Download Guidelines for the Diagnosis and Management of

Guidelines for the Diagnosis and Management of Heart Failure 7/1/14
This guideline has been developed to assist clinicians and staff in providing evidence-based therapy for patients presenting with signs
and symptoms of systolic or diastolic heart failure, excluding isolated cor pulmonale, who do not require hospitalization in the intensive
care unit. This guideline is not meant to substitute for clinical judgment and may not meet the needs of each individual patient. This
guideline is intended for use for patients 18 years of age and older only.
American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guidelines
The recommendations in this CPM are derived from the ACCF/AHA Guidelines Executive Summary:
Guidelines for the Management of Heart Failure, published in 2013.
Basic principles of management of Heart Failure:
Key References:
•Recognition of the condition and precipitating factors
•Classification by type of Heart Failure, severity of symptoms and clinical stage
•Guideline Directed Medical Therapy (GDMT)
•Patient engagement and education
•Discharge planning
•Follow-up care
•Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE
Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR,
Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV,
Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ,
Wilkoff BL. 2013 ACCF/AHA guideline for the management of heart
failure: a report of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol
2013;62:e147–239.
•Guideline for the Management of Patients With Atrial Fibrillation: Executive
Summary: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and the Heart Rhythm Society.
J AM Coll Cardiol. 2014;doi:10.1016/j.jacc.2014.03.021
•Intermountain Health Care CPMs
Recognize common factors that precipitate HF requiring hospitalization and
during hospitalization and treat promptly (I,C)
• Non-adherence to medication regimen, sodium and/or fluid restriction
•Acute myocardial ischemia
•Uncorrected high blood pressure
•AF and other arrhythmias
•Recent addition of negative inotropic drugs (e.g., steroids, thiazolidinediones, NSAIDs)
•Pulmonary Embolus
•Initiation of drugs that increase salt retention (e.g., steroids, thiazolidinediones, NSAIDs)
•Excessive alcohol or illicit drug use
•Endocrine abnormalities (e.g., diabetes mellitus, hyperthyroidism, hypothyroidism)
•Concurrent infections (e.g., pneumonia, viral illnesses)
•Additional acute cardiovascular disorders (e.g., valve disease endocarditis, myopericarditis,
aortic dissection
Key to Classification of Recommendation & Level of
Evidence
Class I
Benefit>>>Risk
Should be done
Class IIa
Benefit>>Risk
Reasonable to do
Level A
Multiple populations
Multiple RCTs or
meta-analyses
Level B
Limited
populations
Single RCT or nonrandomized
studies
The inside pages of this tool provide an algorithm and associated quick reference tables, and
can be posted in your office or clinic.
The medications referenced include Flagstaff Medical Center and IHS formulary.
Final Version 11.2014
Class IIb
Benefit≥Risk
May be
considered
Level C
Very limited
populations
Only consensus,
case studies, or
standard of care
Class III
Risk≥Benefit or
No Benefit
Do not do
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Guidelines for the Diagnosis and Management of Heart Failure 7/1/14
Tip Box
Suspect Diagnosis of HF
Echo I,C/BNP I,A
Heart Failure Confirmed
If isolated Cor Pulmonale, refer to
Cor Pulmonale CPM
Consider Cardiology Consult for all
HF patients
Mandatory Cardiology Consult:
•Newly diagnosed HF
•When prescribing spironolactone
•Ischemic Evaluation
•Consideration for device therapy
•Consideration of changes to anti-arrhythmics
or requiring two diuretics
Labs , EKG, CXR review
(class I,A)
If suspected ischemic disease:
•Cardiology consult
•Consider cardiac cath if angina
present (IIa,C) or no known CAD (IIa,C)
•Non-invasive cardiac imaging if h/o
CAD and angina absent unless not
eligible for cath/stent or CABG in
which case NO imaging (IIa,C)
Indicate cause of HF , if known
(valvular, ischemic, non-ischemic)
Classify Type of HF a
•Known heart failure with acute exacerbation
•New signs or symptoms of heart failure including: dyspnea, fatigue, exercise intolerance, weight gain, pulmonary edema,
orthopnea, peripheral edema, elevated BNP, hyponatremia with volume overload
Tip Box
In ambulatory patients with dyspnea, measurement of BNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP) is useful
to support clinical decision making regarding the diagnosis of HF, especially in the setting of clinical uncertainty. (I,A)
*ECHO indicated for initial evaluation of pts presenting with HF, pts who have had significant change in clinical status, pts who
have received treatment that might affect cardiac function or for consideration of device therapy. (I,C)
Repeat ECHO in the absence of clinical status change or treatment interventions should NOT be performed (III,B)
Tip Box
Labs: fasting lipids (only if new onset HF), CBC,CMET, Troponin, Mg, U/A,
TSH (all are class I,A)
Table b
Table a
ACCF/AHA Stages of HF
(37)
Classification
Systolic heart
failure, specify
acute/chronic
I. Heart failure
with reduced
ejection
≤40
fraction
(HFrEF)
Also referred to as systolic HF. Randomized controlled trials have
mainly enrolled patients with HFrEF, and it is only in these
patients that efficacious therapies have been demonstrated to
date
A
At high risk for HF but
without structural heart
disease or symptoms of
HF
None
Diastolic Heart
Failure, specify
acute/chronic
II. Heart
failure with
preserved
ejection
fraction
(HFpEF)
Also referred to as diastolic HF. Several different criteria have
been used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
B
Structural heart disease
but without signs or
symptoms of HF
I
No limitation of physical activity.
Ordinary physical activity does not
cause symptoms of HF.
These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar
to those of patients with HFpEF.
C
Structural heart disease
with prior or current
symptoms of HF
I
No limitation of physical activity.
Ordinary physical activity does not
cause symptoms of HF.
II
Slight limitation of physical
activity. Comfortable at rest, but
ordinary physical activity results in
symptoms of HF.
III
Marked limitation of physical
activity. Comfortable at rest, but
less than ordinary activity causes
symptoms of HF.
IV
Unable to carry on any physical
activity without symptoms of HF,
or symptoms of HF at rest.
Diastolic heart
failure combined
a. HFpEF,
with systolic
heart failure,
borderline
specify
acute/chronic
No ICD-10 dx,
consider systolic
heart failure,
chronic/improved,
+/- acute
exacerbation
b. HFpEF,
improved
EF (%)
≥50
41 to
49
>40
Description
It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or
recovery in EF may be clinically distinct from those with
persistently preserved or reduced EF. Further research is needed
to better characterize these patients.
Classify HF based on stage and
NYHA symptom severity b
Obtain prior Dry Weight
(I,A)
Management
NYHA Functional
Classification (38)
ICD 10
diagnoses
Justification of classification: Correct recognition of the type of heart failure
(preserved EF vs. reduced EF rEF) allows appropriate tailoring of guidelinedirected medical therapy and, as a result, better clinical outcomes with the
potential for reduced morbidity and mortality and improved HRQOL
D
Refractory HF requiring
specialized interventions
Final Version 11.2014
TIP: Dry Weight can be obtained from patient, PCP, Cardiologist, Dialysis unit, or on Health Summary for all IHS pt’s. **Use recent lowest value**
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Guidelines for the Diagnosis and Management of Heart Failure 7/1/14
Management
STAGE A
e.g., Patients
with:
•HTN
•Atherosclerotic
disease
•DM
•Obesity
•Metabolic
Syndrome
Or
Patients
•Cardiotoxins
(meth)
•with family h/o
cardiomyopathy
THERAPY
Drugs
•ACEi or ARB in
appropriate
patients for
vascular
disease/HTN or
DM
•Statins as
indicated(I,A
for h/o MI)
•Control
conditions that
contribute to
development
of HF (DM2,
HTN, obesity,
smoking,
cardiotoxin
exposure)
(I,A-C)
STAGE C
STAGE B
At high risk for HF
but w/o structural
heart disease or
symptoms of HF
e.g., Patients with:
•Previous MI
•LV remodeling
including LVH and
Low EF
•Asymptomatic
valvular disease
THERAPY
Drugs
•ACEi for all
reduced EF, ARB if
ACEi intolerant
(I,A)
•ACEi or ARB for all
patients with MI+
reduced EF (I,A)
•evidence-based
beta blockers for
low EF+/- h/o MI
(I,A)
•Avoid verapamil
& diltiazem after
MI or low EF (III,C)
•Statin if CAD or
hyperlipidemia
Selected Patients:
CRTg
ICD h
STAGE D
Structural heart disease w/prior or current
symptoms of HF
Structural heart
disease w/o signs
or symptoms of HF
Structural
Heart Dz
Symptomatic
Heart Failure
New sxs
of HF
e.g., Patients with:
•Known structural heart disease and
•HF signs and symptoms
Refractory HF
Refractory symptoms of HF at
rest, despite GDMT
Treatment for ALL Stage C and D pts:
•Dry weight teaching (I,B)
•Continue outpatient medications unless •Exercise training or regular physical
new contraindication identified(I,B)
activity
• Low Sodium Diet (IIa,C)
•Cardiac rehab referral inpatient (IIa,B)
•Daily weights (I,C)
•Aggressive Care Coordination (IIa,B)
HFpEF
HFrEF
diastolic
systolic
THERAPY
Strategies
•Identification of comorbidities
•Control sbp and dbp(I,B)
•Coronary intervention if indicated (IIa,C)
•Guideline-directed care for Afib (IIa,C)
Treatment
•Diuresis as needed (I,C)
•Use beta blockers, ACEi or ARBs to control
BP
•ARB may decrease hospitalizations(IIb,B)
•Omega 3 fatty acids if NYHA II-III and no
ESLD, eGFR>30, no chronic lung dz, no PAD
(IIa,B)
e.g., Patients with:
•Marked HF
symptoms at rest
•Recurrent
hospitalizations
despite GDMT
•HF specific educational Components
•Appropriate treatment for OSA
•Statins if ischemic HF or other indication
THERAPY
Drugs for all patients
•DC all potentially harmful medications including all
NSAIDS, thiazolidinediones,most anti-arrhythmics (cards c/s
required prior to cessation),calcium channel blockers (III
harm, B/C) except amlodipine
•Diuretics for fluid retention (I,B) f
•ACEi or ARB if ACEi intolerant(I,A) f
•Evidence-based Beta Blockers if stable (carvedilol,
metoprolol succinate (I,A) f
Drugs used for selected patients
•Aldosterone antagonists* (Spironolactone)
both
THERAPY
Goals
Fluid restriction
1.5L/day esp if
hyponatremic (IIa,C)
•Control symptoms
•Improve HRQOL*
•Reduce hospital
readmissions
•Establish patient's
end of life goals (I,B)
Options for select pts
•Advanced care
measures
•Heart transplant
•Chronic
inotropes(IIb,B)
•Temporary or
permanent MCS(IIa,B)
•Experimental surgery
or drugs
•Palliative
care/hospice (I,B)
•ICD deactivation
•Isosorbide dinitrate+hydral(NYHA III-IV, AfricanAm
w/persistent sxs in spite of ACEi &beta blocker)(I,A)
•Isosorbide dinitrate+hydral for any pt who cannot get ACEi
*Aldosterone receptor antagonist
or ARB (IIa,B)
(spironolactone) is recommended in pt’s
•Digoxin (can reduce hospitalizations)(IIa,B)
with NYHA class II-IV HF with LVEF of
•Omega 3 fatty acid (same caveats as for HFpEF)
35% or less, unless contraindicated, to
•Add ARB to ACEI if persistent symptoms (non-African
reduce morbidity and mortality,
American) if no aldosterone antagonist is indicated. (IIb,A)
provided estimated GFR>30mL/min and
**Do NOT use ACE-I +ARB +aldo antagonist (III:Harm, B)
K+<5.0 mEq/dl (I,A)
•Add IV NTG, nitroprusside or nesiritide if dyspnea persists
Also indicated for post acute MI w/
(IIb,A)
EF≤40% w/DM or symptoms of HF (I,B)
Treatment In Selected patients
CRTg
Final Version 11.2014
3
ICD h
*HRQOL, health-related quality of life
Revascularization or valvular surgery as appropriate
Table f Drug Recommendations: **NOT on most IHS Formularies: Captopril,Valsartan, Isosorbide mononitrate, Metoprolol succinate**
Medication choices
Start Dose
Clinical Trial Dose
Max
ACE INHIBITORS (ACE-I)
lisinopril (Prinivil, Zestril):
**captopril (Capoten):
2.5-5mg PO daily
6.25mg PO TID
32mg
40mg/dose
40mg PO daily or
divided BID
50mg PO TID
Labs and other notes
Obtain BMP to check K+ and creatinine. If K+ >5.0, decrease or discontinue K+
supplementation, aldosterone antagonists, or modify target dose of
ACE-I.
**Captopril NOT on most IHS Formularies**
Use ACE-I with caution in patients with renal impairment (creatinine >3.0).
† Not FDA-approved for heart failure.
ARBs (if ACE-I intolerant)
losartan (Cozaar)†
25-50mg PO daily
129mg/day
150mg/day
At FMC, valsartan only available for high dose therapy, >320mg
**valsartan (Diovan):
20-40mg PO BID
127mg/dose
160mg PO BID
**Valsartan NOT on most IHS Formularies**
Combination isosorbide dinitrate and hydralazine is recommended for African
Americans with persistent symptoms on ACE-I and beta blocker therapy.
If ACE-I and ARB intolerant use COMBINATION isosorbide and hydralazine
isosorbide dinitrate (Isordil,
Sorbitrate):
20-30mg PO TID or
QID
30mg PO TID or
22.5mg PO QID
40mg PO TID
30mg PO QID
hydralazine HCl (Apresoline)
25-50mg PO TID or
QID
58mg PO TID or 44mg PO QID
300mg/day
isosorbide mononitrate
(Imdur):
30mg PO daily
240mg/day
BETA BLOCKERS
carvedilol (Coreg):
3.125mg PO BID
18.5mg PO BID
50mg PO BID
**metoprolol succinate
(Toprol XL)
12.5-25mg PO daily
159mg/day
200mg/day
This combination is preferred for control of BP, over non-dihydropyridine CCBs
**isosorbide mononitrate NOT on most IHS Formularies**
Before starting or titrating beta blockers, ensure patient is euvolemic (with HR >55 bpm
and systolic BP >90) and off vasodilators and inotropes. Use caution if pt has required
inotropes this hospitalization (I,b)
Educate about initial side effects (fatigue, hypervolemia)
**Metoprolol succinate NOT on most IHS Formularies**
Use caution to avoid dig toxicity with following meds: Thiazides, Spironolactone,
Metolazone, Loop Diuretics (less serious), Metoprolol (brady), Amiodarone
DIGOXIN
digoxin (Lanoxin):
0.125mg PO daily
ALDOSTERONE ANTAGONISTS (requires cardiology consult & labs 72hrs after starting therapy)
spironolactone
(Aldactone):
Combination also indicated for all patients for whom ACEI/ARB/Aldosterone antagonist
are contraindicated.
12.5-25mg daily
26mg/day
25mg daily or BID
Consider Reducing/stopping potassium supplements.
Monitor serum K+ 3 days after starting therapy, at 1 week, then monthly for the first 3
months, and with changes in renal function
eGFR ≥50, K ≤5:start 12.5-25mg/day, max 25mg/day or BID after 4 wks if K ≤5
eFGR 30-49: K ≤5: start 12.5mg daily or QOD, max 12.5-25mg daily after 4 wks if K ≤5
eGFR <30: do not use
Diuretics (IV)
Initial Dose
oral
Maximum Dose
give metolazone 30min prior to IV lasix, cardiology c/s required
Furosemide
Bumetanide
Metolazone
20-80mg IV Q8 or 2.5-10mg/hr
0.5-1mg IV daily
20-40mg daily or BID
0.5-1mg daily or BID
2.5-10mg daily w/loop
600mg/24hrs
10mg/24hrs
n/a
Hydrochlorothiazide (oral)
Chlorothiazide (IV)
25-50mg once or twice + loop
500-1000mg once + loop diuretic
use IV loop diuretics at or above usual outpatient dose (I,B) . No difference in efficacy
between divided doses vs drip. (I,B)
Daily BMET, Mg, weights, assessment of volume status.
Inadequate response to diuresis: consult cardiology for addition of 2nd diuretic vs higher
doses. (IIa,B for increasing dose or adding a second diuretic)
Q12-24hrs
Q24hrs
Final
Version 11.2014
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Guidelines for the Diagnosis and Management of Heart Failure 7/1/14
Indications for Cardiac Resynchronization Therapy
(CRT)
Indications for ICD (Implantable Cardioverter-Defibrillator)(I,A) for
PRIMARY prevention of sudden cardiac death (see separate recs for history of
VT/Vfib which are NOT covered here)
Patient with cardiomyopathy on GDMT for ≥40d post MI or with implantation of pacing or defibrillation
Table
h
All
ICD
patients should have > 1year life expectancy
device for special indications
Table g
If LVEF ≤35%, evaluate non-cardiac health
 If comorbidities and/or frailty DO NOT limit survival with good
functional capacity to <1 year: EVALUATE NYHA class and refer to
table below.
 If comorbidities/frailty limit survival to <1 yr, cont GDMT alone
NYHA Class I
NYHA Class II
Special CRT Indications
LVEF≤35%
QRS≥150ms
LBBB pattern
Sinus rhythm
NYHA Class III &
Ambulatory
Class IV
LVEF≤35%
QRS≥150ms
LBBB pattern
Sinus rhythm
LVEF≤30%
QRS≥150ms
LBBB pattern
Ischemic CM
Sinus rhythm
QRS≤150ms
Non-LBBB
pattern
LVEF≤35%
QRS 120-149ms
LBBB pattern
Sinus rhythm
LVEF≤35%
QRS 120-149ms
LBBB pattern
Sinus rhythm
Atrial fibrillation, if ventricular
pacing is required and rate control
will result in near 100% V pacing
with CRT
LVEF≤35%
QRS≥150ms
Non-LBBB
pattern
Sinus rhythm
QRS≤150ms
Non-LBBB
pattern
LVEF≤35%
QRS≥150ms
Non-LBBB
pattern
Sinus rhythm
LVEF≤35%
QRS 120-149ms
Non-LBBB
pattern
Sinus rhythm
EF
NYHA
Ischemic
(at least 90d post revascularization (PCI or
CABG))
<30%
I-III
Indicated if on GDMT at least 40d post MI
(IIa,B)
<35%
II-III
Indicated if on GDMT at least 40d post MI
(I,A)
Nonischemic
Indicated if
on GDMT at
least 90 days
(I,A)
Anticipated to require frequent
ventricular pacing (>40%)
If patient meets criteria for ICD or CRT Class I-IIb, consult Electrophysiologist
Color
Evidence Class
I
IIa
IIb
III
If patient needs Pacemaker for non-HF indication, consult Electrophysiologist for
evaluation for possible CRT
Recommendation
Should be done
Reasonable to do
May be considered
Do not do
Final Version 11.2014
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Guidelines for the Diagnosis and Management of Heart Failure 7/1/14
TIP:
Control of Afib in patients with HF
(This algorithm does NOT apply to patients in Afib without evidence of heart failure)
•Prevalence of atrial fibrillation in patients with HF by NYHA class: Class I: 4% Class IV 40%
•Afib is present in 30% of patients presenting with acute HF
~AF causes HF and HF causes AF~
Heart Failure with Atrial Fibrillation*
Anti-coagulation for AFib/Flutter
Rhythm control
Rate Control
*if the HF is new, assume it is a rate-related cardiomyopathy.
Rate related cardiomyopathies can recover with adequate
treatment
•
•
•
•
•
•
Amiodarone + anticoagulation with
plans for future cardioversion
FAILED,
rhythm or rate
control
Try opposite
method; rhythm
or rate
Select anti-thrombotic based on risk of thromboembolism regardless of Afib pattern
(paroxysmal, persistent or permanent) (I,B)
Indications for anti-coagulation of Aflutter are the same as for Afib(I,C)
For non-valvular Afib, CHA2DS2-VASc is recommended to assess stroke risk (I,B)
For Afib with mechanical heart valve, use warfarin (I,B)
For pts with non-valvular AF & prior CVA/TIA or CHA2DS2-VASc≥2, use oral anticoagulant (I,B)
Consider anticoagulation for patients with chronic HF who have Afib and NO additional
cardioembolic risk factors. (IIa,B)
Treatment suggestions
HFpEF Diastolic
•Beta blocker or verapamil or diltiazem
•+/- digoxin as adjunct
HFrEF Systolic
•Beta blocker +/- digoxin (transition to evidence-based beta blocker when
transition to oral)
compensated
FAILED
both
Decompensated
•Cardioversion
•Amiodarone can be useful to enhance the efficacy of cardioversion
•Start Heparin concurrently if AF of >48hrs duration
AV node ablation and CRT
Dronedarone should not be administered to patients with class IV heart failure or patients who have had an episode of decompensated heart failure in the past 4 weeks,
especially if they have depressed left ventricular function (left ventricular ejection fraction < 35%). (III harm, B)
Final Version 11.2014
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Guidelines for the Diagnosis and Management of Heart Failure 7/1/14
Interdisciplinary team:
•Dietician
•Cardiac Rehab Team,
•Care Coordination
•Outpatient Care Managers
•Pharmacy
• RT
• Primary care RN
Discharge Checklist
Readiness for DC:
RED
•Identify patient
•CPM enrollment
•BOOST assessment
(risk prediction)
•Begin DC Checklist
Yellow
•Transitional Care Plan
•Assistance with
practical needs
•BH integration
•Care Processes,
structured
•Support for life
instabilities
Green
•DC Checklist
complete
•Meds in Hand
•DC
HF Education and Patient Activation
•Sodium restricted diet
•Fluid restriction (if indicated)
•Monitoring of daily weights
•What to do if HF symptoms worsen/whom to call
•Physical activity level counseling (next phase of Cardiac
rehab/exercise plan)
•Treatment and adherence education
•Smoking cessation counseling if indicated
•Weight reduction counseling if indicated
•Review of Medications
HF education needs to be specific to facilitate self care with
at least 60minutes by trained HF educator
Discharge Checklist must be complete before patient is considered for hospital discharge.
Final Version 11.2014
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Final Version 11.2014
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