elevated values (i.e., > 400 for BNP or > 450 – 1800, depending on age, for NT-proBNP) have a high
positive predictive value for the diagnosis of HF. BNP (or NT-proBNP) testing for confirmation of a
HF diagnosis is recommended if there is diagnostic uncertainty and/or there is an anticipated delay
in obtaining a timely echo. At p r e s e n t , BNP (or NT-proBNP) testing should not be used routinely
for monitoring HF disease severity. Refer to Appendix A: Natriuretic Peptide Testing for Heart Failure
in the Primary Care Setting for further information.
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Non pharmacological
Heart Failure 101 Patient
Information Handout
Multidisciplinary HF care including specialized HF
clinics where available
Patient Education with focus on HF self management
o Diet
Low
Sodium
 Low sodium diet (less than 2000mg per day)
 Fluid Restriction 6-8 glasses/day (1500-2000ml
Fluid
or 48-64 oz per day: IF on a diuretic such as
Restriction
nn
Furosemide)
o Activity (if stable HF, attempt regular aerobic
Activity
and anaerobic activity OR consider referring to
a cardiac rehabilitation program)
Smoking
o Smoking cessation counseling or referral to
Cessation
smoking cessation program where available
o Daily weights
Daily Wt
 Weight gain
Chart
(No more that 4 lbs (2 kg) in 2 days or
> 5 lbs (2.5 kg) in one week
Immunizations – annual influenza, one time only
pneumococcal
Counseling for alcohol abstinence and substance abuse
Stress
Alcohol & Substance
Abuse Counseling
Snap Shot of Your Visit
Patient Form
REFER TO HEART FAILURE ZONES FORM
Also on BC Heart Failure Website: www.bcheartfailure.ca
Heart Failure Zones
Patient Handout
Depression
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Print Handout
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Page 1 of 4
Understanding Heart Failure
The Basics
How does the heart work?
What is Heart Failure?
Your heart is a muscle
about the size of your
fist. It works like a
pump, pumping blood
and nutrients around
your body.
Heart failure is when your heart is not
pumping as strongly as it should. Your body
does not get the right amount of blood,
oxygen, and nutrients it needs to work
properly.
The heart is actually a
2-sided pump. The right
side of the heart pumps
‘used’ blood from the
body to the lungs. In the lungs, your blood is
loaded up with oxygen. The left side of the heart
pumps ‘fresh’ blood full of oxygen from the
lungs to the rest of the body. The left side of
the heart is usually the larger than the right.
That is because it has to pump hard to get the
blood out to all parts of your body.
Each side of the heart has 2 chambers. Valves
link the chambers and keep blood pumping in
the right direction. These valves open and close
with each heartbeat.
Heart failure usually gets worse over time.
While heart failure cannot be cured, people do
learn to live active, healthy lives by managing
their heart failure with medication, changes in
their diet, weighing daily and physical activity.
There are two main types of heart failure:
• A weak pump: When the heart muscle is
weak, it gets larger and ‘floppy’.
• A stiff pump: When the heart muscle
cannot relax between beats because the
muscle has become stiff. The heart cannot
properly fill with blood between beats.
Both types of heart failure reduce the
blood flow and oxygen to your body.
Draft #10 March 13-12. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Page 2 of 4
What causes Heart Failure?
Heart failure has many causes including:
• Heart attack
• High blood pressure
• Heart valve problems
• Heart defects at birth
• Lung conditions
• Excessive use of alcohol or drugs
Other possible causes of heart failure include:
• Obesity
• Sleep apnea
• Infections affecting the heart muscle
• Abnormal heart rhythm
• Severe anemia
• Severe kidney disease
• Overactive thyroid gland
• Exposure to chemotherapy or radiation
Not sure what caused your heart failure? Ask
your doctor or nurse practitioner.
Signs of Heart Failure
You may notice any of the following signs.
You feel short of breath
when you do daily activities.
You find it harder to breathe
when resting or lying down.
You wake up at night
feeling short of breath.
You find it easier to sleep by adding
pillows or by sitting up in a
chair.
You cough often, especially
when lying down.
Your cough is either dry and hacking, or
moist and you cough up mucus (which
could be slightly pink).
You feel your heart beat faster and it does
not slow down when you rest.
You feel your heart racing, jumping, or
pounding in your chest.
You cannot walk as far you normally can.
You are tired all the time and have no
energy to do daily activities.
You feel lightheaded or
dizzy, especially when you
stand up or increase your
activity and this is new for
you.
You cannot eat as much as
you normally would.
You are not hungry and do
not feel like eating.
You feel bloated or your
clothes feel tighter than normal.
You have swelling in your
feet, ankles, legs, or even up
into the belly (abdomen).
Sudden increase in body
weight where you gain
more than 4 pounds (2
kilos) in 2 days.
You feel uneasy, like something does not
feel right.
You feel confused and have trouble
thinking clearly (and this is new for you).
Draft #10 March 13-12. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Page 3 of 4
Tests to identify heart failure
How is heart failure treated?
There is no single test for heart failure. Instead
your doctor does a number of tests. The doctor
looks at all the test results to determine if you
have heart failure.
Look in the mirror - the key to
treatment is you.
Tests can include:
• Blood tests to check certain enzymes
• Chest x-ray to look at the size of your heart
• Electrocardiogram (or ECG) to look at the
electrical activity of the heart
• Exercise stress test to look at how your
heart responds to exercise
• Nuclear medicine scan to get a close look
at the pumping of your heart
• Angiogram to look for blockage in your
heart arteries
• Echocardiogram or ultra sound of the
heart to look at the movements of your
heart and measure your ejection fraction
More about Ejection Fraction
This test is usually done during an
echocardiogram or a nuclear medicine scan.
Your ejection fraction can go up and down,
depending on your heart condition and how
well the treatment is working. It is good to
know what your ejection fraction reading is.
The reading is given as a percentage with
normal being between 55 and 70%. Less than
55% means your heart is not pumping as
strongly as it should be. Your ejection fraction
helps your doctor or nurse treat your heart
failure.
Your doctor relies on you to make changes
in your lifestyle and eating habits. While
there is a team of health care providers
working with you to manage your heart
failure, you are the one in charge.
Treatment is focused on helping you live a
longer and healthier life. This includes:
• Monitoring your symptoms
• Reducing salt in your diet
• Increasing your daily activity through
regular exercise
• Keeping your blood pressure low
• Maintaining a healthy weight
• Stopping unhealthy habits such as
smoking
• Taking your medications as prescribed
For some people, surgery and medical devices
are needed to treat the problem that led to the
heart failure. Treatments could include:
• Coronary bypass surgery
• Valve repair or replacement surgery
• Implanted device such as a pacemaker
and/or defibrillator
• Mechanical device to help the heart pump
• Heart transplant
For novel new ideas on heart failure treatment
consult your health care provider.
Draft #10 March 13-12. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Page 4 of 4
Plan today for the future
Why learn to manage your heart failure?
Your heart failure may get worse over time.
Start thinking now about how you wish to be
cared for if your disease progresses. This is
called ‘advanced care planning’. Advance care
planning allows you to have a say in your
health care if you are unable to speak for
yourself.
When you take charge of your health and learn
to manage your heart failure, it helps you:
Talk to your family and your doctor about
helping you live well with heart failure and
about the care you do or do not want in the
future.
Things to think about and consider:
What does it mean to live well with heart
failure?
What is important to you to make your life
the best it can be?
What is important to you as your condition
progresses?
Improve the quality of your life.
Feel confident that you can manage your
heart failure.
Control your condition so it will not control
you.
Know when to ask for help from your care
team.
Limit the need to go to the hospital for care.
Prevent or limit heart failure complications
as the disease progresses.
Talk with your family and your care team
about your disease and care plan.
People who learn to manage their heart failure
are more likely to live a longer, healthier life
than those who do not.
For more information on heart failure
What worries and concerns do you have?
How will your progressing heart failure
affect you and your family?
BC’s Heart Failure Network
www.bcheartfailure.ca
Who or what gives you support when you
need it?
Interior Health Authority Heart Failure
Online Education
www.bcheartfailure.ca/for-patients-andfamilies/e-learning-module-on-hf/
If you are not able to make your own health
care decisions, who will you want to make
them for you? Does that person know what
you want?
Do you have written instructions for how
you want to be cared for if you cannot
make decisions for yourself (this is called
an advance directive).
HealthLinkBC on Heart Failure
www.healthlinkbc.ca/kb/content/special/hw4
4415.html#tp17534
Canadian Cardiovascular Society
www.ccs.ca
Canadian Heart Failure Network
www.chfn.ca
Heart Failure Society of America
www.hfsa.org
Draft #10 March 13-12. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Heart Failure Zones Check Weight Daily ♥ Weigh yourself in the morning before breakfast. Write it down. Compare your weight today to your weight yesterday. ♥ Keep the total amount of fluids you drink to only 6 to 8 glasses each day. (6‐8 glasses equals 1500‐2000 mL or 48‐64 oz) ♥ Take your medicine exactly how your doctor said. ♥ Check for swelling in your feet, ankles, legs, and stomach. ♥ Eat foods that are low in salt or salt‐free. ♥ Balance activity and rest periods. Which Heart Failure Zone Are You Today? Green, Yellow, or Red Safe Zone Caution Zone ALL CLEAR – This zone is your goal! Your symptoms are under control. You have: z No shortness of breath. z No chest discomfort, pressure, or pain. z No swelling or increase in swelling of your feet, ankles, legs, or stomach. z No weight gain of more than 4 lbs (2 kg) over 2 days in a row or 5 lbs (2.5 kg) in 1 week. CAUTION – This zone is a warning Call your Health Care provider (eg. Doctor, nurse) if you have any of the following: S You gain more than 4 lbs (2 kg) over 2 days in a row or 5 lbs (2.5 kg) in 1 week. S You have vomiting and/or diarrhea that lasts more than two days. S You feel more short of breath than usual. S You have increased swelling in your feet, ankles, legs, or stomach. S You have a dry hacking cough. S You feel more tired and don’t have the energy to do daily activities. S You feel lightheaded or dizzy, and this is new for you. S You feel uneasy, like something does not feel right. S You find it harder for you to breathe when you are lying down. S You find it easier to sleep by adding pillows or sitting up in a chair. Health Care Provider ____________________ Office Phone Number __________
Danger Zone EMERGENCY – This zone means act fast Go to emergency room or call 911 if you have any of the following: ¦ You are struggling to breathe. ¦ Your shortness of breath does not go away while sitting still. ¦ You have a fast heartbeat that does not slow down when you rest. ¦ You have chest pain that does not go away with rest or with medicine. ¦ You are having trouble thinking clearly or are feeling confused. ¦ You have fainted. The information in this document is intended solely for the person to whom it was given by the healthcare team.
For more information refer to: www.bcheartfailure.ca
Form Number
June 2013
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Print Handout
Caring for Someone with Heart Failure
Taking Care of Yourself
If you give care to someone with heart failure,
you could find yourself facing new
responsibilities. It can be both rewarding and
challenging to be a ‘caregiver’.
A ‘caregiver’ is anyone who
gives help and care to
another person in need.
Signs of caregiver stress
Tips to prevent caregiver stress
When you are focused on caring for someone
else, you might not realize your own health is
suffering. At times, you might feel
overwhelmed, physically or emotionally. This
is called ‘caregiver stress’.
Too much stress can harm your health,
especially if you care for someone for a long
time. Here are some ways to help prevent and
manage caregiver stress.
Watch for these signs of caregiver stress:
 feeling tired all the time
 having trouble sleeping
 gaining or losing a lot of weight
 feeling guilty, like you are not doing
enough
 feeling overwhelmed and irritable
 having conflicts with the person you care
for
 having conflicts with family members
 feeling you don’t have time for yourself or
to be with others
 having no interest in doing activities you
used to enjoy
 feeling emotional and moody, maybe
crying often
 worrying about having enough money now
and for the future
 using substances to help manage your
feelings such as smoking more, drinking
more alcohol, taking medications to help
sleep or improve your mood, or taking
illegal drugs
 Ask for help and accept help when offered.
 Look to others to help share
the care.
 Make a list of ways others
can help you such as pick up
groceries or cook a meal.
 Set health goals for yourself.
 Make time to be physically active most
days of the week.
 Make and eat healthy meals and snacks.
 Get enough sleep, even if it means taking a
nap during the day.
 Take time to relax each day. Find a place in
your home where you can have a few
moments to relax, close your eyes, and do
some deep breathing.
 Do things you enjoy.
 Give yourself a break.
Take some time away
from being a caregiver at
least once a week.
April 2014. For more information on heart failure, go to www.bcheartfailure.ca.
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The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Tips to prevent caregiver stress
 Focus on what you can do.
 Be realistic about what you can and cannot
do. You can’t control everything.
 Don’t be too hard on yourself. Your home
might not be as clean as you would like it
to be.
 If you feel like it, eat a healthy breakfast
for dinner or eat leftovers three or four
days in a row. No one cares.
 Seek support from family and friends.
 Make an effort to stay connected with
family and friends.
 Share your feelings, worries,
and concerns with someone
you are comfortable talking
with about your situation.
 Get connected with community supports.
 Rather than struggling on your own, take
advantage of local resources for caregivers.
 Explore opportunities for support in the
home from health services. Talk to your
health care provider or call 8-1-1 for
information on what supports are
available.
 Stay as strong and healthy as possible.
 Keep up with your own medical care.
 Get regular health checks. Make sure you
tell your healthcare provider you are a
caregiver.
 If you are feeling stressed, depressed, or
unusually worried, the BC Heart Failure
website has resources to help you.
 See your healthcare provider when you
notice signs of caregiver stress or you feel
really overwhelmed or depressed.
 Communicate with the person you are
caring for.
 Talk with the person you are caring for
about what would be helpful in giving
care and helping to manage their heart
failure.
 Help the person find ways that will work
for them to do as much as possible on their
own. This might include ways to
remember when to take medications, to
record daily weight, to keep track of fluids,
to eat less salt, or to keep active.
 Agree on a plan of care so you don’t feel
like you are always telling or reminding.
 If the person is not doing what is needed
to manage their health, talk to them about
your worries or concerns. Remember you
cannot make someone do something they
do not want to do.
 Help the person prepare for medical
appointments such as reviewing recent
health and concerns, resting before the
appointment, as well as taking all
medications and a healthy snack to the
appointment.
 If you can, go with the person to medical
appointments. Take notes. Help
communicate health concerns but be
careful not to answer for the person. You
are there to clarify what is going on at
home.
As a caregiver, taking care of yourself is the
most important, and most often forgotten,
thing you can do.
When you take care of yourself, the person
you give care to benefits too.
April 2014. For more information on heart failure, go to www.bcheartfailure.ca.
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Learning to Live with Heart Failure
You can do it! You can make changes in your
life to help you feel better and stay healthy.
This resource gives you tips for daily life and
answers common questions.
Conserve your energy
 Rest at least 1 hour every day.
 Aim for balance.
- Balance activity with rest.
-
Balance hard activities with
easy activities.
-
Do activities when you feel your best.
 Plan ahead.
- Plan your chores and daily activities ahead
of time.
-
Space them out throughout the day and
week. You do not have to do everything in
one day.
-
Whenever you can, sit to work or do daily
chores.
-
Keep things you use the most within reach.
-
Prepare bigger meals and freeze portions to
save preparing meals another day.
 Use things that help conserve energy.
- Choose clothes that have zippers instead of
buttons. Make sure the zipper is in the front
and not the back.
-
Use long-handled tools to make reaching
easier.
-
If needed, use a walker, shower chair, and
bedside toilet.
- Choose
light weight house hold or kitchen
items. For example, choose aluminum pots
and pans instead of cast iron.
 Avoid things that drain energy, such as:
- Doing chores or activities right after you eat
-
Doing intense physical activity
-
Lifting, stretching, or any other strenuous
arm movement
 Ask for help.
- Ask those you live with to share in doing
the daily tasks and household chores.
-
Ask family and friends to help out.
Get enough sleep
 Practice good sleep habits.
-
Have a regular bedtime.
-
Relax before bedtime.
-
If you cannot get to sleep within 30
minutes, get up and read or watch TV.
-
Only use your bed for sleeping and
intimacy. This means get out of bed to read
or watch TV.
 If you get short of breath lying down, prop
yourself up with pillows.
 If you get up often to go to the toilet, talk to
your health care provider. Your medications
might need adjusting.
Take care of your physical health
 Keep in contact with your health care team.
 Getting sick can be deadly when you have
heart failure.
-
Get a flu shot every year.
-
Get a pneumonia shot.
April 29 2014. For more information on heart failure, go to www.bcheartfailure.ca.
Page 1 of 3
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Take care of your emotional health
Many people find it hard to do everything
needed to manage their heart failure. If you are
feeling stressed, depressed, or unusually
worried, the BC Heart Failure website has
resources to help you (www.bcheartfailure.ca).
Don’t hide these feelings. Talk to your health
care provider.
Can I drive?
Whether or not you drive depends on how you
are feeling. Generally, people can drive as long
as their heart failure is under control.
However, the Motor Vehicle Act defines when
a person is or is not medically fit to drive. If
your health care provider feels your health
affects your ability to drive safely, it must be
reported to the Superintendent of Motor
Vehicles. You might have restrictions on your
driver’s licence or have your licence removed.
It is all about public safety.
Can I work?
It depends on your overall
health, how you are managing
your heart failure, and the
type of work. For some
people, working might be
helpful, but for others it might not be good.
Every person is different. Talk to your health
care provider about what is right for you.
If your health care provider says you can work,
you might be able to start as soon as your signs
of heart failure are under control, or you might
have to gradually build up to doing all aspects
of the work.
Benefits of working:
- Helps you get into a daily routine
- Helps you feel better and improves your mood
- Lessens money worries by having an income
Return to Page 1
What about having sex?
Some people worry about whether it is safe to
have sex when they have heart failure. Once
your signs of heart failure are under control,
you should be able to have an active and safe
sex life. Human touch and good sexual
relations are part of a healthy life.
When you have sex, it can take a lot of energy,
both emotionally and physically. The physical
energy is like climbing 20 steps in 10 seconds.
Sex should be fun and feel good:
 Wait at least 1 hour after eating.
 Do not drink alcohol before sex.
 Choose a time when you are rested and
relaxed.
 Choose a comfortable place where it is not
too hot or cold.
 Stop and rest if you get short of breath or feel
uncomfortable.
 Find other ways to express love and
affection.
 Don’t get upset if you are not able to perform
as you expected.
 Talk to your partner about how you feel.
Problems are possible. Your interest in sex
might drop. You might get short of breath
during sex. Men might have problems getting
an erection. Problems can be a side effect of a
medication or a sign your heart failure is
getting worse. Talk to your health care
provider about any problems having sex.
Remember there are other ways to express love
and affection.
April 29 2014. For more information on heart failure, go to www.bcheartfailure.ca.
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How do I stay on track during special
occasions?
Whether eating out or eating in, food for
special occasions is more likely to be high in
salt, especially sauces and gravies. Also, people
tend to eat and drink more.
 Make healthy choices.
- Choose food prepared with little or no salt.
-
Where possible, choose fresh vegetables
and fruit.
 Plan big meals for midday.
 Pay special attention to your snacking and
portion size.
 Watch your fluid intake.
Future heart failure care
Have the conversation with your family
and healthcare provider
Heart failure is a condition that is not curable
and gets worse over time. In the future, there
could be a time when you might be too sick to
consent to treatment offered by your
healthcare provider or doctor. If this happens,
your healthcare provider will look to your
family for help with decisions about your care.
Planning now for the future can give you
comfort knowing your family and healthcare
provider knows what is important to you. It
can also ease the stress for your family if they
have to make medical decisions for you.
A word about…
Drinking alcohol
Some alcohol can be helpful to a
normal heart. However,
sometimes even a small amount of
alcohol can cause heart failure to get worse.
Alcohol can weaken your heart muscle and
increase your blood pressure, creating more
work for your heart.
To learn more about this, talk to your health
care provider, or family doctor and read the
booklet: ‘My Voice: Expressing My Wishes for
Future Health Care Treatment’ from the BC
Ministry of Health (available online at
www.seniorsbc.ca).
Ask your health care team if any amount of
alcohol is okay for you.
Smoking
Everyone knows smoking and
using tobacco products damages
your heart and lungs. But quitting is not easy.
Your chances of quitting are much better if
you ask for help.
Ask your health care team for:
- Help to quit smoking
- Ways to
deal with second-hand smoke
To learn more about quitting smoking, check
the website: www.quitnow.ca.
April 29 2014. For more information on heart failure, go to www.bcheartfailure.ca.
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Limiting Sodium (Salt)
When You Have Heart Failure
Sodium is a mineral found in food, table salt, and sea salt. Your body needs some sodium, but too much sodium causes your body to hold on to (or retain) fluid. This fluid build‐up makes your heart work harder. The fluid build‐up can cause swelling in your feet, legs, or belly. Fluid can also build up in your lungs, making it hard for you to breathe. If your weight increases by more than 2 kg (4 lb) in two days, or 2.5 kg (5 lb) in 1 week, you are retaining fluid. If this happens, you should call your health care provider right away. You should restrict the amount of sodium you eat to 2000mg or less each day. Remove the salt shaker from the table. Don’t add salt, flavoured salts or seasonings high in salt to your foods. One teaspoon of salt contains 2300mg of sodium! Season your food with herbs, spices, lemon juice, dry mustard, and garlic. Try one of the many seasoning blends which contain no salt such as Mrs. Dash. Stay away from eating:  processed foods  deli meats  pickled foods  salted snack foods such as potato chips, pretzels, dips, and salted nuts Limit the amount of canned foods you eat. Choose products labelled ‘low sodium’. Foods labelled ‘lower’, ‘less’ or ‘reduced in salt or sodium’ may still be high in sodium (including soups and meats). In the average Canadian diet, where does
sodium come from?
 In ready‐made processed foods and restaurant meals (77%)  Naturally occurring in food (12%) 11%
12%
77%
 Added to food in cooking and at the table (11%) Eat out less often.  Ask restaurants to provide information on low sodium choices. 
Restaurant meals and fast foods are always higher in salt than home cooked low sodium meals. 
For more info, please refer to Low Sodium (Salt) Eating Out fact sheet at www.healthlinkbc.ca (or click here). How to avoid salt (sodium)?
Eat fresh foods most of the time and prepare home‐cooked, low sodium meals. Frozen foods are acceptable if they do not have added salt or sodium additives (which are used as preservatives). X
Updated: January 2012. For more information on heart failure, go to www.bcheartfailure.ca.
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Can I use Salt Substitutes?
Some salt substitutes use potassium instead of sodium. Check with your doctor or dietitian before using a salt substitute because some people need to limit how much potassium they have each day. Keep your sodium intake to less than 2000mg each day. As you gradually reduce the amount of salt you are eating, your taste buds will adjust! How do I know how much sodium is in food?
Here are some helpful tips when reading the nutrition label: Serving Size: Per ½ cup (125ml) Look at the serving size – the amount of sodium listed is per serving (not the whole package). Keep track of the total amount of sodium you eat. Remember: Your maximum recommended daily amount of sodium is no more than 2000mg per day from all sources. Keep the sodium content of each meal below 650mg – this helps spread out your sodium intake over the day preventing excessive thirst and/or fluid retention. By law, foods labelled ‘low sodium’ must contain 140mg or less per serving. Other ingredients high in sodium include: baking soda, brine, monosodium glutamate (MSG), soy sauce, fish sauce, garlic salt, celery salt, or any ingredient with ‘sodium’ as part of its name. Nutrition Facts
Amount
% Daily Value
Calories 140 Total Fat 0.5g 1% Saturated Fat 0.2g + Trans Fat 0g 1% Cholesterol 0mg 0% Sodium 390mg 16% Total Carbohydrate 28g 9% Dietary Fibre 5g 20% Sugars 9g Protein 7g Vitamin A 2% Vitamin C Calcium 8% Iron 0% 15% Look what happens to the sodium content of foods when they are processed Unprocessed Processed Cucumber 7 slices = 2mg Dill pickle 1 medium = 569mg Chicken Breast 3oz = 74mg Chicken Pie 1 serving frozen = 889mg Tomato 1 small = 14mg Tomato Soup 1 cup = 960mg Pork Tenderloin 3 oz = 58mg Ham 3oz = 1095mg Updated: January 2012. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Print Handout
Foods High in Potassium
Foods with more than 200mg per serving
Based on ½ cup servings
(Unless indicated otherwise)
Fruits
Vegetables
Other foods
Apricots (fresh)
Avocado
Artichoke (cooked)
Asparagus (boiled)
Swiss Chard (cooked)
Tomatoes (medium, raw)
Black licorice
Bran muffin
Banana
Beet Greens (boiled)
Tomato Paste
Bran cereals
Breadfruit
Bok Choy (cooked)
Tomato Sauce
Chocolate
Cantaloupe
Broccoli (cooked/frozen)
Yams
Coconut milk
Carrots (raw grated)
Brussels Sprouts
Coconut dried
Celery (cooked)
(unsweetened)
Coconut Water
Coconut Milk
Dried Fruits
Durian
Pear (medium)
Persimmon,
Japanese (medium)
Milk and Dairy products
Juices
(dried and cooked)
Pumpkin
Papaya
Peach (medium)
Edamame
Lentils
Mushrooms
Jack fruit
Passion fruit
Dried Peas
Hemp seeds (2 tablespoons)
Kohlrabi
Parsnips (cooked)
Nectarines
Orange (1 medium)
Dried Beans
Corn (cooked)
Guava
Honeydew
Kiwi
(1/2 cup, 249 mg)
Potatoes
Rutabaga
Seaweed (dried)
Spinach (cooked)
(limit to 1 cup/day = 366mg)
Maple Syrup
Carrot
Molasses
Coconut water
Nuts
Grape fruit
Do not drink within 2
hour of taking your
heart pills
Salt Substitute
Seeds
Soya flour
Orange
Squash (acorn,
Passion fruit
butternut, hubbard, Pomegranate
zucchini)
Prune
Sweet Potato
Tomato
Vegetable
Plantain
Pomegranate
Pummelo
Strawberries
What should your blood Potassium level be?
Danger to low
 Lower than 3 mmol/L
Safe (Normal)
 3.5-5.0 mmol/L
Caution
 5.0-6.0 mmol/L
Danger to high  Higher than 6.0 mmol/L
Nov 2015. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Foods with less Potassium – Better Food Choices
Note: Almost all foods contain some potassium.
Watch your serving size. A larger serving of a low potassium food can make it a high potassium food.
To check the amount of potassium in food not on this list, check http://ndb.nal.usda.gov/ndb/search/list
One serving = 1/2 cup
Enjoy up to 5 servings per day
Fruits
Vegetables
Apples
Alfalfa Sprouts
Okra
Applesauce
Asparagus (fresh)
Onions
Apricots (canned)
Bamboo shoots, (canned)
Parsley
Berries (blackberries,
Bean Sprouts
Peas, green (raw)
Casaba Melon
Beets (boiled)
Bitter melon
Peppers (Raw: Red, Green)
Potato (double boil)
Bokchoy (raw)
Radicchio
Broccoli (raw)
Radishes
Cabbage
Chia (2 tablespoons)
Seaweed (raw)
Shallots
Collards
Spinach (raw)
Carrots (double boil)
Summer squash
Cauliflower
Celery (raw)
Spaghetti Squash
Swiss Chard (raw)
Cilantro
Turnip (double boil)
Corn (canned)
Water chestnuts (canned)
blueberries, boysenberries,
cranberries, gooseberries, loganberries, raspberries,
strawberries)
Cherries
Coconut (raw/shredded)
Crabapple
Currants, fresh
Figs fresh
Fruit Cocktail (canned)
Grapes (red/green)
Grapefruit
Do not drink within 2 hour of taking
your heart pills
Kumquat
Lemon /Lime
Longans
Lychee
Mandarin Orange
Mango
Oranges
Pineapple
Plums
Rhubarb
Tangerine
Watermelon
Cucumber
Eggplant
Fennel bulb
Gai lan (Chinese Broccoli)
Green beans
Green onions
Jicama (double boil)
Kale (boiled)
Leeks
Lettuce
Juices
Apple juice
Apricot Nectar
Grape Juice
Papaya nectar
Peach Nectar
Pear Nectar
Pineapple Juice
Mushrooms, raw
Mustard Greens
Double boiling root vegetables lowers the amount of potassium
 Peel, cube or slice vegetables
 Add double the amount of water
 Bring to a boil, then drain the water
 Add fresh water, finish cooking, and drain again
Limit servings of root vegetables to 1/2 cup per day (or as discussed with your dietitian)
References: Pennington, J.A.t, Spungen, J. (2012). Bowes & Church’s food Values of Portions Commonly Used. 19th Edition. USDA National Nutrient Database for Standard Reference (Release 25)
website: http://ndb.nal.usda.gov/ndb/foods/list
Nov 2015. For more information on heart failure, go to www.bcheartfailure.ca.
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Print Handout
Herbs and Herbal Supplements
Herbs and herbal supplements can be
harmful to people taking heart medications.
Always tell your health care provider about any
herbs or herbal supplements you are taking.
Bring the herbs and herbal supplements you are
taking to every medical visit so they can be
checked.
What are herbs and herbal supplements?
Herbs and herbal supplements are plants
that are used for medicinal purposes. Some
people call them botanicals or herbal
remedies.
Why should you be careful taking these
products?
We do not always know what the active
ingredients are in many herbs and herbal
supplements.
Herbs and herbal supplements:
• Can act in the same way as medications. This
means they can be dangerous to your health
if not taken correctly, if taken in large
amounts, or if taken in combination with
other medications.
•
Can interact with heart medications. This
could cause the medication to not work as it
should, magnify the medication’s side
effects, or cause a life-threatening reaction.
•
Have not been studied to the same extent as
other medications.
•
They are classified as dietary supplements
not medications. Therefore they are not
regulated the same way other medications
are regulated. The rules for making
dietary supplements are not as strict.
Tips
Before you cook with herbs contact your
health care provider
Always talk to your health care provider or
pharmacist before taking herbs or herbal
supplements. They can review the herbal
medicine and tell you whether it could
impact your heart medication.
If you are not sure what is considered an
herb or herbal supplement, see the list on
the next page.
Never use herbs or herbal supplements if
you are taking one of these medications:
•
•
•
•
•
•
•
aspirin
digoxin
diuretics
hypoglycemic medications such as insulin
Non-steroidal anti-inflammatory
medications such as ibuprofen (Advil,
Motrin), naproxen (Aleve), Celebrex
spironolactone
warfarin
Health care provider contact information
______________________________________
If you have questions about herbs or herbal
supplements, contact your health care provider
or pharmacist.
To learn more about herbal supplements, go
online to MedlinePlus. Click on the tab ‘Drugs
& Supplements’ then select ‘Herbs and
Supplements’ (or click here).
Adapted from Cleveland Clinic and Mayo Clinic information on herbs and herbal supplements.
March 2013. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Herb or
Herbal Supplement
Reasons for taking
Possible problems
when you have a heart condition or
you are taking heart medication
Aloe Vera (Oral)
For constipation or indigestion
To prevent skin irritation
Causes abnormal heart rhythms in pregnancy and in children
Angelica (Dong
quai)
Appetite loss, indigestion, infection,
pre-menstrual tension syndrome
Can increase the risk of bleeding, especially when taking warfarin
Arnica
To reduce aches, or pain from injury
To relieve constipation
Raise blood pressure and can be toxic to the heart
Black Cohosh
(Cimicifuga
racemosa)
To relieve symptoms of menopause or
pre-menstrual tension syndrome
Lowers blood pressure
Can increase the risk of bleeding (cause more bleeding)
Can be toxic to liver
Beta carotene
Antioxidant helps get rid of substances
that harm the body (free radicals)
Increases the risk of death
CoQ10 (Co-enzyme
Q10, Ubiquinone,
Ubiquinol)
To increase your energy
To treat heart failure or other heart
conditions
Does not improve heart function
Can decrease the effect of warfarin
Danshen (Salvia
miltiorrhiza-root)
To treat heart conditions
Can increase the risk of bleeding (cause more bleeding)
Echinacea
To prevent colds
Interferes with an enzyme in the liver that helps clear medications
out of the body
Ephedra (Ma
Huang)
To treat asthma, obesity
Increases heart rate and blood pressure
Could cause death if taken with certain heart medications
Feverfew
To treat/prevent migraines, arthritis
Can interfere with the clotting of your blood
Fish Oil
A common supplement
Can increase the risk of bleeding, especially if used in excess
Flaxseed
To lower cholesterol.
Can increase the risk of bleeding
Ginger
To relieve nausea, lower cholesterol,
stop your blood from clotting, aid in
digestion
Can interfere with the clotting of your blood
Can interfere with how heart or high blood pressure medications
work
Garlic
To lower cholesterol
To prevent and treat colds and infections
If you are taking aspirin, warfarin or other anticoagulants, it can
increase your risk of bleeding
Ginkgo
To improve circulation, memory.
To prevent altitude sickness
If you are taking aspirin, warfarin or other anticoagulants, it can
increase your risk of bleeding
Interferes with the actions of diuretics (Lasix)
Ginseng
To improve memory, physical capacity,
immune system and to slow aging
Increases blood pressure and heart rate. Do not take if you have
high blood pressure (hypertension)
Can increase blood levels of digoxin
Can increase the risk of bleeding
Goldenseal
To treat constipation,
Can also acts as an anti inflammatory
Increases blood pressure, causes high blood pressure
Can interfere with blood thinners (anticoagulants)
Hawthorn
To treat high blood pressure and heart
failure
Do not take if you are taking digoxin and blood pressure
medications
Kelp
Commonly used supplement
Can increase effects of blood pressure and anticoagulant
medication
Causes low blood pressure and increases risk of bleeding
Licorice root
To treat coughing, stomach ulcers and
liver cirrhosis
Increases blood pressure: Do not take if you have a heart
condition or on heart medications
Nettle
To treat bladder infections, kidney
infections, and kidney stones
Do not take if you have fluid retention caused by heart failure or
poor kidneys
St Johns Wort
To treat depression and injuries
Can increase the risk of bleeding
Can decrease the effect of digoxin
Should not be taken with certain antidepressants
Yohimbine
To treat impotence
Increases heart rate
Increases or decreases blood pressure
Adapted from Cleveland Clinic and Mayo Clinic information on herbs and herbal supplements.
March 2013. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Print Handout
Daily Weight Information
Patient Name: Health Care Provider: _________________________________ Heart Function Clinic or Physician’s office: Contact phone number: ______________________ Check Your Weight Every Day
Why:
Checking your weight every day lets you know if your body is retaining fluid. Excess fluid build up in your body makes your heart work harder. When you report weight gain early to your health care provider, they can help you prevent your heart failure from getting worse. This can help prevent a hospital admission. If your weight increases by:  More than 2 kg (4 lb) in two days, or You are retaining fluid.  More than 2.5 kg (5 lb) in 1 week You should call your health care provider. For further directions, please refer to ‘Heart Failure Zones’ information sheet. When:
Same time every day Preferably before breakfast How:
After you have emptied your bladder (gone ʹpeeʹ) Wear the same amount of clothing Record your weight in the attached calendar. (or You may prefer to use your own method such as a notebook, a computer.) Remember to bring your record to your doctor or clinic appointment. Updated: January 2012. For more information on heart failure, go to www.bcheartfailure.ca.
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Your ‘Dry Weight’ (when you don’t have excess fluid in your body): _________________________
Write down your weight each day compare today’s weight to yesterdays weight. If your weight increases by:  More than 2 kg (4 lb) in two days, or You are retaining fluid.  More than 2.5 kg (5 lb) in 1 week You should call your health care provider. Month _____________________
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Updated: January 2012. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Limiting Fluid
When You Have Heart Failure
What is a fluid?
Any food or drink that is liquid at room temperature. This includes water, ice, milk, juices, soft drinks, hot drinks, alcohol, soups, gelatin desserts, ice cream, popsicles, and liquid nutrition supplements (such as Ensure or Boost). How do you know when you have too much
fluid?
To keep track of whether your body is holding on to too much fluid, weigh yourself daily. Here is how to weigh yourself: Weigh yourself at the same time every day. The best time is first thing in the morning. Why do you have to limit fluid?
When you have heart failure, fluid can build up causing swelling in your feet, legs or belly making your heart work harder. Fluid can also build up in your lungs, which may cause you to have trouble breathing. Weigh yourself after emptying your bladder (gone pee). Wear the same amount of clothing each time. You are holding on to too much fluid when: or  Your weight  Your weight increases by more increases by than 2 kg or 4 lb more than 2.5 kg in two days. or 5 lb in a week. How much fluid can you have in a day?
You should have no more than 1.5 to 2 litres of fluid in a day. You may find you are thirsty to begin with. As you gradually reduce your fluid intake, your body will adjust! Guide to Fluid Measures
2 tablespoons = 30 ml = 1 ounce 1 glass = 250 ml = 8 ounce 1 pint = 500ml = 16 ounce 1 litre or 1 quart = 1000 ml = 32 ounce 2 litres = 2000 ml = 64 ounce Total amount of fluid per day 1.5‐2 litres = 48‐64 ounces = 6‐8 glasses Contact your health care provider right away if you are holding too much fluid. Tips for reducing your fluid intake
Use smaller cups and glasses. Measure the amount of fluid your mugs and glasses hold. They may measure more than 250 ml or 8 ounces! Sip your fluids slowly. Write down the amount you drink each day until limiting your fluid becomes a habit. (More tips on page 2.)
Updated: January 2012. For more information on heart failure, go to www.bcheartfailure.ca.
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More tips for reducing your fluid intake
Limit the amount of sodium you eat to 2000mg or less each day. Salt will make you thirsty. For more information, refer to the handout Limiting salt (sodium) when you have heart failure. Try not to eat sweet foods. They can make you thirsty. If you have diabetes, controlling your blood sugar also helps control your thirst. Sip your fluids throughout the day. Keeping track of fluids is the only way to learn how to make the 1.5 to 2 litres of fluid last you through the day. X
You may find it easier to use a reusable water bottle. Measure how much the bottle holds so you know exactly how much water you are drinking. Drain the fluid from canned fruit. Try not to drink alcohol. Alcohol dehydrates your body and makes you thirsty. Be aware of foods with high water content like watermelon, yogurt, and pudding. If you can, swallow your pills with soft food like yogurt or porridge. Tips to deal with thirst
Rinse your mouth with water often, but do not swallow. Suck on a lemon wedge, lemon candy, or sour candy. Brush your teeth often. Use lip balm to keep your lips from drying out. Use a mouth wash. However, do not use a mouth wash that contains alcohol. They tend to dry out your mouth. Don’t overheat your home. Consider using a humidifier to increase the moisture in the air. Snack on a small piece of cold or frozen fruit such as a frozen grape or cold orange slice. Try cold crisp vegetables too. Ask your pharmacist about gels or sprays that can add moisture to your mouth. Chew sugar‐free gum. For more tips and resources for limiting fluid, call HealthLink BC (dial 8‐1‐1) to speak to a health care professional. You can also refer to www.healthlinkbc.ca (or click here). Updated: January 2012. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Why People with Heart Failure Should Keep ‘Active’
What does it mean to be ‘active’?
Is the activity level right for me?
Activity and exercise ‐ People often use these two terms to mean the same thing. All physical activities and exercise do involve increasing the heart rate and strengthening muscles. Get to know your body. It is important that you feel comfortable doing the activity. There is, however, a small difference in their meanings. Physical activity is when you are using energy to move your body to get from place to place. Exercise is a type of physical activity. The difference is ‐ exercise is planned. We exercise to improve or maintain fitness or health. As long as you can talk without being too short of breath the level of activity is okay. Balance activity and rest
Be active at a time when you feel rested, such as first thing in the morning or after nap. Why activity is important
Choose which activities to do each day. Keeping active is one of the best ways to keep healthy. Any amount of activity is better than none at all. Spread your activities throughout your day. Keeping active helps you:  Sleep better If you are tired after an activity or the next day, then you have tried to do too much.  Feel less tired  Feel less breathless  Feel more confident and in control Studies show that daily activity is good for you. It can help you to live better and longer. Getting started
Always check with your health care provider first before starting an activity to make sure you find an activity that matches your personal needs and ability. Start off slowly and pace yourself. It may take your body a while to find a balance between activity and rest, so don’t give up. Activities most people with heart failure
can do







Walking Light housework Gardening Light vacuuming Stretching Laundry Grocery shopping January 2012. For more information on heart failure, go to www.bcheartfailure.ca.
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When to stop an activity
Tips about activity
Stop the activity if you:  Cannot carry on a conversation, sing, or whistle without being short of breath.  Stick with it, so it becomes a habit.  Include a variety of different activities so you do not get bored doing the same thing all the time. 
Feel weak, tired, or dizzy. 
Feel sick to your stomach (nauseated).  Wear loose, comfortable 
Feel your heart is pounding or racing. 
Feel your heart beating irregularly and this is new for you. 
Have pain in your chest, neck, jaw, arm, or shoulder.
clothing and supportive shoes.  Count the fluids you drink during the activity as part of your daily fluid amount. Stop and rest. Sit in a comfortable chair. Do not go to bed for a nap.
Activity most people with heart failure
should not do
 Activities that involve working above your head such as painting or washing walls, washing windows, vacuuming curtains. What if you don’t feel confident doing
activities and exercises on your own?
There are many community‐based programs designed specifically for people with heart disease.  Lifting or pushing heavy objects. To find a program in your community:  Talk to your health care provider  Straining or holding your breath to do an 
Call HealthLink BC at 8‐1‐1 
Go to the HealthLink BC website (www.healthlinkbc.ca).  Click on the ‘Find’ button.  Type in ‘cardiac rehabilitation’ in the ‘What?’ box.  Type in your location in the ‘Where?’ box.  Click the ‘Go’ button.  Choose a program. 
Contact the Physical Activity Line (PAL)  1‐877‐725‐1149  www.physicalactivityline.com  [email protected]
activity.  Sit ups or push ups.  Climbing a lot of stairs.  Heavy housework or yard work.  Going into sauna or hot tub. Learn more about how important activity is
Review the ‘Actionset’ called ‘Heart Failure: Activity and Exercise’ on the HealthLink BC web site. www.healthlinkbc.ca/kb/content/actionset/aa87369.html Check the BC Heart Failure Network web site. January 2012. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Why People with Heart Failure Should Exercise
Exercise for your health
Exercise is a planned physical activity. All
types of exercise involve increasing the heart
rate and strengthening muscles. Exercise is
intended to improve or maintain fitness or
health.
Why exercise is important
No matter how old you are, exercise benefits
your heart failure in a number of ways.
Exercise helps you to:
 Sleep better
 Feel less tired
 Breathe better
 Lower your blood pressure
 Strengthen your muscles and bones
 Reduce stress and tension
 Reduce feelings of anxiety or depression
When you increase your fitness and health,
you improve your quality of life.
Types of exercise
Some exercises focus more on increasing the
heart rate and blood flow. Others focus on
increasing strength. Many exercises are a
combination of both.
Aerobic Exercise
Any steady physical activity that increases
your heart rate for at least 10 minutes is
an aerobic or cardiovascular exercise
(‘cardio’ meaning heart, ‘vascular’ meaning
blood flow). Aerobic exercise improves
your body’s ability to use oxygen.
Over time, your heart will not have
to work as hard as it did. You can do
more and feel better!
Strength exercise
Any time you contract a muscle
against resistance such as weight
or gravity is a strength exercise.
Once you have a routine of aerobic
exercise, adding strength exercise
can improve your overall fitness.
Getting started
Always check with your healthcare
provider first before starting an exercise
routine.
Choose an exercise you enjoy.
Examples of aerobic exercise: walking
outside or on a treadmill, using an exercise
bike, swimming
Examples of strength exercise: doing wall
push-ups, doing leg lifts, using resistance
tubing, lifting free-weights
Check your Heart Failure
Zone before you start
every exercise session.
Exercise only if you are
in the ‘Green Zone’.
Start slowly with what
you can do (not what
you think you should do) and pace
yourself.
Aim to exercise most days of the week.
Aim to exercise for at least 30 minutes each
day.
Take rest breaks when you need them.
October 2014. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Starting aerobic exercise
How hard to exercise
Step 1
Warm up.
Take at least 5 minutes to warm up. This
prepares your heart and body for the extra
work. This means walk or cycle slowly for 5
minutes.
Step 2
Condition yourself.
Gradually increase the exercise to a steady,
moderate pace. Aim for continuous exercise
for up to 30 minutes.
Step 3
Cool down.
Take 5 to 10 minutes to slow down your
exercise. This helps your heart slowly
return back to your resting heart rate.
Starting strength exercise
It is best to have a cardiac rehabilitation
professional help you start strength
exercises. You will learn the proper way to
do the exercise.
Generally:
 Choose 6 to 8 basic strength exercises for
the larger muscle groups of both the
upper and lower body.
 Start with low resistance or light weights.
 Repeat each exercise only 10 to 15 times.
 Do your strength exercise routine 1 to 3
times a week with rest days in between.
Balance exercise and rest
If you are tired either right after you
exercise or the next day, you have done too
much. Cut back a little on the amount you
exercise and progress more slowly.
Exercise at a time when you feel rested. It
could be first thing in the morning or after a
nap.
It may take your body a while to find a
balance between exercise and rest, so
don’t give up.
Get to know your body. Pay attention to
how exercise makes you feel. As long as
you have enough breath to carry on a
conversation, the exercise level is okay.
Use the table below as a way of measuring
your effort.
Aim to stay within the 3 to 5 scale during
your exercise.
Rate your exercise effort
Talk Test
0
0.5
1
2
3
4
5
Resting
Nothing at all
Very, very easy
Very easy
Easy
Moderate
Somewhat hard
Hard
6
7
Very hard
8
9
Very, very hard
10
Maximum
Sing
You have enough breath to
sing
Talk
You have enough breath to
carry on a conversation
Gasp
You cannot say more than
4 to 6 words without
gasping
You cannot say more than
2 to 3 words without
gasping
You cannot talk at all
When to stop an exercise
Stop the exercise if:
 You feel lightheaded or dizzy.
 You feel more tired than usual.
 You feel more short of breath than usual.
Call 9-1-1 if:
 You feel pressure or pain in your chest,
neck, jaw, or shoulders that does not go
away with rest or medicine.
 You have a fast heartbeat that does not
slow down with rest.
 You feel like throwing up (nauseated).
 You feel your heart skipping beats and this
is new for you.
 You get a shock from your implanted heart
device (ICD).
October 2014. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Tips for exercise
 Stick with it, so it becomes a habit.
When you don’t feel confident doing
exercises on your own
 Include a variety of exercises so you do not
get bored.
There are many community-based programs
designed specifically for
people with heart disease.
They are usually called
cardiac rehabilitation
programs.
 Wear loose, comfortable clothing and
supportive shoes.
To find a program in your community:
 Talk to your healthcare provider.
 Choose to walk whenever you can instead
of driving.

Call HealthLink BC at 8-1-1.

Go to the HealthLink BC website
(www.healthlinkbc.ca).
 Go to the ‘Find Services’ section of the
home page.
 Type ‘cardiac rehabilitation’ in the
‘What?’ box.
 Type your location in the ‘Where?’ box.
 Click on the ‘Find’ button.
 Choose a program.
 Schedule exercise sessions into your daily
routine.
 Exercise at the same time each day.
 Choose the stairs instead of the elevator.
 Wait 1 hour after eating a meal to exercise.
 Adjust your pace when walking in hilly
areas.
 Exercise indoors when it is too cold, too hot,
or too humid outside.
 Count the fluids you drink during the
activity as part of your daily fluid amount.
 Keep an exercise record. This helps you see
your progress.
Learn more about the importance of
exercise
Review ‘Heart Failure: Activity and
Exercise’ on the HealthLink BC website
(www.healthlinkbc.ca).
 Go to the ‘Search Health Information’
section of the home page.
 Type ‘heart failure exercise’ in the ‘All
Health Topics’ search box.
Check the BC Heart Failure Network
website.
October 2014. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Depression
Depression can affect anyone but people with
heart failure are more likely to become
depressed. For every 10 people with heart
failure, 5 to 7 will likely experience depression.
What is Depression?
It is a medical condition where a person feels
sad, loses interest in daily activities, withdraws
from people, and feels hopeless about the
future.
Depression is different from grief, sadness
related to an event, or low energy.
How can a health care professional tell a
person has depression?
You must have a number of the
following signs most of the day,
every day for at least 2 weeks:
 Constantly feeling sad for
no reason

Feeling hopeless, guilty, or worthless

Little or no interest in people or
activates you use to enjoy

Feeling really tired or low on energy

Sleeping too much or not enough

Feeling like you are speeding up or
slowing down

Unplanned changes in your weight
(weight loss or weight gain)

Changes in your appetite

Having trouble thinking, concentrating,
or remembering

Having trouble making decisions

Thinking about hurting yourself or
about dying
How can depression affect your heart
failure?
Depression can make your heart
failure worse. If you are
depressed, you will find it harder
to do the things you need to do to
manage your heart failure (such
as exercising, eating well, limiting fluids,
and taking your medicines as directed).
What causes depression?
Depression may be caused by one factor or a
number of factors. Some factors that might
cause depression include:
 An imbalance in the natural chemicals
in the brain
 A heart condition
 A chronic health condition such as
anemia or hypothyroid
 Difficult life events such as:
- Death of a loved one
- Divorce
- Loss of a job
- Childbirth
 Using too much alcohol or drugs
 Family history of depression
Depression is not caused by a personal weakness.
Sometimes when people feel very depressed
and overwhelmed, they start to think about
hurting themselves. If you have started to
make a plan to hurt yourself, go to the nearest
emergency room right away.
Support for those in crisis
Crisis Line Association of BC
1-800-784-2433
1-800-SUICIDE
December 3, 2013. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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How do you know if you are depressed?
When should you get help?
Ask yourself the following question (Choose
the number that most reflects your feeling over
the last two weeks.)
If you scored 3 or lower
 You are probably coping pretty well. Your
feelings of depression are probably not
interfering with your life too much.
If you scored 4 to 6
 You are probably mildly to moderately
depressed. Talk to your family doctor. Try
some of the ideas on this page to help you
with your depression.
Over the last two weeks, how much have I been
bothered by feeling sad, down, or uninterested in
life?
0
(None)
1
2
3
(A little)
4
5
6
(Moderate)
7
8
9
(Severe)
If you scored between 7 to 9
 You are probably severely depressed.
See your family doctor or a mental health
professional right away.
Some Ideas on How to Manage Depression
Set small goals
 Set small self-care goals (taking a shower,
taking a walk, eating well-balanced meal)

Set small household goals (doing the
dishes, paying some bills, take care of
business you have been avoiding)
Watch out for negative thinking
 Try to be aware of your thoughts. (Negative
thinking is very common with depression.)


Socialize and have fun
 Reach out to friends and family.

Make social plans and go even if you “don’t
feel like it”.

Make time for pleasant activities. You may
need to gently force yourself to do these
things. Don’t wait until you want to!
Problem solving
 Identify and define problems.

Ask yourself what you would say to a
friend who had that negative thought.
Make a list of possible actions to address
the problem.

Identify pros and cons for each action.
Try to be kinder to yourself.

Pick the best action and try it out.

Think about how it went.
How is depression treated?
It is essential to get medical treatment. Some effective treatments include:



Talk Therapy – especially Cognitive Behavioural Therapy - is helpful for people with heart
conditions.
Medicines to improve mood.
Lifestyle changes such as exercise and proper sleep.
December 3, 2013. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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This will be a separate resource
More information on Depression
Online Resources
Bounce back program
www.cmha.bc.ca/how-we-can-help/adults/bounceback
Positive coping with health conditions a self care workbook
www.comh.ca/publications/resources/pub_pchc/PCHC%20Workbook.pdf
Antidepressant Skills Workbook
www.carhma.ca
HealthLink BC
www.healthlinkbc.ca
Depression Hurts
www.DepressionHurts.ca
Books
‘Mind Over Mood: Changing how you feel by changing the way you think.’
By Greenberger & Padesky (1995) - At your local bookstore (about $25). An excellent self-help
book for depression and anxiety.
Finding a Therapist
You can arrange to see a Registered Psychologist without needing a referral from you doctor.
Call the BC Psychological Association for a psychologist in your area. 1-800-730-0522
Mental Health Centres
Talk to your family doctor to find out what services are available in your area. You can also
call your local health authority (listed in the blue pages of your phone book) for mental health
services.
December 3, 2013. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Stress
What is Stress?
How do you know if you are stressed?
Stress is your body’s reaction to an
event or situation (real or
imagined). Stress is not so much
what happens to you, but how
you respond to a situation or
event. Too much stress is hard on your mind,
body, and especially your heart.
Ask yourself the following question (Choose
the number that most reflects your feeling over
the last two weeks.)
While stress is a part of everyday life, too much
stress increases a person’s chances of getting or
worsening heart disease. High levels of stress
or stress over long periods can cause:
 Increased blood pressure
 Increased higher cholesterol
 Increased chances of having a heart
attack or stroke
What are Stressors?
A stressor is any situation or event that triggers
your body’s stress response. Stressors are
different for each person.
Examples of stressors:
 Having a new diagnosis of heart failure

Limits in physical ability

Having chronic pain

Dealing with a number of health
conditions

Conflict in a relationship

Being isolated from friends and family

Dealing with the death or illness of a
loved one

Changes at work

Money worries
Over the last two weeks, how much have I been
bothered by feeling stressed?
0
1
(None)
2
3
(A little)
4
5
6
7
(Moderate)
8
9
(Severe)
If you scored 4 or lower
 You are probably coping pretty well with
your stress. If you feel you would like more
help than this sheet gives you, please talk to
someone you trust.
If you scored between 5 and 8
 It would be good for you to talk to your
health care provider or a mental health
professional about how you are feeling.
If you scored 8 or higher
 You are very stressed and need to get help
right away.
Sometimes when people feel very stressed and
overwhelmed, they start to think about hurting
themselves. If you have started to make a plan
to hurt yourself, go to the nearest emergency
room right away.
Support for those in crisis
Crisis Line Association of BC
1-800-784-2433
1-800-SUICIDE
December 3, 2013. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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What might happen if you have too much stress
How stress can affect your thinking
 Trouble concentrating, short attention span,
easily distracted
 Poor judgement
 Lapse in memory
 Difficulty making simple decisions
 Brooding over problems
 Imagining the worst
 Confusion
How stress can affect your emotions
 Feeling helpless and frustrated
 Feeling overwhelmed by your life
 Feeling anxious, or worried
 Feeling irritable, hostile, or angry
 Feeling down, depressed, or hopeless
How stress can affect your behaviour
 Crying
 Fidgeting, and pacing
 Having more arguments
 Drinking more coffee, tea, cola
 Withdrawing from others
 Overeating or loss of appetite
 Smoking
 Drinking alcohol
 Sexual difficulties
How stress can affect your body
 Headache
 Knots in your stomach, feeling sick to your
stomach
 Restlessness
 Sweating
 Increased heart rate and blood pressure
 Rapid, shallow breathing
 Muscle tension in jaw, neck, or shoulders
 Tremors in hands or legs
 Tingling or numbness in fingertips
 Trouble sleeping, feeling tired all the time
Some ideas on how to manage your stress
(You can find detailed help on how to make these changes in the resources listed at the bottom of this page.)
 Practice deep breathing and other forms of
relaxation such as:
 Meditation, yoga, and stretching
 Make small changes to organize your life.
 Use a calendar and a ‘to do’ list to help you
manage your time.
 Call a friend.
 Look for the good in self or others.
 Maintain healthy habits such as:
 When a worry enters your mind, ask yourself if

Exercising daily to get rid of tension.

Eating a healthy diet to nourish your body.

Getting a full night’s sleep.
 Limit what you take on. It is okay to say ‘no’.
 Be assertive.
it is a problem you can solve.
If the answer is yes, set aside some time to
problem solve.
If the answer is no, let the worry go!
 Have as much fun as possible! You deserve it!
CAUTION: Alcohol, tobacco, or street drugs should not be used to manage your stress
For more information on Stress, check these resources:
Bounce Back Program: www.cmha.bc.ca/how-we-can-help/adults/bounceback
Positive Coping with Health Conditions - A Self-Care Workbook
www.comh.ca/publications/resources/pub_pchc/PCHC%20Workbook.pdf
HealthLink BC www.healthlinkbc.ca
Managing Stress Workbook, Happy Hearts Community Wellness Program, St Paul’s
Hospital:http://www.heartcentre.ca/documents/12Module-ManagingStressMar28-12.pdf
December 3, 2013. For more information on heart failure, go to www.bcheartfailure.ca.
The information in this document is intended solely for the person to whom it was given by the healthcare team.
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Anxiety
What is anxiety?
What are the signs of anxiety?
Everyone experiences anxiety at times. It is our
body’s natural response to a threat (sometimes
called the ‘fight-flight-freeze’ response). Our
body releases adrenalin in response to a real
danger or to something that feels threatening
or dangerous. Our heart rate increases and
blood shifts to our large muscles. All this
prepares our body to respond to the danger by
fighting, fleeing (flight), or freezing.
Many people do not
recognize what they are
feeling as being signs of
anxiety. Instead, they think
something is physically
‘wrong’ with them.
Normally, anxiety goes away once the threat is
gone. Anxiety can become a problem when a
person continues to have worrying thoughts or
reacts as if there is a danger when no real
danger exists.
What causes anxiety?
It is different for every person. Any number of
situations can cause you to feel anxious,
worried, or tense.
There are things that can make your anxiety
response worse:
 Medical conditions such as thyroid
problems, heart or lung problems, seizure
disorders
 Stopping certain medicines on your own
(without your doctor knowing)
 Being dependant on or addicted to alcohol,
cocaine, amphetamines, tranquilizers, or
heroin
 Always telling yourself the worst will
happen
You are more likely to feel anxiety if:
 You have a family history of problems with
anxiety.
 You have an imbalance of certain chemicals
in your brain.
Anxiety can affect your body, your thoughts,
and your behaviour.
 Possible body responses
 Fast, pounding heart
 Rapid breathing, shortness of breath
 Chest pain or discomfort
 Sweating
 Feeling dizzy or lightheaded
 Dry mouth, nausea, stomach upset
 Pale
 Muscle tension
 Trembling, shaking
 Numbness and tingling
 Hot or cold flashes
 Possible thoughts
 Having frightening dreams or thoughts
 Overestimating the chances something bad
will happen
 Magnifying how bad the situation is or how
bad a future situation will be
 Not believing you can cope
 Having trouble concentrating or making
decisions
 Possible behaviours
 Using alcohol or drugs to lessen the anxiety
 Needing others to reassure you all the time
 Needing to be with a ‘safe’ person
 Staying away from certain places, activities
or people
October 2014. For more information on heart failure, go to www.bcheartfailure.ca.
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When should you get help?
How can anxiety affect my heart failure?
Ask yourself the following question (Choose
the number that most reflects your feelings.)
The increased heart rate and blood pressure
adds stress on your heart.
Over the last two weeks, how much have I been
bothered by feeling anxious, worried, nervous, or
tense?
Anxiety needs energy. Anxiety can increase
your blood sugar and cholesterol. Both can
make your heart failure worse.
0
(None)
1
2
3
(A little)
4
5
(Moderate)
6
7
8
9
(Severe)
If you scored 3 or lower
 You are probably coping pretty well with
your anxiety. If you feel you would like more
help than this sheet gives you, please talk to
someone you trust.
If you scored between 4 and 7
 It would be good for you to talk to your
health care provider or a mental health
professional about how you are feeling.
To find a mental health professional, contact
the Canadian Mental Health Association.
 604- 688-3234 or 1-800-555-8222
 [email protected]
 www.cmha.bc.ca
If you scored 8 or higher
You are probably very anxious. See your
family doctor or a mental health professional
as soon as possible.
Anxiety can make it hard to sleep, leaving you
feeling more tired.
What can you when you have mild anxiety?
It is not unusual for someone with a health
condition such as heart failure to feel scared,
worried, or tense. Included below are some
ideas to help you deal with your anxiety.
For more detailed help on how to manage your
anxiety, see the resources on the next page.
Sometimes when people feel very anxious and
overwhelmed, they start to think about hurting
themselves. If you have started to make a plan
to hurt yourself, go to the nearest emergency
room right away.
Support for those in crisis
Crisis Line Association of BC
1-800-784-2433 or 1-800-SUICIDE
Some Ideas on How to Manage Your Anxiety
 Be aware how you experience anxiety.




Identify things that trigger your anxiety.
 Ask yourself “Is this really a threat or a
danger?”
Ask yourself if your worry is something you
have some control over. If it is, try to resolve it.
If it isn’t, let it go.
Practice deep breathing and other forms of
relaxation such as:
 Meditation, yoga, and stretching, praying,
reading, going for a walk, listening to music
Eat a healthy well balanced diet.
 Get a good night sleep.

Do not drink caffeine close to bed time.
 Reduce any stress in your life.
 Reduce things that stimulate your body:


Reduce the amount of caffeine you drink
(coffee, tea, colas) in a day.
Do not smoke cigarettes.
 Set a routine for doing daily activities
 Use a calendar and a ‘to do’ list to help you
manage your time.
 If you are having a bad day, talk to someone
you can trust.
Never use alcohol, tobacco, or street drugs to help you manage your anxiety
October 2014. For more information on heart failure, go to www.bcheartfailure.ca.
Page 2 of 3
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How do we know when anxiety is a
problem?
Sometimes anxiety and worry can become so
severe that a person develops an anxiety
disorder. A doctor or mental health
professional can tell if you are suffering from
an anxiety disorder by asking you a number of
questions.
Sometimes blood tests are done to see if a
medical condition is making the anxiety worse.
How is moderate to severe anxiety treated?
Anxiety disorders respond well to treatment.
Treatment can include:
- Counselling
- Support group
- Behaviour therapy (focusing on
thinking and behaviour)
- Exposure therapy (focusing on facing
the situation in a safe environment)
- Medications to treat any chemical
imbalance in your brain
For more information on Anxiety, check these resources
AnxietyBC
 To learn more about anxiety, select the ‘Adults’ tab.
www.anxietybc.com

For specific resources, select the ‘Resources’ tab.
 Select ‘Resource Documents’ from the list on the left.
 Scroll down to the ‘Helpful “How To” Documents for Self-Help’ for topics such as:
- ‘What is Anxiety?’
- ‘Tips for Healthy Living’
- ‘Self-Help Strategies for GAD (Generalized Anxiety Disorder)’

To watch a video about Generalized Anxiety Disorder:
 Select the ‘Adults’ tab.
 Select ‘Generalized Anxiety Disorder’ on the left.
 Click on the video link on the page.

To download the ‘MindShift’ mobile app:
 Select the ‘Resources’ tab.
 Select ‘Mobile App’ from the list on the left.
 Scroll to the bottom and download either from the iTunes App Store or Google Play.
HealthLinkBC
 Look for ‘Anxiety’ under the ‘Health Topic A-Z’ tab.
www.healthlinkbc.ca
Here-to-Help
www.heretohelp.bc.ca
 To learn more about mental health wellness, select ‘Self-Help Resources’.
 Under ‘Resource Type’ on the left, select ‘Workbooks’.
 Scroll down to find ‘Wellness Module 1: Mental Health Matters’ workbook.
Positive Coping with Health Conditions - A Self-Care Workbook
www.comh.ca/pchc/
 Choose to download the complete workbook or selected excerpts from the workbook such as
‘Managing Worry’ or ‘Relaxation’.
Books


Local book stores or www.amazon.ca
‘Coping with Anxiety: 10 Simple Ways to Relieve Anxiety, Fear, and Worry’ by Edmund Bourne and
Lorna Garano (2013)
‘The Anxiety And Phobia Workbook’ by Edmund Bourne (2010)
October 2014. For more information on heart failure, go to www.bcheartfailure.ca.
Page 3 of 3
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Tips for Travelling When You Have Heart Failure
With some planning, people with heart
failure can safely travel.
Planning for travel
 Talk with your healthcare
provider before you commit to any trip,
especially if you have a pacemaker or
implanted cardioverter defibrillator (ICD).
 Make sure your immunizations are up to
date.
 Buy travel health insurance, especially when
travelling outside of Canada and even if
only for a day. Make sure it covers preexisting illnesses.
 Buy cancellation insurance on flights and
bookings, in case you have a sudden change
in your health.
 When flying, especially outside of Canada,
you might need a travel letter from your
doctor explaining why you need to travel
with all your medications. Check with your
travel agent or airline.
 Know where to go to get medical help when
you get there by finding out before you
leave. Check to see if there is a hospital or
medical clinic nearby.
 Pack a cell phone. Check with your cell
phone provider to make sure you have
coverage in the area you are travelling.
 If possible, weigh yourself while you are
traveling.
 If travelling to a different time zone, ask
your healthcare provider if you should
adjust your medication schedule.
 Consider wearing a Medical Alert bracelet
or necklace.
 Carry copies of your medical information
such as:
 results of recent blood tests
 a list of health and medical problems
 names and contact phone numbers of
your healthcare providers
 a list of all your current medications
 Take enough of each medication to last the
whole trip plus extra, in case of an
emergency or a travel delay.
 Keep all your medications in the packaging
supplied by the pharmacy.
 Consider asking your pharmacist to put
your medications into ‘blister packs’ so
you don’t have to travel with all your
original containers.
 Make sure each medication name is
clearly marked. (This is very important
when crossing borders.)
When not to travel
It is best to stay home if:
 Your healthcare provider has advised you
not to travel.
 You have recently come home from being in
the hospital.
 Your doctor has changed one or more of
your medications, such as a change in dose
or how often you take it.
 You cannot get travel health insurance.
 You notice increased signs of heart failure
(shortness of breath, weight gain, fatigue,
cough, swelling in your feet or belly area, or
dizziness).
April 2014. For more information on heart failure, go to www.bcheartfailure.ca.
Page 1 of 2
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Travelling with a heart device
 If you have a heart device (a pacemaker or
an implanted cardioverter defibrillator),
check with your healthcare provider,
especially if your device is being monitored
remotely.
 If you have just had a heart device
inserted, wait until your first follow-up
appointment to find out when it is safe for
you to travel.
 Ask your doctor for a copy of your heart
device instructions in the language of the
country you are travelling to.
 Ask for a recent print out of settings for
your heart device.
 If you have an implanted cardioverter
defibrillator (ICD), ask what you should
do if you get a shock while away.
 Keep your cell phone at least 6 inches away
from your heart device.
 Always carry your heart device
identification card with you.
 When going through security:
 Show your heart device identification
card before going through the metal
detectors.



Ask for a ‘hand check’ instead of a wand
metal detector check. A wand metal
detector could momentarily change the
settings on your heart device.
Tell security using wand metal detectors
they can only pass over your heart
device once every 5 or more seconds.
Did you know? It is safe to go through archway
metal detectors, body scanners, and retail store
anti-theft equipment with a heart device.
During your travels
 When sitting for long periods, get up or get
out for a walk every 2 hours.
 Whenever you have to check your luggage,
carry all your medications with you in a
carry-on bag.
 Take your medications on schedule.
 It is best not to buy any medications in other
countries. Ingredients can vary from what is
in the medication from Canada.
 Be careful you don’t drink too much fluid.
When in hot climates or when socializing,
people tend to drink more.
 Watch your portion size for both meals and
snacks. Eating more than normal can cause
bloating, an upset stomach, and indigestion.
 Eat your largest meal either at lunch or
earlier in the afternoon. Have a light dinner
or early evening snack.
 Eating out usually means foods high in
sodium. Whenever you can:
 Ask for “no added salt”.

Choose low calorie and low salt meals
and snacks.

Say “no thanks” to sauces, gravies, and
prepared foods.

Make your own low salt meals.
Know your heart device is going to set
off an alarm when walking through an
archway metal detector; you may need a
‘hand check’ as well.
Plan ahead. Travel safely. Enjoy!
April 2014. For more information on heart failure, go to www.bcheartfailure.ca.
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Therapeutic Approach to Patients with Heart
Failure and Reduced Ejection Fraction
Canadian Journal of Cardiology
Vol 32 2016
Patient with LVEF <40%
Triple Therapy
ACEi (or ARB if ACEi intolerant), BB, MRA
Titrate to target doses or maximum tolerated evidence-based dose
Titrated to minimum effective dose to maintain euvolemia
Diruetics to Relieve Congestion
Continue Triple
Therapy
ADD Ivabradine1 and
SWITCH ACEi or ARB
to ARNI for eligible
patients**
NYHA II-IV
SR with HR<70 bpm
or AF or Pacemaker
SWITCH ACEi or ARB to
ARNI for eligible
patients**
Reassess Symptoms and LVEF
NYHA I or
LVEF >35%
NYHA I-III and
LVEF ≤35%
Continue present
management
Refer to ICD/CRT
algorithm
Consider:
- Hydralazine/nitrates
- Referral for
advanced HF therapy
(mechanical
circulatory support/
transplant
- Advanced HF referral
Reassess every
1 - 3 years or
with clinical
status change
Consider LVEF
reassessment
every
1 - 5 years
Reassess as
needed
according to
clinical status
NYHA IV
*Pending Health Canada approval
1
Ivabradine may be added when available in Canada
**ANRI - Sacubitril/Valsartan is an angiotensin II receptor blocker neprilysin inhibitor which replaces ACEi or
ARB in patients with elevated NP or recent hospitalization (BNP > 150pg/ml or NT-pro-BNP > 600pg/ml
Advance Care Planning and Documentation of Goals of Care
NYHA I
NYHA II-IV
SR, HR≥70 bpm*
Non-pharmacologic therapies (self-management, exercise)
Reassess Symptoms
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Management of Heart
Failure with Preserved
Left Ventricular
Ejection Fraction
(EF > 40%)
Diuretic Titration
At present there are no medication therapies with mortality benefit in patients who
have heart failure with preserved ejection fraction (EF >40%)
1. ACE Inhibitors ( Evidence: PEP CHF trial, 2006)
a. Perindopril: has been shown to decrease hospitalization in older patients
i. Consider its usage if hypertension is present
2. ARB (Evidence: CHARM preserved trail, 2003 & LIFE trail, 2002)
a. Candesartan: has a moderate impact in preventing hospital admission for HF patients
with a LVEF > 40%.
b. Losartan: has been shown to decrease Left ventricular hypertrophy (LVH)
i. Consider in patients with hypertension and LVH
3. Beta Blockers (Evidence: no clinical trial)
a. Physiologically beta blockers may be advantageous given that they decrease heart rate
and improve diastolic filling time
i. Consider BB in patients with atrial fibrillation or increased heart rate in the
absence of conduction system disease (eg. 1st degree block, 2nd degree, 3rd
degree)
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Commonly used Drugs in Heart Failure Care1, 2, 3
Generic Name
(trade name)
(strengths and
dosage form)
Adult Dosages
Cost
per 30
days*
Initial: 1.25-2.5 mg BID
$8-12
PharmaCare
Coverage
Common Adverse
Effects
Therapeutic
Considerations &
Contraindications
Drug Interactions
Angiotensin Converting Enzyme Inhibitors (ACE-I)
ramipril
Altace®, G
(IR capsule: 1.25, 2.5, 5,
10 mg)
enalapril
Vasotec®, G
(IR tablet: 2.5, 5, 10, 20
mg)
captopril
G
(IR tablet: 6.25, 12.5, 25,
50, 100 mg)
lisinopril
Prinivil®, Zestril®, G
(IR tablet: 5, 10, 20 mg)
perindopril
Coversyl®
(IR tablet: 2, 4, 8 mg)
trandolapril
Mavik®
(IR capsule: 0.5, 1, 2, 4
mg)
Regular Coverage
Target: 5 mg twice BID
Max dose: 10 mg BID
Initial: 1.25-2.5 mg BID
$35
Regular Coverage
Hypotension, hyperkalemia,
dry cough, renal
insufficiency, angioedema,
skin rashes, taste
disturbance, proteinuria,
neutropenia, headache,
dizziness.
Titrate dosage slowly by
50-100% every 2 - 4 weeks.
Monitor serum creatinine and
potassium 7 - 14 days after
initiation of therapy or dose
changes.
Target: 10 mg BID
Max dose: 20 mg BID
Initial: 6.25-12.5 mg TID
Contraindication: Avoid in
pregnancy.
$12-78
Potassium-sparing diuretics,
potassium supplements,
angiotensin receptors
blockers: hyperkalemia.
NSAIDs: reduced hypotensive
effect, fluid retention, renal
failure.
Regular Coverage
Lithium: increased lithium
levels and toxicity.
Target: 50 mg TID
Max dose: 150 mg TID
Initial: 2.5-5 mg once daily
Diuretics: hypotension.
$8-69
Regular Coverage
$17
Regular coverage
$9-31
Regular coverage
Target: 20-40 mg once daily
Max dose: 80 mg once daily
Initial: 2 mg once daily
Target: 8 mg once daily
Max dose: 8 mg once daily
Initial: 0.5-1 mg once daily
Target: 4 mg once daily
Max dose: 4 mg once daily
Angiotensin Receptor Blockers (ARB)
candesartan
Atacand®, G
(IR tablet: 4, 8, 16, 32 mg)
losartan
Cozaar®, G
(IR tablet: 25, 50, 100 mg)
valsartan
Diovan®, G
(IR tablet: 40, 80, 160,
320 mg)
Initial: 4 mg once daily
$9-10
Special Authority
(IR tablet: 8, 16, 32 mg)
Target: 32 mg once daily
No Coverage
(IR tablet: 4 mg)
Initial: 12.5 mg once daily
$5-$20
Special Authority
Target: 150 mg once daily
Initial: 40 mg BID
$18-19
Special Authority
Hypotension, hyperkalemia,
renal insufficiency,
angioedema (rare, less
frequent than with ACE-I),
headache, dizziness.
Angioedema less frequent than
with ACE-I.
Monitor serum creatinine and
potassium 7–14 days after
initiation of therapy or dose
changes.
Contraindication: Avoid in
pregnancy.
diuretics: hypotension.
Potassium-sparing diuretics
and ACE-I: hyperkalemia.
Potassium: hyperkalemia.
NSAIDs: reduced hypotensive
effect, fluid retention, renal
failure.
Target: 160 mg BID
Lithium: increased lithium
levels and toxicity.
BC Guidelines: Chronic Heart Failure – Diagnosis and Management (DEV)
October 2015
Continued
To Pharmeceutical Meds
Generic Name
(trade name)
(strengths and
dosage form)
Adult Dosages
Return to Page 1
Cost
per 30
days
Common Adverse
Effects
PharmaCare
Coverage
Therapeutic
Considerations &
Contraindications
Drug Interactions
Beta-Blockers
carvedilol
G
(IR tablet: 3.125, 6.25,
12.5, 25 mg)
bisoprolol
G
(IR tablet: 5, 10 mg)
Initial: 3.125 mg BID
$22-44
Special Authority
Target:
25 mg BID if <75 kg
50 mg BID if >75 kg
Max dose: 50 mg BID
Initial: 1.25 mg once daily
$1-9
Regular Coverage
Orthostatic hypotension,
worsening heart failure,
worsening fluid retention,
bronchospasm, dyspnea,
bradycardia, malaise,
fatigue, asthenia, erectile
dysfunction, masking of
symptoms of hypoglycemia.
Increase by 50-100% every 2 to
4 weeks.
HF symptoms may get worse
before they get better.
More likely to cause orthostatic
hypotension than bisoprolol.
digoxin, amiodarone,
diltiazem, and verapamil:
brandycardia.
Nondihydropyridine calcium
channel blockers (e.g.
verapamil and diltiazem):
additive cardiodepressant
effect.
Target: 10 mg once daily
CYP2D6 inhibitors (e.g.,
SSRIs, bupropion, ritonavir,
sertraline, St. John’s Wort,
citalopram, amiodarone): may
increase carvedilol levels
HF symptoms may get worse
before they get better.
Max dose: 20 mg once daily
Mineralocorticoid Receptor Antagonists (MRAs; also known as aldosterone receptor antagonists)
spironolactone
Aldactone®, G
(IR tablet: 25, 100 mg)
Initial: 12.5 mg once daily
$2-5
Regular Coverage
Target: 25-50 mg/day
(>25 mg/day rarely
indicated)
Hyperkalemia, dehydration,
nausea, gynecomastia
(usually reversible upon
discontinuation).
Monitor serum creatinine and
potassium 3 and 7 days after
initiation or titrating the dose.
Repeat every 1-3 months once
stable.
ACE-I, ARB, and potassium
supplements: hyperkalemia.
NSAIDS: reduced diuretic
effect, worsening renal
function, hyperkalemia.
Contraindications:
Pregnancy.
eplerenone
Inspra®
(IR tablet: 25, 50 mg)
Initial: 25 mg once daily or
once every 2 days
$43-86
No Coverage
Target: 50 mg once daily
Hyperkalemia, dehydration,
dizziness, diarrhea, nausea.
Monitor serum creatinine and
potassium 3 and 7 days after
initiation or titrating the dose.
Repeat every 1-3 months once
stable.
Contraindications:
Use with strong inhibitors of
CYP3A4 (e.g., ketoconazole,
itraconazole, ritonavir, nelfinavir,
clarithromycin, telithromycin,
nefazodone): significant
increases in eplerenone levels.
Pregnancy.
ACE-I, ARB, and potassium
supplements: hyperkalemia.
NSAIDs: reduced diuretic
effect, worsening renal
function, hyperkalemia.
Strong inhibitors of CYP3A4
(e.g., ketoconazole,
itraconazole, ritonavir, nelfinavir,
clarithromycin, telithromycin,
nefazodone): significant
increases in eplerenone levels.
Strong inducers of CYP3A4
(e.g., carbamazepine, phenytoin,
phenobarbital, St. John’s Wort,
refampicin): significant
decreases in eplerenone
efficacy.
BC Guidelines: Chronic Heart Failure – Diagnosis and Management (DEV)
October 2015
Continued
To Pharmeceutical Meds
Generic Name
(trade name)
(strengths and
dosage form)
Adult Dosages
Return to Page 1
Cost
per 30
days
PharmaCare
Coverage
Common Adverse
Effects
Therapeutic
Considerations &
Contraindications
Drug Interactions
Direct-Acting Vasodilators
hydralazine
G
(IR tablet: 10, 25, 50 mg)
Initial: 10-25 mg TID
isosorbide dinitrate
G
(IR tablet: 10, 30 mg)
Initial: 10-20 mg TID
furosemide
Lasix®, G
(IR tablet: 20, 40, 80 mg )
Initial: 20-40 mg/day once
daily or BID
$13-79
Regular Coverage
$4-19
Regular Coverage
$1- 107
Regular Coverage
Target: 75 mg TID to QID
Hypotension, GI complaints,
SLE-like syndrome,
tachyphylaxis, may worsen
oxygen demand.
Headache, hypotension.
Should be used in combination
with isosorbide dinitrate or
nitroglycerin.
Should be used in combination
with hydralzine.
sildenafil, vardenafil and
tadalafil: severe hypotension.
Target: 40 mg TID to QID
Diuretics
Max total daily dose: 600
mg
metolazone
Zaroxolyn®
(IR tablet: 2.5 mg)
May be administered BID or
TID for decompensated HF.
Initial: 2.5 mg once daily
$7-52
Dehydration, hypokalemia,
hypocalcemia, nausea,
hypotension, azotemia,
hypomagnesemia, anorexia,
hyperglycemia,
hyperuricemia, weakness,
fatigue, rash, increased total
cholesterol.
lithium: lithium toxicity.
digoxin: digoxin toxicity if K+
depleted.
oral corticosteroids:
hypokalemia.
NSAIDs: reduced diuretic
effect, increased renal toxicity.
Regular Coverage
Ototoxicity with high doses
of furosemide.
Max total daily dose: 20
mg
Digoxin
digoxin
Toloxin®, G
(IR tablet: 0.0625, 0.125,
0.25)
0.0625-0.25 mg once daily
in the evening.
$8
Regular Coverage
Lower doses may be
appropriate in patients with
low body mass or impaired
renal function.
Measure trough serum
concentrations at least 8
hours after administration
and adjust the dose to
maintain the serum
concentration between 0.6
and 1 nmol/L.
Anorexia, nausea, vomiting,
visual disturbances, fatigue,
dizziness, confusion,
delirium, cardiac arrhythmia.
May improve symptoms,
exercise tolerance, and quality
of life, but has not been shown
to improve survival.
Use only in patients with systolic
HF.
Electrolytes, creatinine, and
digoxin serum concentrations
should be obtained 5-7 days
after dose adjustments.
amiodarone, clarithyomycin,
cyclosporine, erythromycin,
itraconazole, propafenone,
quinidine, ritonavir,
tetracycline, and verapamil:
increased digoxin serum
levels.
antacids, cholestyramine,
colestipol, neomycin, rifampin,
St. John’s Wort, and
sulfasalazine: reduced digoxin
serum levels.
amiodarone, beta-blockers,
diltiazem, and verapamil:
increased risk of bradycardia.
Abbreviations: ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin II receptor blockers; BID = twice daily; G = generic; GI = gastrointestinal; HF = heart failure;
IR = immediate-release; kg = kilogram; mg = milligram; NSAID = nonsteroidal anti-inflammatory drugs; QID = four times daily; SLE = systemic lupus erythematosus; SSRI =
selective serotonin reuptake inhibitor; TID = three times daily.
Footnotes: Pricing is approximate as of May 1, 2015 and does not include dispensing fee or additional markups.
Note: Please review product monographs at hc-sc.gc.ca/dhp-mps/prodpharma/databasdon/index-eng.php and regularly review current Health Canada advisories, warnings and
recalls at www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/index_e.html
BC Guidelines: Chronic Heart Failure – Diagnosis and Management (DEV)
October 2015
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Hemodynamic Subtypes of Heart Failure
Warm and dry
Adequate perfusion, no congestion
• Normal pulmonary capillary
wedge pressure (PCWP)
• Normal cardiac index (CI)
• No signs or symptoms
Management
•This is the target profile
•Emphasis on titration of chronic therapy
to optimal doses
Cold and dry
Poor perfusion, without congestion
• Low or normal PCWP
• Decreased CI
• Signs and symptoms:
 adventitious breath sounds,
 leg swelling, ascites,
 decreased peripheral
 perfusion
Management
•To Distinguish from hypovolemic shock.
•Emphasis on inotropic and mechanical
support
•Hemodynamic monitoring may be
required
Warm and wet (common)
Normal perfusion with congestion
• Elevated PCWP
• Normal CI
• Signs and symptoms:
 dyspnea
 leg swelling
Management
•Emphasis on diuretic therapy with
addition of vasodilators
•Significant diuresis may be required
•B-blockers can be continued BUT NOT
initiated
Cold and wet
Poor perfusion with congestion
• Elevated PCWP
• Decreased CI
• Signs and symptoms:
 Altered mental status,
decreased
 oxygen saturation,
 reduced urine output
 possibly other indicators of
cardiogenic shock
Management
•Emphasis on vasodilator therapy and
diuresis
•B-blockers and ACE inhibitors may
need temporary withdrawal
Adapted from: Nohria A et al. Medical Management of Advanced Heart Failure. JAMA 2002: 287; 628–40.
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Commonly used Diuretics Furosemide Starting dose
20 mg– 40 mg daily or BID Maximum total daily dose
600 mg Bumetanide 0.5mg – 1 mg daily or BID 10 mg Ethacrynic acid 25mg –50 mg daily or BID 400 mg 2.5 mg once daily 20 mg Metolazone If pre-existing renal dysfunction consider starting with higher dose of diuretic
Diuretic Up Titration & Intervention Guidelines Perform telephone or in clinic assessment of fluid status 3‐4 days after medication changes, and check blood work within 7‐10 days after medication changes Signs and Symptoms Assessment Step 1 Weight gain > 5 lbs (2.5 kg) in one week or 4 lbs (2kg) two days Also assess:  Auscultate lungs  Leg edema  Abdominal girth increase  VS (P,B/P, RR, O2 sat) Step 2 After 3 days reassess fluid status and symptoms If still > 5 lbs (2.5kg) above target weight If patient at goal weight refer to Furosemide down titration guide Step 3 Assess fluid status and symptoms If volume overload persists despite optimal medication therapy Dose/Drug Changes
Actions
Consider doubling the  Order : Electrolytes, BUN, patient’s current dose for 3 SCr, eGFR within 7‐10 days consecutive days or until after change in diuretic cumulative weight loss of dose 5‐10 lbs  Instruct patient to call clinic if desired weight loss Doses > 80 mg should be is achieved prior to having split into twice daily blood work done dosing  Evaluate electrolytes BUN, Continue to increase SCr, eGFR as ordered in Furosemide dose by Step 1 50 – 100% (Watch renal Instruct patient to call clinic if function*) desired weight loss is achieved prior to having blood work done  Reorder: Electrolytes, BUN, SCr, eGFR within 7‐10 days after change in diuretic dose  Repeat Step 2 until patient at goal weight. Add Metolazone 2.5‐ 5 mg Evaluate electrolytes BUN, SCr, 30 min prior to morning eGFR Furosemide dose. Metolazone: Start with Electrolytes, BUN, SCr, eGFR daily dosing for 3 days or 3 within 7‐10 days after change times per week dosing in diuretic dose (as per patient (Mon, Wed, Fri) specific Physician/NP standing OR order Change to Bumetanide as If volume overload persists oral absorption may be despite optimal medical improved therapy proceed to step 4 Comments Review fluid intake, should be 6‐8 cups (48‐64 ounces) per day Review Na intake, should be less than 2000mg per day If volume overload persists despite optimal medical therapy proceed to Step 3. May need to consider down titration if :  symptomatic hypotension  If potassium >5 mmol/L  If SCr > 30% from baseline May need to consider down titration if :  symptomatic hypotension  If potassium >5 mmol/L  If SCr > 30% from baseline Instruct patient to call if desired weight loss is achieved prior to having blood work done Continued
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Step 4 Assess fluid status and symptoms Return to Page 1
Diuretic Down–Titration Guideline Indications Signs and Symptom Assessment 1. Volume Stable Goal weight is met (Euvolemic) Resolution of HF symptoms 2. Volume Depletion (Dry) (hypovolemic) Weight is less than goal weight Signs of volume depletion  Hypotension  Tachycardia  Tachycardia with exercise Symptoms of volume depletion  Lightheadedness  Dizziness  Syncope  Very dry mouth  Constant thirst If volume overload persists despite optimal oral therapy consider:  Refer to Internist/Cardiologist/HFC (may need intravenous Furosemide)  Call RACE line for cardiologist support (604 696‐2131 or toll free 1 877 696‐2131) Drug/Dose Changes Decrease Furosemide by 50 % Hold next dose of Furosemide then reduce maintenance dose by 50% Actions
May need to consider down titration if :  If symptomatic hypotension  If potassium >5 mmol/L  If SCr > 30% from baseline Evaluate electrolytes BUN, SCr, eGFR Comments
After 3 days reassess fluid status Instruct patient to call clinic if weight loss is greater than 10 lbs in 3 days Reassess: Electrolytes, BUN, SCr, eGFR within 7‐
10 days after change in diuretic dose Watch for S & S of volume depletion Signs  Hypotension  Tachycardia  Tachycardia with exercise Symptoms  Dizziness  Lightheadedness  Syncope  Very dry mouth  Constant thirst After 3 days reassess If persistent signs and symptoms of hypovolemia fluid status Reassess fluid intake Reassess: Electrolytes, BUN, SCr, eGFR within 7‐ May consult: 10 days after change  Cardiologist, Internist or Nephrologist at your site in diuretic dose Continued
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3. Worsening Renal Function Increase in serum creatinine by >30% from baseline Serum potassium >5 mmol/L If worsening renal function despite reduction in maintenance Furosemide consider:  Decrease or stop spironolactone Or Metolazone  ensure no other nephrotoxic agents  Decrease ACE inhibitor/ARB dose Return to Page 1
If patient euvolemic reduce maintenance Furosemide dose by 50 % After 3 days reassess fluid status, S & S of hypovolemia Electrolytes, BUN, SCr, eGFR within 7‐
10 days after change in diuretic dose Consider consulting:  Site cardiologist, internist or Nephrology To Pharmeceutical Meds
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Angiotensin Converting Enzyme Inhibitor (ACE‐I) with evidence in Heart Failure Populations ACE-I may be used in HF-pEF patients who have other indications for their
use (e.g., hypertension and Nephropathy)
Drug Captopril (Capoten) Enalapril (Vasotec) Perindopril (Coversyl) Ramipril (Altace) Trandolapril (Mavik) Starting Dose
6.25 mg‐12.5 mg TID
Target Dose 25‐50 mg TID 1.25 mg‐2.5 mg BID
10 mg BID 2 mg once daily
4‐8 mg once daily (24 hr dosing) 5 mg BID 10 mg once daily 4 mg once daily 1.25‐2.5 mg BID
1 mg once daily
ARBS (if unable to tolerate ACE’s) with evidence in Heart Failure Populations (Special Authority required: call the below # 1-250-952-1216 (direct)
or
1-877-657-1188) Candesartan (Atacand) Valsartan (Diovan) Starting doses Target dose 4 mg once daily
40 mg BID
32 mg once daily
160 mg BID
Angiotensin Converting Enzyme Inhibitor (ACE‐I) & ARB Up‐Titration Guideline Signs and Symptoms Assessment Step 1 Step 2 Step 3 Dose/Drug Changes Begin with recommended starting dose Increase by 50‐100% every 2‐4 wks Increase by 50‐100% every 2‐4 wks Actions
Baseline assessment
 Vital signs
 Renal Function
o Creatinine
o BUN
o eGFR
For every medication and dosage change Reassess:  Vital signs B/P

, Renal Function
o Creatinine
o BUN
o eGFR
For every medication and dosage change Reassess:  Vital signs B/P

, Renal Function
o Creatinine
o BUN
o eGFR
Comments Reassess blood work every 2‐
4 weeks especially if you are titrating medications  Electrolytes
 Renal function
Remember: Patients who are clinically “dry” may be more prone to renal failure when ACE/ARB dose is up‐titrated Closer monitoring with CKD and/or diabetes Closer monitoring with CKD and/or diabetes Monitor creatinine, allow a 30% increase from baseline Continued
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ACE‐I/ ARB Symptom Management Guideline Considerations:  Most of the side effects and rise in creatinine are transient and resolve within 2‐4 weeks but can
return with each up‐titration of ACE I medication
 Patients often need support to continue medications through this phase.
 Try to titrate to maximum dose tolerated.
o Typical patients difficult to up titrate include those with:
 Chronic Kidney disease and Diabetes. They require very close monitoring of renal
function
Options for Actions
Comments Dose/Drug Changes For every medication Step 1: Taking other change and dosage Reduce diuretic vasodilator medications change by 50% (per diuretic at alternate times (e.g. Reassess: guideline) if pt BB at noon)  Vital signs
euvolemic  Electrolytes
Step 2: Consider alternate
 Renal function
Taking ACE I at night dosing schedules to
 Assess postural
(if once daily) minimize symptoms
vitals
(eg. morning and
Suggest reduction in bedtime)
vasodilators that are Symptomatic hypotension not associated with mortality benefit in Step 3: patients with HF (e.g. CCB) Decrease ACE-I by
50%
Suggest to patient to rise slowly with position changes Step 4: Decrease BB per guidelines Step 1: Ensure etiology is not Pulmonary edema Cough Step 2: Reduce ACE‐I by 50% OR Consider switching to ARB For every medication change and dosage change Reassess:  Vital signs
 Electrolytes
 Renal function
Continued
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Step 3: After one week, Consider D/C ACE‐I Must Switch to ARB Nausea /vomiting Rise in creatinine Hyperkalemia (less than or equal to 5.5) Step 1: Take with food Step 2: Take at night Step 3: D/C if N/V persists And switch to ARB Step 1: Consider reducing ACE‐I by 50% Step 2: After one week If Cr remains increased consider reducing ACE‐I by 50% Step 3: If Cr remains elevated >200 umol/L consider D/C ACE‐I and start Nitrate/Hydralazine Step 1: Reduce or D/C spirolactone Consider reducing ACE‐I by 50% Step2: after 1 week If K + remains elevated reduce by another 50% Step 3: D/C ACE Assess for:
If N/V persists need to assess:  B/P, HR,RR
 Electrolytes
 Hydration
Reduce until stable renal function Monitor creatinine, allow a 30% increase from baseline If diabetic, may have to stop metformin once Cr > 200 umol/ Normal Creatinine levels Avoid NSAIDS Assess if patient is taking Na substitute as they can be high in K+ Assess if pt is eating food high in K+ Normal K+ 3.5‐5 mmol/L Asses if patient is taking NSAID’s and if they are D/C Caution in clinical conditions which could lead to dehydration (eg. concurrent sepsis or infection) If K+ > 6.0 mmol/L then direct to acute care facility. Assess for S& S of Hyperkalemia To Pharmeceutical Meds
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ARBS (if unable to tolerate ACE’s) with evidence in Heart Failure Populations (Special Authority required: call the below # 1250-952-1216 (direct) or
1-877-6571188) Candesartan (Atacand) Valsartan (Diovan) Starting doses Target dose 4 mg once daily
40 mg BID
32 mg once daily
160 mg BID
ARB Up‐Titration Guideline Signs and Symptoms Assessment Step 1 Step 2 Step 3 Dose/Drug Changes Begin with recommended starting dose Actions
Baseline assessment
 Vital signs
 Renal Function
o Creatinine
o BUN
o eGFR
Increase by For every medication and dosage change 50‐100% Reassess: every 2‐4 wks.  Vital signs B/P

, Renal Function
o Creatinine
o BUN
o eGFR
Increase by For every medication and dosage change 50‐100% Reassess: every 2‐4 wks.  Vital signs B/P

, Renal Function
o Creatinine
o BUN
o eGFR
Comments Reassess blood work every 2‐4 weeks especially if you are titrating medications  Electrolytes
 Renal function
Remember: Patients who are clinically “dry” may be more prone to renal failure when ACE/ARB dose is up‐titrated Closer monitoring with CKD and/or diabetes Closer monitoring with CKD and/or diabetes ARB Symptom Management Guideline Considerations:  Most of the side effects and rise in creatinine are transient and resolve within 2‐4 weeks but can return with each
up‐titration of ACE I medication
 Patients often need support to continue medications through this phase.
 Try to titrate to maximum dose tolerated.
o Typical patients difficult to up titrate include those with:
 Chronic Kidney disease and Diabetes. They require very close monitoring of renal function
Continued
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Meds
Options for Dose/Drug Changes Step 1: Reduce diuretic by 50% (per diuretic guideline) if pt. euvolemic Step 2: Decrease ARB by 50% Symptomatic hypotension Cough Nausea /vomiting Return to Page 1
Actions
For every medication change and dosage change Reassess:  Vital signs  Electrolytes  Renal function Step 3: Consider alternate dosing schedules to minimize symptoms (eg. Morning and bedtime) Step 4 Decrease BB per guidelines : Step 1: Ensure etiology is not Pulmonary edema Step 2: Reduce ACE‐I by 50% OR Consider switching to ARB Step 3: After one week, Consider D/C ACE‐I Must Switch to ARB Step 1: Take with food Step 2: Take at night Step 3: D/C if N/V persists And switch to ARB Comments Taking other vasodilator medications at alternate times (e.g. BB at noon) Taking ACE I at night (if once daily) Suggest reduction in vasodilators that are not associated with mortality benefit in patients with HF (e.g. CCB) Suggest to patient to rise slowly with position changes For every medication change and dosage change Reassess:  Vital signs  Electrolytes  Renal function Assess for:
If N/V persists need to assess:  B/P, HR,RR  Electrolytes  Hydration Continued
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Rise in creatinine Hyperkalemia Return to Page 1
Step 1: Consider reducing Reduce until stable ACE‐I by 50% renal function Step 2: After one week If Cr remains increased consider reducing ACE‐I by 50% Step 3: If Cr remains elevated >200 umol/L consider D/C ACE‐I and start Nitrate/Hydralazine Assess if patient is Step 1: taking Na substitute as they can be high in K+ D/C spirolactone Assess if pt is eating food high in K+ Consider reducing ACE‐I by 50% Asses if patient is Step2: after 1 week taking NSAID’s and if If K + remains they are D/C elevated reduce by another 50% If K+ > 6.0 mmol/L then Step 3: direct to acute care facility. D/C ACE Monitor creatinine, allow a 30% increase in baseline If diabetic, may have to stop metformin once Cr > 200 umol/ Normal Creatinine levels Normal K+ 3.5‐5 mmol/L Assess for S& S of Hyperkalemia Caution in clinical conditions which could lead to dehydration (eg. intercurrent sepsis or infection) To Pharmeceutical Meds
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Commonly used Vasodialatators Hydralazine Isorbide dinitrate OR Nitro patch Starting dose
37.5 mg TID or QID
Maximum total daily dose
75 mg TID or QID
20 mg TID
0.2mg/hr – 0.4mg/hr for 12hrs/per day 40 mg TID
0.6mg/hr‐0.08mg/hr for 12 hrs per day A combination of Hydralazine and Isorbide dinitrate is recommended:
 As part of standard therapy in addition to beta blockers and ACE inhibitors for African Americans with HF and reduced LVEF NYHA III or IV HF  For patients who are unable to tolerate ACE/ARB. Has no effect on renal failure Hydralazine and Nitrates should be Nitrates require a drug free period to Does not cause Hyperkalemia used concurrently decrease tolerance (eg. Remove nitro patch Should not be used in patients on for 12 hrs, or space Isorbide so there is a 12 pulmonary vasodilators such as hr nitrate free period) sildenafil or tadalafil Vasodialator Up Titration & Intervention Guidelines Perform telephone or in clinic assessment 3‐4 days after medication changes, may need to check blood work within 7‐10 days depending on what other medications your patient is taking S & S Assessment Step 1 Unable to tolerate ACE/ARB Dose/Drug Changes Commence vasodilator therapy per recommended starting does (see above table) Continue to increase Step 2 dose by 50 – 100% After 7‐10 days If tolerating starting dosage, continue with up titration to obtain target dose Actions
Assess vital signs, watch for Signs  Hypotension  Tachycardia Symptoms  Dizziness  Lightheadedness  Syncope/Presyncope  Headache Continue to also assess HF S & S:  Auscultate lungs  Leg edema  Abdominal girth increase  Weight watch for gain of > 5 lbs (2.5 kg) in one week or 4 lbs (2kg) two days Assess vital signs, watch for Signs  Hypotension  Tachycardia Symptoms  Dizziness  Lightheadedness  Syncope/Presyncope  Headache Comments Continue with patient self management education:  Review fluid intake, should be 6‐8 cups (48‐64 ounces) per day  Review Na intake, should be less than 2000mg per day May need to consider down titration if :  symptomatic hypotension  headache Continue to also assess HF S & S:  Auscultate lungs  Leg edema  Abdominal girth increase Weight watch for gain of > 5 lbs (2.5 kg) in one week or 4 lbs (2kg) two days To Pharmeceutical Meds
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Beta blocker with Evidence in Heart Failure Populations Drug Carvedilol (Special Authority required: call the below # 1-250-952-1216 (direct) or 1-877-657-1188) Metoprolol:
not been shown to reduce mortality in patients
with Heart Failure Bisoprolol Starting Dose Maximum total daily Dose 3.125mg BID < 85 kg‐ 25mg BID >85 kg‐ 50mg BID 1.25mg once daily
10mg OD at hs
Beta Blocker Up titration & Intervention Guidelines Prior to initiation of Beta Blocker:  Ensure volume status is Evolemic for 1‐2 weeks
 Assess for contraindications for BB usage
o Symptomatic Bradycardia (<60 bpm,
o symptomatic hypotension, (systolic <85 mmHg)
o heart block
o reactive airway disease
Signs and Symptoms Dose/Drug Changes Actions
Assessment Baseline assessment
Step 1 Begin with  VS/ baseline weight
recommended starting  Fluid assessment
dose  Fatigue
 Hx of Asthma
 ECG
Reassess:
Increase dose by Step 2  Symptoms and vital signs
50‐100% every 2‐4 weeks Step 3 Continue to up titrate until target dose is reached Increase dose by 50‐100% every 2‐4 weeks Reassess:
 Symptoms and vital signs
Comments 
BB are best tolerated
when patients are
euvolemic
 Fatigue may worsen
slightly, lasting 2 weeks
for every up titration
Watch for S& S
 Hypotension
 Bradycardia
 Volume overload
 Intolerable fatigue
 Heart block
 SOB
Watch for S& S
 Hypotension
 Bradycardia
 Volume overload
 Fatigue
 Heart block
 SOB
Continued
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Beta Blocker Symptom Management Guideline Symptomatic hypotension Symptomatic Bradycardia Options for Dose/Drug Changes Step 1: Start with If evolemic decreasing diuretic by 50% Step 2: May need to space the timing of other medication Step 3 If S& S persist May need to reduce ACE, ARB 50% Step 4: If S& S persist May consider reducing BB by 50%
Step 1: Consider reducing or D/C other heart rate lower medications (eg, digoxin, antiarrhythmics, CCB) Step 2: If S&S persist consider reducing BB by 50% Step 3: If S& S persist consider D/C BB and/or reducing it Actions
Comments For every medication and dosage change Reassess:  Symptoms and vital signs Give each down titration one week to see if symptoms resolve For every medication and dosage change Reassess: Symptoms and vital signs  ECG Consider holter monitor for more accurate assessment of 24 hr HR control Give each down titration one week to see if symptoms resolve If profound symptomatic Bradycardia EHS transfer to acute care facility To Pharmeceutical Meds
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Mineralocorticoid receptor antagonist (with evidence in heart failure HF-pEF, increased BNP levels) Starting dose
12.5mg‐25mg
Spironolactone Maximum total daily dose
25 daily
50 mg daily
Within 4 weeks of starting the dose Spironolactone may be used in patients with NYHA III‐IV heart failure on optimal medical therapy, while Eplerenone has shown benefit in patients with NYHA II - III symptoms and LVEF < 31 or LVEF 30-35% and QRS duration > 130ms
Patients should be on maximum medical therapy including ACE/ARB and Beta Blocker prior to initiation of an aldosterone antagonist. Mineralocorticoid receptor antagonists have the potential to effect kidney function and increase serum Potassium (K+) Gynecomastia is known to occur in up to 5‐10 % of males treated with spironolactone. Gynecomastia is decreased with eplerenone Mineralocorticoid receptor antagonists are not recommended when creatinine is > 200umol/L, Creatinine clearance
<30ml/min; serum potassium is > 5mmol/L,Severe hepatic impairment, potassium supplements or CYP34 inhibitors or
in conjunction with other potassium-sparing diuretics Once clinically stabilized and on maximum Aldosterone Antagonist therapy assess K+, SCr, and eGFR q 4 weeks until these
laboratory values are stable for three months.
Eplerenone (not covered by MSP) 25 mg daily
Mineralocorticoid receptor antagonist (MRA) Titration & Intervention Guidelines Perform telephone or in clinic assessment of fluid status 7 days after medication changes, and check blood work within 7 days after medication changes Signs and Symptoms Assessment Step 1 NYHA functional class III‐IV symptoms and on maximal tolerated doses of ACE/ARB and BB Dose/Drug Changes
See above chart for starting dose Actions
Comments Mineralocorticoid receptor
antagonist have the potential to effect kidney function and increase serum Potassium (K+): BE AWARE OF K+ LEVEL PRIOR TO STARTING THE MRA  Order : Electrolytes, BUN, SCr,
eGFR within 7 days after change in dose Things to review with your patient:  fluid intake, should be 6‐8
cups (48‐64 ounces) per day
 Na intake, should be less
than 2000mg per day  Instruct pt to decrease
dietary potassium intake  Stop K+ supplements in
favor of aldosterone antagonists 
Step 2 After 7 days reassess fluid status, K+ and symptoms If wt still > 5 lbs (2.5kg) above target weight and K+ not elevated If patient at goal weight may consider down titration of MRA
Continue to increase MRA Keep a close watch on renal to maximum doses based function, SCr, K+ on renal function and K+  Evaluate electrolytes BUN,
SCr, eGFR  after change in medication
dose May need to consider down titration if :  symptomatic hypotension
 If potassium increases 5.5‐
5.9 mmol/L
 If SCr > 30% from baseline
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Eplerenone: If K+ < 5mmol/L increase starting does by 50% If K+ 5.0‐5.4 maintain starting does If K+ 5.5‐5.9 decrease dose to:  50mg daily to 25mg
daily
 25mg daily to 25mg
every 2nd day
 25mg every 2nd day to
HOLD
If K+ > or equal to 6  HOLD dose
Spironolactone If K+ is within normal range increase to  25mg daily
Step 3 Assess fluid status, K+ and symptoms If volume overload persists despite optimal medication therapy Continue up titration per Step # 2 
Evaluate Electrolytes, BUN,
SCr, eGFR within 7 days after
change in medication dose
May need to consider down titration if :  symptomatic hypotension
 If potassium 5.5‐5.9
mmol/L
 If SCr > 30% from baseline
Instruct patient to call if desired weight loss is achieved prior to having blood work done IF S&S of heart failure persist AFTER MAXIMUM MEDICATION THERAPY YOU MAY NEED TO CONSULT AN INTERNIST OR CARDIOLOGIST To Pharmeceutical Meds
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Initiation, Titration and Monitoring Recommendations for Sacubitril/Valsartan (ENTRESTOTM )
Usage in British Columbia
Patient must meet all the British Columbia eligibility criteria prior to initiating Sacubitril/Valsartan
Sacubitril/Valsartan is NOT to be used as first line therapy for HFrEF- (≤ 40%),
Consider initiating Sacubitril/Valsartan ONLY AFTER patient established on guideline-directed triple medical therapy for
HF-rEF including Angiotensin Converting Enzyme Inhibitor (ACE-I), Angiotensin II Receptor Blocker (ARB), Beta Blocker
(BB), Mineralocorticoid Receptor Antagonist (MRA) for a minimum of 3 months (based on the potential for improvement on
standard medical therapy)
Prescribing tips
Sacubitril/Valsartan may be considered instead of an ACE-I or ARB in patients with:
9 NYHA II-III functional status.
9 LVEF ≤ 40% (preferably measured within the last year) despite a trial of optimally tolerated doses of guideline
driven heart failure therapy including ACE-I/ARB, BB and MRA for a minimum of three months,(based on the
potential for improvement on standard medical therapy).
9 Elevated BNP > 150 pg/mL or NT-proBNP ≥600 pg/mL at time of decision to switch or/and a heart failure
hospitalization within the last year.
• Consider decreasing the patient’s diuretic dose for 3-4 days when initiating Sacubitril/Valsartan to reduce the risk of
hypotension and kidney injury.
• NT-pro BNP is the biomarker of choice to be used once Sacubitril/Valsartan has been started, as BNP measurements
will be inaccurate.
• Consider starting at the lowest dose of Sacubitril/Valsartan (24.3 mg sacubitril / 25.7 mg valsartan) in patients who have
risk factors for hypotension or low baseline systolic blood pressure and in patients’ ≥ 75 years of age.
• Patients with moderate hepatic impairment (Child-Pugh B classification) should be initiated on the lowest dose of
Sacubitril/Valsartan.
• Sacubitril/Valsartan doses lower than 97.2/102. 8mg po BID have not yet been shown to reduce morbidity and
mortality. Every effort should be made to reach target dose.
Prescribing CAUTIONS:
When converting from ACE-I, a 36 hour wash out period is required before Sacubitril/Valsartan can be started
x
Sacubitril/Valsartan can cause hypotension, potassium and renal abnormalities.
x
Sacubitril/Valsartan may increase statin levels (especially simvastatin & atorvastatin). Careful monitoring for statin
toxicity is recommended.
x
Concomitant use of Sacubitril/Valsartan with aliskiren (Rasilez™) containing drugs should be avoided.
x
Theoretically patients on Sacubitril/Valsartan could be at risk of Alzheimer’s disease as amyloid β is a substrate for
neprilysin. This will be addressed in ongoing cognitive studies.
x
DO NOT use during pregnancy or if breast feeding.
Ordering sacubitril/valsartan (Entresto™):
sacubitril/valsartan must be ordered using
available strengths as below:
Actual Content
(Sacubitril/Valsartan)
Referred to in clinical studies
as:
Equivalent
Diovan™ dose:
sacubitril/valsartan 24/26 BID (White pill)
sacubitril/valsartan 49/51 BID (yellow pill)
24.3mg / 25.7mg
48.6 mg / 51.4 mg
50mg BID
100mg BID
40mg BID
80mg BID
sacubitril/valsartan 97/103 BID (pink pill)
97.3 mg / 102.8mg
200mg BID
160mg BID
Final April 2016
Continued
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Titration Algorithm
Eligibility Checklist Completed
Patient on guideline directed ACE-I or ARB at optimally tolerated dose
o if not, titrate to optimally tolerated dose and reassess eligibility for
sacubitril/valsartan in 3 months
Assess
If on ACE-I, STOP for 36 hours to reduce the risk of angioedema
Washout
Do not need to stop ARB 36 hours prior to starting sacubitril/valsartan
Initiate
Initiate sacubitril/valsartan 49/51mg BID -if patient at target ACE-I or ARB* dose
Initiate sacubitril/valsartan 24/26mg BID- if patient on less than target dose ACE ARB,*
older than 75 years old, at risk for hypotension, have moderate hepatic
impairment or clinician concern about drug intolerability
Increase to next highest dose every 2-4 weeks to a target dose of 97/103mg BID
sacubitril/valsartan 24/26 mg po BID
sacubitril/valsartan 49/51 mg po BID
sacubitril/valsartan 97/103mg po BID
Titrate
SCr, K+ and blood pressure
1 week after initiation, after each dose increase and with each practitioner visit
Consider assessment of LV Function only if it will alter treatment or if otherwise clinically
indicated
Monitor
x
Reassess
x
x
Consider decreasing or stopping sacubitril/valsartan if:
SCr increases by > 30%
* 36 hour washout of sacubitril/valsartan is required if
K+ is greater than 5.4 mmol/L
Symptomatic hypotension ( < 95 mmHg)
switching back to ACE-I*
Target Daily Dose
ACE-I
ARB
captopril 150mg
valsartan 320mg
enalapril 20mg
candesartan 32mg
perindopril 8mg
ramipril 10mg
trandolapril 4mg
Final April 2016
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Hypertension Considerations
Treatment with non- dihydropyridine Calcium channel
blockers (eg. Verapamil, Diltiazem) are contraindicated in
patients with reduced LVEF (LVEF < 40%) and must be
stopped.
Nifedipine, Amlodipine and Felodipine may be used safely in
HF population but may complicate the assessment of edema
Carvedilol may be the most effective beta blocker when HF
and hypertension are together.
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COPD Considerations
Bisoprolol is the most preferred Beta Blocker when
Heart Failure and COPD co-exist because of its β1
selective properties.
Minimize prn Ventolin as it causes tachycardia.
Oral Steroids can cause fluid retention and may
exacerbate heart failure
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Heart Failure Clinic Referral Form Indication for referral RACE Information
To a Cardiologist/Internist: When healthcare provider needs further direction on how to medically manage the patient Advanced functional symptoms or signs of heart failure despite maximum medication therapy To a Heart Function Clinic: o They have had recent or repeated admissions to hospital o Assessment of ASYMPTOMATIC left ventricular dysfunction o Chronic heart failure management including lifestyle management skills and consideration for advanced therapies including defibrillator/cardiac resynchronization therapy o Heart Failure with persistent symptoms but not decompensated, o New diagnosis of heart failure and STABLE o New diagnosis of heart failure and UNSTABLE  Post MI heart failure; hospitalization HF; worsening HF Patients experience long term benefits associated with referral to a Heart Function Clinic’s as they offer inter‐professional collaborative HF care, evidenced based medical therapy, ongoing close monitoring and individualized interventions tailored to the specific patients needs. Patients with NYHA I‐III should be referred to a cardiac rehabilitation program Continued
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Print Handout
Heart Function Clinic Referral Form *Patient
Name _________________________ Address ______________________ City__________________________ Province______________________ Contact # ______________________ PHN #_______________________ DOB Health Authority Logo * Key Elements*
*Reason For Referral
*Referring Provider
Name _______________________________ Phone _______________________________ Fax # ________________________________ MSP # ________________________________ GP , NP, ED In patient Specialist Specify ___________ *Care Management
Assessment of ASYMPTOMATIC heart failure (HF) Chronic heart failure management Heart Failure with symptoms but Not decompensated, New diagnosis of heart failure and STABLE New diagnosis of heart failure and UNSTABLE o Post MI heart failure; hospitalization HF;
worsening HF Shared care: (GP and Clinic physician/NP) HF physician/NP to stabilize and optimize medication therapy Optimize patient self‐management/ education ONLY Advice only on care management Additional health care professional who needs to be CC’d Name _________________________________ Address _______________________________ Fax # __________________________________ *Specific question referring provider would like answered?
*Primary Language Spoken If not English please ensure there is someone with the patient who can speak English
* Please include/or attach a complete list of all medications your patient is taking
*Co‐morbidities:
Diabetes, Renal Hypertension Angina Thyroid Disease Arrhythmias CABG TIA/CVA Arthritis Malignancy Respiratory Other specify _____________
*Please attach available/relevant cardiac investigation results
For example: Echo, MIBI, MUGA, ECG, Angiogram, CXR, consultation notes, Blood work (BNP, Lytes, etc.) *Acknowledgement of Referral ( Will be completed by HFC staff)
Our office will make an appointment with the heart function DR/NP in the next ___________________________Week (s) Your patient is booked to be seen by the heart function Nurse on ____________________________________________ We require additional information ______________________________________________________________________ o Before we can book the patient
o Prior to the patient’s appointment
*Referring Physician/ NP ________________________________________ *Date: _________________________
# of pages faxed____________ *Fax to: ADD Health Authority Fax #
To expedite care PLEASE ensure ALL aspects of this form are completed To Pharmeceutical Meds
Return to Page 1
REFERRAL GUIDELINES FOR ICD & CRT CONSIDERATION PRIMARY PREVENTION & CRT PATIENTS
(Ischemic & Non-Ischemic)
SECONDARY PREVENTION
Previous Cardiac Arrest, VF or Sustained VT
(induced or spontaneous and not due to a
reversible cause)
OPTIMAL MEDICAL THERAPY (OMT)
Patient is receiving OMT for a minimum of 3
months (Medications may include: Beta Blockers,
ACE inhibitors, Diuretics, Statins)
RECENT LOW LVEF* MEASUREMENT
Measured within past 6 months and 30 days post
MI or 80 days post revascularization procedure
ICD
LVEF  30%**
If admitted,
do not
discharge
patient
CAD
or
Post MI
Non-Ischemic Cardiomyopathy
with persistently low LVEF for at
least 9 months
NYHA Class
II or III
REFER FOR ICD CONSIDERATION,
UNLESS CONTRAINDICATED
CRT2
LVEF  35%**
NYHA
Class II - IV
Cardiomyopathy
with QRS  120ms
REFER FOR CRT
CONSIDERATION, UNLESS
CONTRAINDICATED
1 Tang A, et al. Canadian Cardiovascular Society/Canadian Heart Rhythm Society position paper on implantable
cardioverter defibrillator use in Canada. Can J Cardiol 2005;21 (Suppl A):11A18A
2 Canadian Cardiovascular Society Consensus Conference Heart Failure Management 2006 CAN J Cardiol Vol 22
No1 January 2006
* LVEF – Left Ventricular Ejection Fraction
** For appropriate patients, EF of 31% to 35% will also be considered per CCS/CHRS Recommendations
Sept 2011: Adapted from Medtronic of Canada Ltd’s Referral Guidelines for ICD and CRT Consideration
Continued
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SUDDEN CARDIAC DEATH (SCD) FACTS
SCD is a leading cause of death in Canada, claiming 45 000
lives a year – more than lung, colorectal, breast and prostate
cancers combined 1, 2
Only 5% of SCD victims survive an out of hospital cardiac
arrest3 – defibrillation within 6 minutes is critical with each
additional minute of delay reducing the change of survival
by 7‐10%4
Randomized clinical trials have not shown that
antiarrhythmic drug therapy can effectively reduce mortality
in heart failure patients5,6
With an ICD, over 95% of SCD victims survive7
1.
2.
3.
4.
5.
6.
7.
Davis DR, Tang ASL. CMAJ. 2004;171(9):1037‐1038
Heart and Stroke Foundation Statistics
Myderberg R. Catellanos A. Cardiac Arrest and Sudden Cardiac Death. I: Braunwalk E, ed. Heart Disease:
A Textbook of Cardiovascular Medicine. 5th Ed. New York:WB Saunders. 1997:742‐779
Cummins RO. From concept to standard‐of‐care? Review of the clinical experience with automated
external defibrillators. Ann Emerg Med. December 1989;18(12):1269‐1275.
Moss AJ. Zareba W, Hall WJ, et al; Multicenter Automatic Defibrillator Implantation Trial II Investigators.
Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection
fraction. N Engl J Med. March 21, 2002;346(12):877‐883.
Bardy GH, Lee KL, mark DB, et al; Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT) Investigators.
Amiodarone or an implantable cardioverter‐defibrillator for congestive heart failure. N Engl J Med. January
20, 2005;352(3):225‐237.
Simpson, Christopher S. Implantable cardioverter defibrillators work – so why aren’t we using them? In:
CMAJ⋅July 3, 2007⋅177(1)
Sept 2011: Adapted from Medtronic of Canada Ltd’s Referral Guidelines for ICD and CRT Consideration
Print Handout
Return to Page 1
Patient Resources
BC Heart Failure Network http://www.bcheartfailure.ca/
Canadian Virtual Hospice www.virtualhospice.ca
Health Link BC http://www.healthlinkbc.ca/
Heart Failure Society of America Heart Failure teaching modules
http://www.abouthf.org/education_modules.htm
(These modules are intended for health care professionals/patient/families who would like
more detailed information regarding heart failure. Please remember these modules were
created under the auspice of the American health care system. If you have any questions
please contact your doctor or Heart Function Clinic health care professional.)
Physician/Health Care Professional Links
Ministry of Health’s Heart Failure guideline
http://www.bcguidelines.ca/guideline_heart_failure_care.html
Canadian Cardiovascular Society’s Heart Failure Guidelines
Cardiovascular Library http://www.ccs.ca
American Heart Association’s Heart Failure Resources
http://www.heart.org/HEARTORG/Conditions/HeartFailure/HeartFailure_UCM_002019_SubHomePage.jsp
Heart Failure Society of America – Heart Failure Guidelines
http://www.heartfailureguideline.org/
Return to Page 1
Print Handout
RACE
RAPID ACCESS TO CONSULTATIVE EXPERTISE
RACE means timely telephone advice from specialists for family practitioners,
Community Specialists or Housestaff, all in one phone call.
Monday to Friday 0800-1700
Local Calls:
Toll Free:
Speak to a:
x
x
x
x
x
x
x
x
x
x
Nephrologist
Heart Failure Specialist
Cardiologist
Respirologist
Endocrinologist
Cardiovascular Risk &
Lipid Management Specialist
General Internist
Psychiatrist
Geriatrician
Gastroenterologist
604-696-2131
1-877-696-2131
Provincial Services Include:
x
x
Chronic Pain
Rheumatology
RACE provides:
x
x
x
x
x
x
Timely guidance and advice regarding assessment, management and treatment of
patients
Assistance with plan of care
Learning opportunity – educational and practical advice
Enhanced ability to manage the patient in your office
Calls returned within 2 hours and commonly within an hour
CME credit through “Linking Learning to Practice”
http://www.cfpc.ca/Linking_Learning_to_Practice/
RACE does not provide:
x
x
x
x
x
Appointment booking
Arranging transfer
Arranging for laboratory or diagnostic investigations
Informing the referring physician of results of diagnostic investigations
Arranging a hospital bed.
Unanswered Calls?
If you call the RACE line and do not receive a call back within 2 hours – call the
number below. All unanswered calls will be followed up.
For questions or feedback related to RACE, call:
604-682-2344, extension 66522 or email [email protected]
This work is made possible through a partnership between the Shared Care Committee and Providence Health Care in
collaboration with Vancouver Coastal Health
Return to Page 1
End of Life Care
Symptom Management (Specific to Heart Failure)
Appropriate
Prescribing
Anorexia
Cachexia
Dyspnea
Edema
Ascites
Fatigue
Nausea
Vomiting
Pain
Dealing with ICD Devices
ICD Information for
Professionals
Request or Referral for
Urgent ICD Deactivation
Urgent or Unplanned
ICD Deactivation
Consent for
ICD Deactivation
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Add health authority logo
Anorexia/Cachexia
Heart Failure Symptom Management Guideline
For adults, age 19 and older in British Columbia
What is anorexia?
Anorexia is a syndrome characterized by some or all of the following symptoms: loss of appetite, nausea, early satiety, weakness,
fatigue, food aversion, and significant physical and/or psychological symptoms. Causes of anorexia are multifactorial and include
fatigue, dyspnea, medication side-effects, nausea, depression, anxiety and sodium restricted diets which may all be found in patients
with heart failure.
What is cachexia?
Cachexia is a syndrome characterized by severe body weight, fat and muscle loss and increased protein catabolism due to underlying
disease. The prevalence of cachexia is 16–42% in the heart failure population and is associated with a 50%, 18 month mortality risk
independent of variables such as ejection fraction, age and functional ability.
How is cachexia diagnosed?
Chronic condition with
2
x >5% weight loss in <12 months; or body mass index (BMI) <20kg/m ; and
x 3 out of 5 additional criteria:
1) Fatigue, 2) Decreased muscle strength, 3) Anorexia, 4) Low muscle mass, 5) Abnormal biochemistry
*Blood testing to diagnose cachexia in advanced stages of disease is not advocated.
Reminder: Malnutrition also affects prognosis in patients with heart failure and is often found in early transitions of the disease.
However this symptom management guideline will focus on the assessment and treatment of anorexia and cachexia.
Approach to Managing Anorexia/Cachexia
Assessment
x History: When did weight loss begin? How much weight was lost? Obtain baseline (dry) weight. How is appetite? What do you eat
or drink on a typical day ?
x How has weight loss affected mood?
x Ask about: nausea, early satiety, dyspnea, poor oral hygiene, dysphagia, malabsorption, bowel habits.
x Ask about other factors causing anorexia/cachexia, e.g. cancer, hypothyroidism, severe liver disease, infections, depression.
x Use Edmonton Symptom Assessment System (ESAS) to rate appetite, nausea, fatigue, depression.
x Review medications known to contribute to anorexia/cachexia. eg. amiodarone, digoxin.
x Assess functional capacity for effects of early fatigue and muscle weakness
Tips
Anorexia
Cachexia
Reversibility
Reversible
Irreversible
Malnutrition
Reversible
Comparing Malnutrition and Cachexia
Treatment Options
Other Therapies
Preventative
Nutritional support/ Preventative stratigies
Supportive symptom management as Focus on symptom management and psychological support
there is no cure
Increase nutrient intake
Nutrition support may help
x Focus interventions on treatment of symptoms and reduction of psychological burden for patient and family.
x Cachexia is not the same as starvation in that catabolism and subsequent weight loss can occur even if caloric intake is maintained
or increased.
x Educate patient/family re difference between weight loss related to cachexia versus related to diuresis.
x Artificial nutrition in the setting of advanced cachexia is ineffective and will not improve quality of life.
x If patient is able, gentle physical exercise is recommended as it is in known to improve peripheral blood flow, metabolism and
neurohormonal abnormalities associated with cachexia.
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Anorexia/Cachexia Management Guidelines | Page 2
Non-Pharmacological approach
Cachexia treatment options:
x Emphasis should be placed on maintaining/improving quality of life.
Anorexia treatment resources:
x Refer to a registered dietitian (RD); ensure dietitian aware of goals of care and focus of symptom management.
x Consider focus on maintenance of food and fluid intake for social and psychological benefits; liberalize dietary choices as much as
possible (eg. low fat diet unnecessary).
Pharmacological Approach
x Standard heart failure therapies are known to improve quality of life and reduce symptoms and may reduce symptoms even at
advanced stages of disease.
x Although many guidelines will refer to the use of appetite stimulants and steroids in the treatment of anorexia and cachexia, there
is insufficient evidence of the benefit of these therapies. They are not recommended at the current time.
x Early satiety/nausea: Metoclopramide 10 mg PO or subcutaneous, 30-45 minutes prior to meals and at bedtime (hs) (reduce
dosage in renal impairment).
x Where concomitant depression/anxiety/insomnia is present, the antidepressant Mirtazapine may have the added benefit of
increased appetite and weight gain. Starting dose of 7.5 mg may be up titrated to 30 mg at hs with consideration to sedative
effects.
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Heart Failure End of Life
Appropriate Prescribing Guideline
For adults, age 19 and older in British Columbia
The management of heart failure (HF) involves numerous pharmacological (beta blockers, ACE-I
inhibitors) and non-pharmacological (device therapy) treatments. As end of life (EOL) approaches,
the focus of care shifts from active disease management, towards palliation of symptoms. However,
some HF therapies remain important and reduce symptoms (Goodlin, 2009).
This module is intended to assist with de-prescribing medications, and guide the safe reduction of
medications at the end of life.
Communication early in the trajectory of HF will facilitate decision making between the clinician,
patients and family members, with the aim of hoping for the best but preparing for the worst
(Gadoud, Jenkins & Hogg, 2013).
Guiding Principles for Appropriate Prescribing Medications
x
x
x
x
x
x
x
x
Review meds regularly considering survival and symptom management
and the goals of the patient.
Discuss all medication changes with patient and family
Focus on symptom management
Eliminate unnecessary medications, especially those that may be causing
more adverse effects than benefits.
Avoid medications that cause hypotension or syncope
Maintenance of some HF meds will provide positive benefit, ease
symptoms, potentially avoid re-admissions to hospital as well as improve
quality of life:
o Beta Blockers protect against tachycardia and anxiety
o Diuretics ease pulmonary congestion and shortness of breath.
o ACE-I or ARBs provide positive left ventricular support
Dose reductions may be preferred over discontinuation
When the patient can no longer take oral meds, DO NOT change to IV or
SC route (except possibly diuretics if required)
Gadoud et al, 2013.
January 2015
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Heart Failure End of Life Appropriate
Prescribing Guideline| Page 2
Appendix 1: Gadoud et al. 2013
Table 1. Conventional medical HF management in advanced HF and last days of life.
Drug
HF survival
improved?
Common side effects
Advanced HF
Last days of life
Yes
HF
symptoms
improved?
Yes
ACE Inhibitor
Cough, ↓BP, ↑K+, renal
impairment
Discontinue
Amiodarone
No
Yes
Nausea, liver and
thyroid dysfunction,
QT prolongation
Angiotensin
receptor blocker
Yes
Yes
↓BP, ↑K+, renal
impairment
Aspirin
No
GI irritation and
hemorrhage
Beta blocker
No (unless
recent
infarct)
Yes
Yes
Digoxin
No
Yes
↓HR, ↓BP, cold
peripheries,
nightmares, fatigue
↓HR, nausea and GI
disturbance, agitation,
drowsiness
Continue if tolerated
(except during
hypovolaemic illness *)
Continue if required
for arrhythmia control
unless significant
adverse effects
Continue if tolerated
(except during
hypovolaemic illness)
Discontinue unless
significant vascular
disease/recent infarct
Continue if tolerated
Continue if tolerated
but vigilance required
to avoid toxicity
Diuretic
Possibly
Yes
↓K+, dehydration, gout
Continue with dose
titration as required
Ivabradine
Yes
Yes
Continue if tolerated
Hydralazine
Yes (with
nitrate)
Yes
No
↓HR, visual
disturbance, headache
GI disturbance,
headache, flushing
↑K+, renal impairment,
GI disturbance,
gynaecomastia
(spironolactone only)
Discontinue
but may still
provide
symptom relief
so could
continue
Discontinue
but may still
provide
symptom relief
so could
continue
Discontinue
Continue if tolerated
Discontinue
Continue if tolerated
(except during
hypovolemic illness)
Discontinue
Headache, GI and sleep
disturbance
Liver dysfunction,
myalgia, myositis
Continue if tolerated
Discontinue
Discontinue
Discontinue
Mineralcorticoid
receptor
antagonist
(eplerenone/
spironolactone)
Nitrate
Statin
Yes
Yes (with
Yes
hydralazine)
No
No
Discontinue
Discontinue
Discontinue
Discontinue
* Dosing may need to be adjusted in impaired renal function
+
ACE: angiotensin converting enzyme; BP: blood pressure; GI: gastrointestinal; HF: heart failure; HR: heart rate; K : potassium.
References:
Cruz-Jentoft, A., Bolana, B., Rexach, L. (2012). Drug therapy optimization at the end of life. Drugs Aging 2012: 29(6); 511-521.
Gadoud, A., Jenkins, S., Hogg, K.J. (2013). Palliative care for people with heart failure: Summary of current evidence and future
direction. Palliative Medicine. Published by SAGE @ http://sagepublications.com/content/early/2013/07/05/0269216313494960/
Goodlin, S.J. (2009). Palliative care in congestive heart failure. J Am Coll Cardiol. 2009;54; 386-369.
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Dyspnea
Heart Failure Symptom Management Guideline
For adults, age 19 and older in British Columbia
Dyspnea is the most common, recurrent symptom associated with heart failure (HF) and may affect up to 90% of patients. In end stage HF,
dyspnea is usually related to volume overload. Patients may, however, experience severe dyspnea without hypoxia, hypercapnea or volume
overload. The experience of dyspnea can range from mild to severe and include a feeling of impending doom. A combination of pharmacologic
management and self-management strategies are best employed to reduce and control symptoms of dyspnea. As heart failure advances, therapy
should be tailored to the patients' subjective experience rather than to physiologic parameters.
Approach to Managing Dyspnea
Initial pharmacologic approach
Assessment
x Ask the patient to describe their symptoms and severity (0–10 scale).
x Ask: “Are you short of breath”?
x Use the Edmonton Symptom Assessment System (ESAS) in the setting of
multiple symptoms, and as a useful way to trend burden of the symptom.
x Assess for alternative underlying causes; consider co-morbid conditions
such as anemia, and chronic obstructive pulmonary disease (COPD).
x When cause of dyspnea is thought to be due to either HF or for
example COPD, measurement of BNP may assist in clarifying the
underlying cause. (BNP > 500 pg/ml or NTPro BNP >900 pg/ml- more
likely to be related to HF).
x Obtain a full medical history and complete a full physical exam
concentrating on symptoms and possible causes (this will lead to
accurate diagnosis in two-thirds of cases).
x Treat volume overload http://www.bcheartfailure.ca/wp-
content/uploads/downloads/2012/06/HF-Algorithm-v6-1a21.pdf
x Combination of loop and thiazide diuretic may improve
response.
x Standard heart failure therapies (ACE/ARB, vasodilators, eg.
Nitrates).
x Oxygen for hypoxemia only (access the home O2 application
through your health authority websites).
Persistent Symptoms (despite optimal medication)
x Initiate and titrate opioid therapy as they are effective in both
pain and dyspnea.
Dyspnea tips
x Treat the subjective symptom of dyspnea with medications.
x A combination of pharmacologic and non-pharmacologic
self-management strategies is most effective.
x In advanced disease, it is important to treat constant dyspnea and plan
for episodes of breakthrough dyspnea and severe persistent dyspnea.
x Opioids are safe in cardiopulmonary disease. Start low, go slow.
x Opioids with few/no active metabolites are preferred in renal
failure/frailty-avoid Tylenol #3 and morphine.
x Always order a laxative with opioids as constipation is a
common reason for non-adherence with opioids.
x Breakthrough pre activity dose can be useful for incident
management of dyspnea (usually 10% of total daily dose q1h).
x Consider consultation with palliative care physician if symptoms
persistent.
Non-pharmacologic Approach
x Pace activity to reduce severity of dyspnea episodes.
x Prepare for exertional activities, (take your medication as prescribed
before your activity, this includes opioids).
x Pursed-lip breathing can be an effective strategy for relief of dyspnea.
x Movement of air-flow can improve symptom (use fans, open windows).
x Plan ahead about what to do to reduce anxiety which can worsen
symptom.
x Ensure family or friends are aware of the strategies to support the
patient during incident and crisis dyspnea.
x Noninvasive positive pressure ventilation.
x Relaxation can be an effective strategy for relief of dyspnea.
Fentanyl patch should not be used as an initial opioid, but may be a good choice for long term therapy
Addition of Benzodiazepines for management of anxiety or dyspnea may be required in addition to opioid therapy
http://www.bcguidelines.ca/pdf/palliative2_dyspena.pdf
Medication (Generic/Trade)
hydromorphone (dilaudid)
Available doses forms
IR tabs 1,2,4,8 mg
morphine
(MOS,MS-IR, Statex)
MOS, MS
Oxycodone
(Oxy IR, Supeudol)
IR tabs: 5,10,25,30,40,50,60 mg
Initial Dose and titration
0.5mg-1mg PO q1h, PRN. Once regular dose is achieved then
should adjust to BID or q4hr dosing schedule.
2.5-5 mg PO q1h PRN
Injection: 1,2,5,10,15,25,50mg per/ml
IR tabs: 5,10,20 mg
Crisis dyspnea: 5 mg SC q15 minutes.
2.5-5 mg PO, titrate to q4h
January 2015
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Edema/Ascites
Heart Failure Symptom Management Guideline
For adults, age 19 and older in British Columbia
Edema is common in Heart Failure (HF) and can cause significant discomfort and even cellulitis. In end stage
HF, edema may be even more pronounced with ascites. Management of edema and ascites involves
non-pharmacological, pharmacological, and procedural interventions along with self-management strategies,
and should be tailored to the patient’s goals of care.
Approach to Managing Edema/Ascites
Assessment
x A comprehensive assessment must include a physical,
psychosocial, and patient environment assessment, medications,
review of labs and diagnostics. Assessment needs to determine
the cause, effect and impact on quality of life for the patient.
x Use of the Palliative Performance Scale (PPS) and Edmonton
Symptom Assessment System (ESAS) to assess and monitor
symptomatic burden.
x Edema and ascites should be assessed according to history and
physical examination.
x Symptoms of ascites include: abdominal pain or pressure, early
satiety, nausea and vomiting, dyspnea, orthopnea.
x Physical exam findings include elevated jugular venous pressure,
increased abdominal girth, shifting dullness, or fluid wave.
x Depending on the goals of care, diagnostic tests could include
blood work such as, electrolytes, albumin, blood counts,
coagulation test and/or along with abdominal imaging.
Edema/Ascites Tips
Identify and treat the underlying cause as appropriate.
Consider:
x Exacerbating conditions such as: poor nutrition, liver or renal
disease.
x Medications which provoke fluid retention such as: NSAIDS,
steroids, vasodilators and calcium channel blockers.
Non-pharmacological Approach
x Counsel patient on importance of salt and fluid
restriction.
x Elevation of legs to assist with fluid return.
x Light support hose may also be used if they have
sufficient cardiac output
*Use of compression stockings may worsen HF in
some cases -use with caution.
x In conditions of malnourishment, review protein intake.
x Focused prevention of skin breakdown and early wound
care consultation if available.
Interventions:
x Assess patient’s prognosis and goals prior to considering
interventions such as paracentesis.
x If paracentesis not indicated, manage pain or dyspnea
from ascites with medication.
Possible interventions:
x For ascites: ultrasound/paracentesis
o Given the invasiveness of the procedure and burden of
recurrent visits, a full discussion of risks and benefits
should accompany this procedure.
o Paracentesis can provide temporary symptomatic
relief; the following needs to be considered,
x Usually requires repeat drainage.
x The cost of a long- term tunnelled catheter is not
paid for by MSP at this time.
January 2015
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Edema/Ascites Management Guidelines | Page 2
Pharmacological Approach
http://circ.ahajournals.org/content/120/25/2597.full#T4
Name
furosemide
Dose forms
IV, PO, SC (maximum of
20mg sub q in one site)
Dose
20 mg daily or bid to a maximum of 600 mg
Comments
Not necessary to reduce the dose
with change in route.
For treatment of exacerbation:
Step 1 – Initiate or double the current dose for
three consecutive days or until an accumulated
weight loss of 2.5-5 kg. (Doses > 80 mg should be
split into twice daily dosing)
Step 2 – After 3 days, if not at target weight,
increase dose by 50-100%.
Step 3 – After a further 3 days, and if not at target
weight can add Metolazone ( see below for dosing)
metolazone
PO
2.5 to 10 mg daily used in combination with loop
diuretic (given 30 minutes prior to loop diuretic).
Can be given in divided doses twice daily
spironolactone
(mineralocorticoid
receptor antagonists)
Oral
Edema: 12.5 mg to 25 mg per day
Ascites: 25 mg per day to 100 mg per day; typical
dose for ascites is 100 mg per day spironolactone
with 40mg per day furosemide.
Start with daily dosing of
metolazone for 3 days or 3 times
per week dosing (Mon, Wed, Fri)
and monitor response closely
including renal function and
electrolytes.
In cases of ascites, it is important
to give higher doses of
mineralocorticoid receptor
antagonists to enable diuretic
action.
Monitor electrolyte and renal
function.
For refractory or persistent symptoms, recommend consultation with a palliative care physician or the Palliative Care Consultation Line
Telephone: 1-877-711-5755
January 2015
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Fatigue
Heart Failure Symptom Management Guideline
For adults, age 19 and older in British Columbia
Fatigue is defined as a sustained sense of exhaustion with a decreased capacity for physical and/or mental work. Fatigue is also
subjective and is the most disabling symptom in chronic heart failure. Studies show it is a multidimentional symptom with both
clinical and psychological characteristics effecting patients’ quaility of life.
A combination of pharmacological and self-management strategies a r e best employed to reduce and control symptoms of
fatigue.
Approach to Managing Fatigue
Assessment
x
x
Document history, physical examination,
medications, sleep history, psychosocial
assessment, environment assessment, review of
laboratory and imaging studies.
Assessment needs to focus on determining the
cause, effect and impact on quality of life for the
patient.
Non-pharmacological Approach
x
x
x
x
x
x
x
Fatigue tips
x
x
x
Identify and treat the underlying cause as
appropriate; consider co-morbid conditions such
as anemia, chronic obstructive pulmonary disease,
depression, dehydration, endocrine imbalances,
hypercapnea, hypoxia, medications (eg. beta
blockers, opioids, antidepressants), bradycardia,
poor nutrition, poor sleep, sepsis, pain, diarrhea,
nausea or vomiting, hypokalemia, hypernatremia,
and hypomagnesaemia.
Collect Edmonton Symptom Assessment System
(ESAS ) score to assist with monitoring and
documenting symptomatic burden.
A combination of pharmacologic and nonpharmacologic self-management strategies is most
effective.
Assess and give fluids as appropriate.
Nurition counselling.
Sleep, aromatheraphy.
Massage, music.
Exposure to natural enviornment.
Pace activities to reduce severity of fatigue and help
patient to adapt life to day to day condition.
Prepare for exertional activities, including premedication as indicated (eg. Nitro, opioids).
Initial pharmacological Approach
Treat underlying causes: (content retrieved from FH’s
symptom guideline for fatigue available at)
www.fraserhealth.ca/media/11FHSymptomGuidelinesFatigu
e.pdf)
x Depression – refer to provincial Depression symptom
guideline
http://www.bcguidelines.ca/guideline_mdd.html
x Rule out endocrine imbalances – (Diabetes management
and thyroid hormone replacement).
Hypokalemia
– change loop diuretic to potassium
x
sparing; may need potassium supplement.
x Insomnia – consider sedative or hypnotic medication
(may have high risk of delirium).
x Sepsis – give antibiotics and antipyretics where
appropriate.
January 2015
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Fatigue Management Guidelines | Page 2
Persistent Symptoms
Psychostimulants
Not first line therapy
This medication class should be used in consultation with a palliative care physician and a physician experienced
in heart failure care.
Patients who are elderly, cachexic, debilitated, have renal or hepatic dysfunction may require reduced doses
http://www.bcguidelines.ca/submenu_palliative.html
http://www.bcguidelines.ca/pdf/palliative2_fatigue_appendix_b.pdf
Persistent Symptoms
Name
Methylphenidate
(Risk of arrhythmia and
agitation…..should only
be used in specific
cases)
Trade Name
Ritalin
Dose forms
IR tabs
5, 10, 20 mg
Biphentin
SR capsules 10, 15, 20,
30 mg
XR tabs 18, 27, 36, 54
mg
SR tabs 20 mg
IR tabs
5 mg
Concerta
Dextroamphetamine
Ritalin SR
Dexedrine
SR capsules 10,15 mg
Modafinil
Alertec
Tabs 100 mg
Starting dose
Not recommended for patients over
65 years of age
Age 18-65:
5mg PO BID (AM & noon)
Frail patients: 2.5 mg PO BID
Once does is stabilized in IR give
equivalent daily does as SR or XR once
daily in AM
Not recommended for patients over
65 years of age
Age 18-65
2.5mg PO BID (AM then 4 to 6 hours)
Once dose stabilized on IR, give
equivalent daily does as SR once daily
in AM
Age over 65 years
100 mg PO QAM
Age 18-65 years
100 mg PO BID (AM and noon)
Reference BCMA palliative care guideline
January 2015
Maximum dose
15 mg PO BID (AM and Noon)
20mg PO BID
(AM then 4 to 6 hours)
Age over 65 years
100mg PO BID (AM and
noon)
Age 18-65 years
200 mg PO BID (AM and
noon)
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Nausea and Vomiting
Heart Failure Symptom Management Guideline
For adults, age 19 and older in British Columbia
Nausea and vomiting occurs in 17% to 32% of patients with heart failure. In this patient population, nausea and vomiting is multi
factorial, can occur due to nervous system activation, hypoperfusion, congestion of tissues/organs, or coexistent diseases. Opioids
and drugs with anticholinergic properties (e.g., class 1A antiarrhythmic agents, tricyclic antidepressants) can compound the
problem of slowed gastric emptying innate to advanced heart failure. In patients receiving palliative care, nausea and vomiting
rarely occurs in isolation; it tends to cluster with other symptoms, such as, pain, dyspnea, fatigue and decreased appetite.
Approach to Managing Nausea and Vomiting
Assessment
Pharmacological Approach
x Focused physical examination: vital signs, oropharynx/mucous
membranes; abdomen, rectum (to assess for
constipation/impaction/bowel obstruction); volume status (JVP,
decreased urine output, thirst, dry mouth, dizziness, muscle
cramps) and nutritional status (weight).
x Consider intravenous hydration or hypodermoclysis to
replace lost fluids and electrolytes.
x Medications that may be contributing to symptoms
should be discontinued.
Principles of Antiemetic Therapy
Dietary Approach
x Avoid intolerant food and/or restrict intake as appropriate.
x Start with sips, ice chips or popsicles once nausea improves;
gradually increase from fluids to semi-solid to full food.
x Avoid spicy, fatty, excessively salty or sweet foods, or ones with
strong odors.
x Sit up during and after eating.
x Consult with a clinical dietician and provide dietary/nutritional
advice (www.healthlinkbc.ca/dietician/).
Non-pharmacological Approach
x Treat underlying causes based on mechanism involved, or any
reversible causes where possible and desirable according to the
goals of care.
x Maintain good oral hygiene (brushing teeth and rinsing mouth),
especially after vomiting.
x Environmental modification: eliminate strong smells and sights;
open windows to get fresh air, use a fan, air deodorizers or
fresheners.
x Cognitive therapies: relaxation, visualization/imagery, hypnosis,
distraction.
x Consider alternative therapies: acupuncture, acupressure or
massage.
x Consultation: social worker, physiotherapist, occupational
therapist, spiritual practitioner, counselors for psychosocial care,
or anxiety reduction.
x Select antiemetics based on the central emetogenic
pathways and their corresponding neurotransmitters
involved.
x Give antiemetics prophylactically to prevent nausea
(especially with opioid).
x Give antiemetics subcutaneously (if vomiting) on a
regular dosing schedule with a breakthrough dose
available for persistent symptoms.
x Titrate up antiemetics to their full dose before adding
another drug.
x If symptoms not controlled for 24–48 hours, add
another antiemetic from another group, (do not stop
initial drug)
x Consider combinations but monitor overlapping
toxicities.
January 2015
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Nausea and Vomiting Management Guidelines | Page 2
Persistent Symptoms
May be due to worsening heart failure – consider consultation with the heart failure team and/or palliative care consultation team if
symptoms persist.
Causes – Mechanisms & Pathways
Medication (Generic)
Route
Initial Dose and Titration
Gastrointestinal:
Delayed gastric emptying, liver distension, gut wall
edema, constipation
domperidone*
metoclopramide*
haloperidol
PO
PO, SC, IV
PO, SC, IV
10 – 20 mg TID, or QID
5- 10 mg Q6h
0.5 – 2.5 mg q6h – q24h
dexamethasone
PO, SC, IV
4 – 6 mg daily in AM (avoid BID
or TID dosing which can lead to
insomnia)
Chemoreceptor Trigger Zone:
Drugs (opioids, digoxin, steroids, antiarrhythmic agents,
spironolactone, SSRI antidepressants)
Biochemical (hypercalcemia, uremia, organ failure)
Toxins: infection, drug metabolites, ischemic bowel
haloperidol
prochlorperazine
methotrimeprazine
PO, SC, IV
PO, PR,
PO, SC
0.5 – 2. 5 mg q6h – q24h
2.5 – 10 mg q4h – q6h
5 – 25 mg q8h – q24h
ondansetron
PO,SC,IV
4 to 8 mg Q6H to Q8H
Vestibular:
Motion sickness, opioids
dimenhydrinate
scopolamine
PO, SC, IV
Transdermal
25 – 50 mg q4h
1.5 mg patch q72h
Precautions:
x Use PO route if patient is not vomiting and able to tolerate. Use subcutaneous route if patient is vomiting.
x Steroids can contribute significantly to fluid retention which can worsen heart failure. (This side-effect is more common with prednisone;
dexamethasone in low doses may be effective for severe nausea).
x Methotrimeprazine is an anti-psychotic which has anti-emetic properties and is used in palliative care. Must be used in carefully titrated doses
as it can cause hypotension in those with heart failure and ambulatory patients.
x Metoclopramide – Assess effectiveness within 2 days. Monitor for adverse movement effects.
*Reduce dose in renal impairment.
January 2015
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Pain
Heart Failure Symptom Management Guideline
For adults, age 19 and older in British Columbia
Patients with end-stage heart failure may experience pain from cardiac or non-cardiac causes. Common causes of cardiac pain include angina
and edema (peripheral), while non-cardiac pain commonly results from comorbidities and medical interventions. Research concludes, pain is
reported to be often severe and occurring at multiple sites, and is significantly associated with degenerative joint disease, arthritis, neuropathy,
depression, shortness of breath, and angina.
Regardless of the cause, uncontrolled pain can lead to worsening heart failure symptoms, reduced quality of life, and poor outcomes.
A holistic approach to treating 'total pain’ should be considered by addressing concerns beyond physical pain, and including the psychosocial,
spiritual and emotional needs of the patient.
Approach to Managing Pain
Non-pharmacologic Approach
Assessment
• Assess pain by taking careful history and physical examination and using
standardized tools such as Edmonton Symptom Assessment System
(ESAS), OPQRSTUV acronym.
• Assessments should include identifying the type, cause and
characteristic of the pain symptoms, and determining its correlations to
the heart failure, comorbid conditions, medical interventions, other
symptoms and/or pain medication.
• Physical exam includes looking for signs of disease progression, trauma
or neuropathic etiologies.
Pain Tips
• Treat the underlying cause of pain using both non-pharmacological and
pharmacological approaches and taking into account the context of the
patient’s overall condition, prognosis and goals of care.
• Physical therapy, massage, acupuncture, heat/cold, ultrasound.
• Repositioning, relaxation, distraction and alternative approaches
including pet therapy, music therapy and aromatherapy.
• Psychosocial interventions, spiritual counseling, patient
education.
Pharmacological Approach
• The severity of pain determines the required strength of
analgesics as specified by the World Health Organization (WHO)
Analgesic Ladder.
• Select adjuvant analgesics based on the type and cause of pain
(e.g., nociceptive, neuropathic, bone pain), concomitant disease,
drug therapy and side effects and interactions experienced.
Adjuvant analgesic should be trialed starting with initial low
doses, optimize as tolerated and discontinue if ineffective.
• Tailor drug dosage and route of administration as appropriate.
Types of Pain
Mild
Moderate to severe
Treatment Options
Start with non-opioids like acetaminophen
Start with short-acting opioids, given regularly and with breakthroughs, and titrate to patient’s comfort.
Treat intermittent pain with intermittent medications, and persistent or chronic pain with around-the-clock or long
acting opioids. Use short-acting opioids for breakthrough pain.
Angina and/or Persistent Standard therapy: beta blockers, calcium channel blockers, nitrates, morphine, intracoronary stenting should be
considered in the appropriate patient
angina
Uncontrolled pain
Even with opioids
Consult palliative care
General principles of opioid prescribing (BC Heart Failure Network: iPALL)
•
•
•
•
•
•
•
•
Opioids are usually agents of choice for pain (including dyspnea) refractory to cardiac medications.
Opioids are safe and evidence based in cardiopulmonary disease. Use lowest possible dose to achieve comfort, however, there is no ceiling dose.
Opioids with few/no active metabolites preferred in renal failure/frailty – avoid Tylenol #3 (due to codeine) or morphine.
Treat persistent or chronic pain with around-the-clock or long acting opioids.
Consider increasing regular opioid dose when 3 or more breakthroughs are used in 24 hours.
Use short-acting opioids for breakthrough pain.
Breakthrough doses must always be available (10% of total daily dose and dosed at q1h).
Consider switching from short -acting opioids to long acting when the symptom is well controlled with minimal breakthrough usage and when
total daily dose of short- acting reaches a starting dose for long- acting opioid.
• Always order a regular laxative with regular opioids (stimulant and + or – osmotic laxative).
• If side effects are intolerable consider rotating to a different opioid.
December 2014
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Pain Management Guidelines | Page 2
Patients who are elderly, cachetic, debilitated or with renal or hepactic dysfunction may require low dosage
G e n er i c / T r a d e N a m e
acetaminophen, Tylenol®
NSAIDs
Tylenol #3,
traMADol, OxyCODONE
morphine
M.O.S.®, MS-IR®, Statex®, G
M-Eslon®, M.O.S. SR®,
MS CONTIN®, G
Injectable: 10 mg per ml (remember,
injection route usually has twice the
potency as the PO doses)
oxyCODONE (1.5 as potent as
morphine)
oxy.IR®, Supeudol®, G
HYDROmorphone
Dilaudid®, G,
HYDROmorph CONTIN®,
Injectable: 2,10, 20, 50, 100 mcg per
ml (Reminder- Injectable is TWICE AS
POTENT AS PO)
fentaNYL Patch
Duragesic, Mat®, G
Inj: 50 mcg per ml
SUFentanil®, G
Inj. 50 mcg per ml
methadone,
(to prescribe a methadone license is
required)
gabapentin, Neurontin®
pregabalin, Lyrica®
December 2014
S t a n d a r d Ad u l t D o s e
Comments
NON-OPIOIDS and OPIOID COMBINATIONS
325 to 650 mg PO q4-6h
• Max: 4 g PO/PR per day for short term use; 3.2 g per day for long term
use.
650 mg PR q4-6h
• Max: 2.6 g PO/PR per day for elderly clients/liver impairment.
• Usually contraindicated in heart failure because they antagonize the
effects of diuretics and ACE inhibitors, promoting fluid retention
resulting in edema and volume overload (Adler, et al., 2009).
• Combination agents are generally not recommended; the adjuvant
agents may prevent dose escalation (Adler, et al., 2009).
• Use caution with caffeine as it may cause tachycardia. Consider using
EMTEC 30.
• Tramadol should be avoided, there are drug interactions with
neuropathic agents as it lowers the seizure threshold.
OPIOIDS
Start with 2.5 mg-5mg PO
• There is no limits to OPIOIDS
then reassess q 4h
• Meperidine (Demerol®) should not be used for the treatment of
chronic pain.
• Morphine is the least preferred in renal failure because of renal
cleared active metabolites.
Start with 10mg PO q12h
• Use caution in starting long acting- short acting agents should be
trialed before rotating to long-acting.
• The total daily dose of short acting preparation must be at least 20 mg
2 to 25 mg SC q4h
per day, before you switch to the long acting preparation.
• The lowest dose of a long acting preparation is 10 mg and is given
twice daily q12h.
• Injectable oxyCODONE is not available in Canada.
5 to 20 mg PO q4h
2 to 8 mg PO q3h
3 to 30 mg PO q12h
2 to 10 mg SC q4h
12 to 100 mcg per hr
applied to skin every
72hours
25 to 100 mcg sublingual
per dose PRN
For incident pain: 12.5 mcg
sublingual dose PRN;
incremental doses titrated
q2h PRN up to 75 mcg
• HYDROmorphone is the opioid of choice (comment: not necessarily
better than oxyCODONE or methadone) in renal impairment.
• Immediate release formulations should be used before slow release
preparations to facilitate dose adjustment and reduce the potential
risk of toxicity.
• FentaNYL is primarily (75%) cleared as inactive metabolites by the
kidney. Risk of delayed absorption and overdose potential.
• Should not be started on opioid naive patients who are taking less
than 50 mg PO morphine equivalent daily.
• SUFentanil is a potent opioid- (refer to your local health authority
protocol).
• SL SUFentanil may be considered for patients receiving at least
Morphine PO 60 mg equivalent over the last 7 days. Palliative Care
Consult is recommended.
NEUROPATHIC PAIN
Dosing:
The dose ratio of morphine: methadone is highly variable- eg. from 1:1
Consult palliative care
with lower doses to as high as 12: 1 in high doses- caution in switching
from one medication to the other is recommended.
100 to 1200 mg PO TID
75 mg PO BID
Once a stable dose is reached, the dosing interval may be extended to
every 8 to 12 hours, or longer
Use lower doses for patients with renal impairment.
Increase q 7 days up to 300 mg BID- use lower doses for patients with
renal impairment.
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Health Authority Logo
Patient Consent for
Implantable Cardioverter Defibrillator (ICD) Deactivation
(must be reviewed with/ and signed by patient/ parent/legal guardian/temporary substitute decision maker* prior to deactivation)
Section 1: Physician Discussion
I have discussed the following with the patient/family/parent/legal guardian or temporary substitute decision
maker who, in my opinion understands the information provided
x Turning off the ICD will not cause death
x In the event of a dangerous rapid heart rate turning off the ICD will no longer provide a potentially lifesaving
therapy such as electric shock and anti-tachycardia pacing
x Turning off the device will not be painful, nor will its failure to function cause pain
x Turing off the ICD lifesaving therapy function does not turn off the pacemaker function
x Patient can change their mind and have the ICD lifesaving therapy turned back on
x Shocks at end of life can cause a painful death
x There is a plan of care to ensure healthcare professionals contact information is available to the patient if they
have new questions or concerns
Section 2: Patient or Substitute Decision Maker Consent
I ________________________________________________ (Circle: Patient / parent/legal guardian/temporary
substitute decision maker name) having been given the full details of the consequences by Dr_____________________
agree to the turning off the lifesaving therapy of (pts name)____________________________ Implantable
Cardioverter Defibrillator (ICD). I understand I can change my mind and request the ICD’s lifesaving thearpy to be
turned back on.
Signed (by patient/ parent/legal guardian/ temporary substitute decision maker*)__________________________
Date __________
*if signed by a temporary substitute decision maker, complete the confirmation of Substitute Decision Maker form.
Signature of physician: ____________________________ Date: ______________Time:__________
Section 3: Telephone Consent
I have discussed the points in section 1 and expected effects of ICD deactivation with (print name)
____________________________, who is the patient’s (state relationship) _______________________ and who has
given verbal consent as substitute decision maker
Physicians name: ______________________Signature _______________ Date (dd/mm/yyyy) ____________
Section 4: Interpreter Declaration
I have accurately translated this document and acted as interpreter for the (circle: patient/ parent/legal gauardian/
temporary substitute decision maker) who told me that he/she understands the explanation and consents as described
above
Interpreter name (print) ______________________ Signature________________ Date ___________
Note: Where possible, at the earlist opportunity, the person who granted consent over the phone should sign Section 2 of this form
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Implantable Cardioverter Defibrillator (ICD)
Information Sheet for
Health Care Professionals
An implantable cardioverter defibrillator (ICD) is a device implanted in a patient’s upper chest which monitors the heart rhythm,
can act as a standard pacemaker, can provide anti-tachycardia pacing and if required, can deliver one or more high energy shocks
to terminate potentially lethal arrhythmias such as ventricular tachycardia (VT) or ventricular fibrillation (VF).
Receiving a shock can be painful and psychologically traumatic and is often described by patients as feeling like a kick in the chest.
Graphic copyright of Hamilton Health Sciences and used with permission.
Limitations of an ICD
Although ICDs reduce sudden cardiac death, patients will ultimately die from either heart failure or another disease. As a patient’s
disease progresses, physiologic changes may cause more arrhythmias and increase the frequency of shocks. Because ICD shocks can
cause pain and anxiety and may not prolong a life of acceptable quality, it is important to consider deactivating the ICD when a
patient’s clinical status worsens and death is near.
Deactivating an ICD with a programmer
MUST have a physician’s order and a qualified health care provider to apply the magnet
Deactivating an ICD refers to turning off the defibrillator function of the device, not the pacemaker function. Deactivating an ICD is
not a difficult procedure; however it does require the use of a programmer - a laptop computer specifically made by the device
manufacturer. Typically an ICD is deactivated by a health care provider who is familiar with the programmer and is competent in
adjusting the settings of an ICD.
It is possible to turn off the pacemaker function of the ICD; however this is generally not something that is done. While
deactivating the defibrillator function prevents painful shocks, deactivating the pacemaker does not prevent pain and may actually
worsen the patient’s heart failure symptoms by reducing the amount of blood pumped out of the heart.
Deactivating an ICD with a magnet
MUST have a physician’s order and a qualified health care provider to apply the magnet
The preferred method of deactivating an ICD is to use a programmer; however one may not always be available, particularly in
urgent situations. If a programmer is not available, it is possible to prevent the delivery of a shock with the use of a magnet. Placing a
large magnet (the size of a doughnut) over the device will temporarily suspend the arrhythmia detection function of the ICD and
prevent the delivery of a shock. The site of magnet placement is important, as a poorly placed magnet may not inhibit shock
therapy. Magnets are best placed directly on top of the ICD. When the magnet is removed, the ICD will return to its previous
settings.
Things to keep in mind
x Deactivating the ICD will not cause the patient’s death; it is simply allowing nature to take its course.
x Deactivating the ICD will not cause the patient’s death to be more painful.
x Deactivating the ICD will mean that the device will not prevent sudden death in the event of a dangerous arrhythmia.
x Patients may reach a point in their lives when their goal of care is to be comfortable during their remaining time and an active ICD
is not congruent with that goal.
x It is not morally or legally wrong to stop any medical treatment if it no longer meets the patients’ needs.
December 2014
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Referral for Deactivation of Implanted Cardioverter Defibrillator (ICD)
Client/Patient Contact Information
Name: _______________________________________________________
Address: _____________________________________________________
Phone Number: _______________________________________________
Patient’s current location:
Acute Care hospital
Non Acute hospital
Community facility
Home
If Patient Transitioning to End of Life/Palliative care, it is strongly recommended the patient be referred to
Home and Community care
Name of hospital/ facility ____________________________________________________________________
Referring physician/NP must fax Do Not Resuscitate order or Home DNR form with the deactivation request
(completed and signed)
Name/ contact information of family member/legal guardian or temporary substitute decision maker:
Name: _________________________________Address ______________________________________
h
b
Contact Information for Person Requesting Deactivation of the ICD
Name: _______________________________________________________
Position:
RN
Nurse Practitioner
GP
Internist
Cardiologist
Family member
Phone Number: _________________________ Fax number: ________________________________
Primary Care Physician contact information (if different from above): _________________________
Is the patient aware the ICD deactivation has been requested?
Yes
No
If No explain why
Name and contact information of other health care provider team members that need to be contacted
__________________________________________________________________________________________
Device Details
ICD Manufacturer _______________________________________________________
Include with the referral:
x
x
Copy of most recent consultation from palliative care (if available)
Any pertinent history
o Last Electrophysiology consultation
Comments:
Signature of person requesting:
__________________________________
Date:_____________________
Acknowledgment of referral
(Device clinic fax back date and time to referring physician/NP)
Your patient has been booked for their ICD deactivation
at: _________________________hospital
Date ____________________________________
Time ___________________________________
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Clinic
Fraser Health
Abbotsford Regional
Burnaby General
Chilliwack General
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Device Clinic Contact Information
Address
Phone #
Fax #
32900 Marshall Road Abbotsford BC V2S 0C2
604-851-4700
Ext. 644853
604-851-4852
3935 Kincaid Street Burnaby BC V5G 2X5
604-412-6379
604-412-6213
45600 Menholm Road Chilliwack BC V2P 1P7
604-702-2885 local
604-702-2882
612739
Delta
JP Outpatient Care and Surgery Center
5800 Mountain View Boulevard Delta BC V4K 3V6
9750 140 Street Surrey BC V3T 0G9
#604-582-4550 Local
604-582-3773
763959
Langley Memorial
22051 Fraser Highway Langley BC V3A 4H4
#604-534-4121 local
604-533-6474
745276
Peace Arch
15521 Russell Avenue White Rock BC V4B 2R4
604-535-4500
Ext.757544
Ridge Meadows
11666 Laity Street Maple Ridge BC V2X 7G5
604-463-1862
604-466-6990
Royal Columbian
220 Royal Ave New Westminster BC V3L 1H6
604-520-4246
604-520-4803
2268 Pandosy Street Kelowna BC V1Y 1T2
250-862-4450
1200 Hospital Bench Trail BC V1R 4M1
250-368-3311 ext-
Interior Health
Kelowna General
Kootenay Boundary Regional
250-862-4104
2350
Penticton Regional
Royal Inland
Shuswap
Vernon Jubilee
550 Carmi Avenue Penticton BC V2A 3G6
311 Columbia Street Kamloops BC V2C 2T1
601 10th St NE Salmon Arm BC V1E 4N6
2101 - 32 Street Vernon BC V1T 5L2
Northern Health
University Hospital of Northern BC
1475 Edmonton Street Prince George BC V2M 1S2
250-565-2439
250-565-2527
Vancouver Coastal Health
Lions Gate
Richmond Hospital
# 100 - 123 East 15th North Vancouver BC V7L 2P7
7000 Westminster Highway Richmond BC V6X 1A2
St. Paul's
1081 Burrard Street Vancouver BC V6Z 1Y6
Vancouver General
855 West 12th Ave Vancouver BC V5Z 1N1
604-875- 4244
375 2nd Avenue Campbell River
250-850-2608
250-850-2617
1200 Dufferin Cresent Nanaimo BC V9S 2B7
250-739-5914
250-755-7663
1955 Bay Street Victoria
250-370-8670
250-370-8658
Vancouver Island Health
Campbell River
Nanaimo General
Royal Jubilee
BC V9W 3V1
BC V8R 1J8
Final- Provincial Heart Failure End of Life
Implantable Cardioverter Defibrillator (ICD) Deactivation Decision Algorithm
Questions to ask yourself to help you determine if a patient is transitioning to an EOL trajectory which should trigger the use of this algorithm
1) Surprise Question- In the next 6 months, would I be surprised to hear this individual had died?
2) Has the patient made a choice for comfort measures or is the patient in need of supportive palliative care? (e.g. non a transplant
candidate, VAD at end of life)
3) Does the patient have at least 2 of the following clinical indicators? a) NYHA III or IV, b)Thought to be in last year of life, c) Repeated HF hospitalizations
4) Is the patient having difficult physical or psychological symptoms despite optimal therapy?
(Adapted from the Gold Standards Framework, 2008)
Yes
Yes
Does the ICD therapy meet the patient’s goals of care?
Reassess at
next visit
No
Decision is made by patient and physician to deactivate the ICD after goals of care have been discussed
(If patient known to a specialist include her/him in the discussion)
Is the ICD deactivation urgent?
No
Yes
Unplanned/Urgent
Physician order ICD Deactivation
x
x
Written or signing of pre-printed order.
Planned/Non-Urgent
1. Provide patient/family with
education pamphlet on ICD
deactivation.
2. Complete the ICD deactivation
referral form and fax to
appropriate device clinic.
3. Patient to complete ICD
deactivation consent.
4. Physician to sign the ICD
deactivation pre printed order or
write the order.
Verbal orders accepted in urgent situation if unable to write order
but must follow-up by written order or signing of preprinted orders.
If appropriate - patient to complete ICD deactivation consent form
Do you have access to both a
programmer and a qualified health care
professional to use the programmer?
Yes
No
Best practice is:
1. ICD deactivation is done by a programmer
2. Provider has the competencies to utilize a programmer
or magnet
3. The location for the ICD deactivation is chosen by the patient
4. Physician order is written or pre printed orders signed prior to the
ICD deactivation
Do you have access to a magnet?
Yes
No
Magnets could
be accessed
through
hospice
palliative care
program,
closest device
clinic or ER
Use of magnet is only temporary until a programmer can come to the
patient to deactivate the tachyarrhythmia functions
Do you have a
qualified health care
professional to apply
the magnet?
No
Have MRP arrange to have
a qualified health care
professional to come to the
patient to apply the magnet
(could be a critical care or
ER RN,cardio tech or
physician)
Ensure MRP
completes the
preprinted orders for
ICD deactivation
MRP to inform
programmer of ICD
deactivation request.
Yes
Best practice is for
device staff to come
to the patient
If unable – have MRP
arrange transport to
the clinic, critical care
or ED
Ensure the critical care
or ED staff are
qualified to use the
programmer
Ensure MRP
completes the
preprinted orders
for application of
magnet
Apply the
magnet
Deactivate the ICD using
the ICD programmer
Documentation: It is highly recommended that a written order or signing of a pre printed order occur prior to deactivation.
In an emergency situation whereby a written order cannot be provided a verbal order will be accepted but it must be accompanied by a written or signed
preprinted order.
The details of the advance care planning discussion and subsequent deactivation must be recorded by the physician in the patient’s progress notes and by other
health care providers in the nursing notes.