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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 Return to Page 1 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 Return to Page 1 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: Return to Page 1 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 Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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 Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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 Return to Page 1 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. Return to Page 1 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 To Non Pharmeceutical Print Handout Return to Page 1 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. Next Page Return to Page 1 To Non Pharmeceutical 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. Next Page Return to Page 1 To Non Pharmeceutical 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. Next Page Return to Page 1 To Non Pharmeceutical 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. To Non Pharmeceutical Print Handout Return to Page 1 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 To Non Pharmeceutical Return to Page 1 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. Page 1 of 2 The information in this document is intended solely for the person to whom it was given by the healthcare team. Next Page Return to Page 1 To Non Pharmeceutical 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. Page 2 of 2 The information in this document is intended solely for the person to whom it was given by the healthcare team. To Non Pharmeceutical Print Handout Return to Page 1 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 The information in this document is intended solely for the person to whom it was given by the healthcare team. Next Page To Non Pharmeceutical 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. Page 2 of 3 The information in this document is intended solely for the person to whom it was given by the healthcare team. Next Page Return to Page 1 To Non Pharmeceutical 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. Page 3 of 3 The information in this document is intended solely for the person to whom it was given by the healthcare team. To Non Pharmeceutical Print Handout Return to Page 1 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. The information in this document is intended solely for the person to whom it was given by the healthcare team. 1 Next Page Return to Page 1 To Non Pharmeceutical 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. 2 To Non Pharmeceutical Return to Page 1 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. Next Page Return to Page 1 To Non Pharmeceutical 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. The information in this document is intended solely for the person to whom it was given by the healthcare team. To Non Pharmeceutical Return to Page 1 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. 1 Next Page Return to Page 1 To Non Pharmeceutical 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. 2 To Non Pharmeceutical Return to Page 1 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. The information in this document is intended solely for the person to whom it was given by the healthcare team. 1 Continued To Non Pharmeceutical Return to Page 1 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. Saturday 2 To Non Pharmeceutical Print Handout Return to Page 1 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. The information in this document is intended solely for the person to whom it was given by the healthcare team. 1 Next Page Return to Page 1 To Non Pharmeceutical 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. 2 To Non Pharmeceutical Print Handout Return to Page 1 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. The information in this document is intended solely for the person to whom it was given by the healthcare team. 1 Next Page Return to Page 1 To Non Pharmeceutical 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. 2 To Non Pharmeceutical Print Handout Return to Page 1 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. 1 Next Page Return to Page 1 To Non Pharmeceutical 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. 2 Next Page Return to Page 1 To Non Pharmeceutical 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. 3 To Non Pharmeceutical Return to Page 1 Print Handout 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. 1 Next Page Return to Page 1 To Non Pharmeceutical 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. 2 Next Page Return to Page 1 To Non Pharmeceutical 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. 3 To Non Pharmeceutical Return to Page 1 Print Handout 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. 1 Next Page Return to Page 1 To Non Pharmeceutical 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. 2 To Non Pharmeceutical Print Handout Return to Page 1 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. Page 1 of 3 The information in this document is intended solely for the person to whom it was given by the healthcare team. Next Page Return to Page 1 To Non Pharmeceutical 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 The information in this document is intended solely for the person to whom it was given by the healthcare team. Next Page Return to Page 1 To Non Pharmeceutical 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 The information in this document is intended solely for the person to whom it was given by the healthcare team. To Non Pharmeceutical Print Handout Return to Page 1 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 The information in this document is intended solely for the person to whom it was given by the healthcare team. Next Page Return to Page 1 To Non Pharmeceutical 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. Page 2 of 2 The information in this document is intended solely for the person to whom it was given by the healthcare team. To Non Pharmeceutical Return to Page 1 Print Handout Fax Referral Form 1-888-857-6555 PROVIDER Service Provider Name & Title Today’s Date Organization Service Provider Telephone Fax T Please inform me by fax of my patient’s enrolment in this service Email Please give patient a copy before faxing to QuitNow By Phone at 1-888-857-6555 PATIENT INITIALS PATIENT INFORMATION PATIENT INITIALS I give permission to my service provider to fax this information to QuitNow By Phone. I understand that a QuitNow By Phone counsellor will call me within the next week. I understand that this is a free service. I agree to let QuitNow By Phone send information about my enrolment in the service to my service provider(s) listed above. PATIENT INITIALS I agree to let QuitNow By Phone leave a message at the phone number(s) listed below. Patient Name (PLEASE PRINT) Patient Signature Date of Birth Pregnant? T YES T NO Lactating/Nursing? T YES T NO Language Preference Patient Telephone Email Patient Address Postal Code 8-10 AM DAY QuitNow By Phone will call you. Please check the best time(s) for the counsellor to reach you. 10AMNOON NOON2PM 2-4 PM 4-6 PM 6-8 PM AFTER 8PM (SPECIFY TIME) ALTERNATIVE PHONE NUMBER Monday Tuesday Wednesday Thursday Friday Saturday Sunday If we are unable to reach you after 3 attempts, may we send material to your address? T YES T NO QuitNow For QuitNow By Phone use only to fax back to service provider Counsellor’s Initials Stage of readiness: Contact Date T Pre-contemplation T Contemplation Type of QuitNow By Phone service accepted (check all that apply): T Enrolment in T Referral to pharmacy or QuitNow By Phone physician for pharmcotherapy Set quit date? T YES Specify quit date: T Did not wish to enroll T Preparation T T Action Referral to local community service T Unable to contact T Relapse Prevention T Self-help material(s) T NO QUIT DATE SET To order more fax referral forms go to www.quitnow.ca To Non Pharmeceutical Print Handout Return to Page 1 Addressograph SNAP SHOT OF YOUR VISIT Date: __________________________________ Blood work to be done ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Medication changes ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Other tests ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Reminders ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Next Visit _________________________________________________ Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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) To Pharmeceutical Meds Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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. To Pharmeceutical Meds Return to Page 1 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 To Pharmeceutical Meds 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 To Pharmeceutical Meds 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 Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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 Return to Page 1 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 To Pharmeceutical 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 To Pharmeceutical Meds 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 Return to Page 1 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 Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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 Return to Page 1 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 Continued To Pharmeceutical Meds Return to Page 1 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 Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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. To Pharmeceutical Meds Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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 To Pharmeceutical Meds Return to Page 1 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 Return to Page 1 Return EoL Care 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. Next Return to Page 1 Return EoL Care 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. Return to Page 1 Return EoL Care 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 Return to Page 1 Return EoL Care 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. Next Page 2 of 2 Return to Page 1 Return EoL Care 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 Return to Page 1 Return EoL Care 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 Next Return to Page 1 Return EoL Care 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 Return to Page 1 Return EoL Care 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 Next Return to Page 1 Return EoL Care 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) Return to Page 1 Return EoL Care 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 Next Return to Page 1 Return EoL Care 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 Return to Page 1 Return EoL Care 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 Next Return to Page 1 Return EoL Care 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. Return to Page 1 Addressograph Return EoL Care 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 Return to Page 1 Return EoL Care 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 Return to Page 1 Return EoL Care 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 ___________________________________ Next Return to Page 1 Clinic Fraser Health Abbotsford Regional Burnaby General Chilliwack General Return EoL Care 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.