Download G 1.2 Adult Heart Failure Management

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DATE: May 2011
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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO
CLINICAL CARE GUIDELINE
ADULT HEART FAILURE MANAGEMENT
Updated May 2011
Key Content Experts:
Dr. George Kondos, Professor of Medicine, Cardiology*
Carolyn Dickens, Cardiology Nurse Practitioner*
Dr. Thomas Stamos, Assistant Professor of Medicine, Cardiology
Dr. Rob DiDomenico, Clinical Associate Professor of Pharmacy
*Co-Chairs, Cardiovascular Quality Improvement Committee
These systematically developed statements have been created to assist the practitioner in the formulation of
health care decisions in specific clinical circumstances. They are not to be construed as an inflexible set of
correct procedures or protocols.
In each clinical circumstance the exercise of individual judgment is essential.
Guidelines are based upon statistical averages and opinions of practicing clinicians. Variation from these
guidelines does not constitute improper care or improper professional judgment. Evaluation of these
variations requires detailed analysis of the facts and circumstances surrounding the individual patient’s
care.
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CLINICAL CARE GUIDELINE
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DATE: May 6, 2011
SUBJECT: Adult Heart Failure Management
OBJECTIVE
To improve the quality and efficiency of care for our adult heart failure patients, specifically:
1.
2.
3.
4.
Treat to improve cardiac function
Reduce mortality
Return patient to normal activity levels including exercise.
Prevent recurrent exacerbations and minimize the need for emergency room visits or
hospitalizations.
5. Maximize optimal pharmacotherapy with minimal adverse effects.
6. Meet patient and family expectations of and satisfaction with heart failure care.
These goals will be achieved by:
1.
2.
3.
4.
Accurate diagnosis and assessment of severity.
Periodic assessment and monitoring.
Pharmacologic therapy.
Education.
DEFINITIONS
Heart Failure: Inadequate blood supply to meet the metabolic demands of the body.
 Systolic heart failure (systolic dysfunction): Inability of the heart to eject/pump sufficient
blood supply to meet the metabolic demands of the body.
 Diastolic heart failure (diastolic dysfunction): Inability of the heart to fill properly, resulting in
an inadequate supply of blood to meet the metabolic demands of the body.
Heart Failure can result from:
 Narrowed arteries that supply blood to the heart muscle -- coronary artery disease.
 Past heart attack, or myocardial infarction, with scar tissue that interferes with the heart
muscle's normal performance.
 High blood pressure.
 Heart valve disease due to rheumatic heart disease or other causes.
 Primary disease of the heart muscle itself or cardiomyopathy.
 Heart defects present at birth (congenital heart defects).
 Infection of the heart valves and/or heart muscle itself (endocarditis and/or myocarditis).
Heart failure affects more than 5 million Americans, with more than 500,000 new cases
occurring annually and a resultant 1,000,000 hospitalizations, which translates into an annual
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estimated cost of nearly $23 billion dollars. Mortality with this condition is high, approximately
50% at 5 years. Implementation of the advances in management of heart failure have the
potential to improve patients' quality of life, reduce the need for hospitalizations, reduce total
medical costs, and prolong survival.
Hypotension: Systolic blood pressure less than 90 mmHg, however this can be subdivided into
symptomatic and asymptomatic hypotension.
 Symptomatic hypotension: systolic blood pressure less than 90 mmHg with evidence of
hypoperfusion (altered mental status, cyanosis, cool extremities, decreased urine output).
 Asymptomatic hypotension: systolic blood pressure less than 90 mmHg without evidence of
hypoperfusion, as above.
 Medications should not be held or discontinued for asymptomatic hypotension.
POSITION STATEMENTS
Appropriate drug therapy will be administered to all patients with heart failure (unless
contraindicated) to improve symptoms and decrease morbidity/mortality. Once on appropriate
medical therapy, every effort will be made to optimize medication doses.
Patients will be educated on this chronic disease and provided with the knowledge they need to
live with heart failure.
Attempts will be made at improving quality of life and reducing hospitalizations for these
patients.
Regular monitoring with serial measurements of ejection fraction (i.e., left ventricular systolic
dysfunction) will be done to assess response to therapy.
PROCEDURE
Ambulatory Care
I.
Assessment/Diagnosis
A. The assessment of any patient with a diagnosis of heart failure begins with a thorough
history and physical. The patient should be questioned about:
1. History of hypertension.
2. History of diabetes.
3. Hypercholesterolemia.
4. Coronary valvular or peripheral vascular disease.
5. Rheumatic fever.
6. Chest irradiation.
7. Exposure to cardiotoxic agents.
8. Illicit drug use.
9. Alcohol use.
10. Sexually transmitted disease(s).
11. Family history.
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B. The patient should have regulator monitoring with serial measurements of ejection
fraction (i.e., left ventricular systolic dysfunction) to assess response to therapy.
1. The study should quantitate/evaluate:
a. LV size.
b. Hemodynamics.
c. Diastolic function.
d. Valvular function.
e. Infiltrative disease.
2. Repeat imaging should not be done within 1 year of last study unless clinically
indicated.
C. The following laboratory test should be performed:
1. Electrolytes, BUN, Creatinine - exclude renal disease.
2. CBC - exclude anemia.
3. T4, TSH - exclude thyroid disease.
4. Liver Function Tests - evaluate for right heart failure.
5. Cholesterol panel (LDL) - evaluate risk for CAD and need for statin.
6. Urinalysis - exclude nephrotic syndrome.
7. BNP- when the diagnosis is uncertain, should not be interpreted in isolation
D. The following diagnostic tests should be performed:
1. EKG.
2. Chest X-ray.
E. The following additional tests can be performed if clinically indicated:
1. ETT/Nuclear Imaging/Stress Echocardiogram: in patients with known CAD but no
angina.
2. Coronary Angiogram: patients with angina or suspected CAD.
3. Radionuclide ventriculography (MUGA scan): highly accurate assessments of global
and regional functions.
a. The following assessments should be specified when ordering:
(a) Left ventricular ejection fraction (LVEF).
(b) Right ventricular ejection fraction (RVEF).
(c) Regurgitant index.
4. Cardiac Magnetic Resonance Imaging (CMR): may be obtained to assess left and
right ventricular function and viability when clinically indicated
5. All heart failure patients will be encouraged to obtain an influenza vaccine each fall
and to assure that the patient is up to date on their pneumococcal vaccine.
II. Care Treatment Plan
A. The general approach the pharmacologic therapy in heart failure patients is to start at a
low dose and titrate up (every two weeks, if tolerated) to goal doses (see Table 1).
1. Patients with asymptomatic left ventricular dysfunction, the following therapy is
recommended (barring any contraindications):
a. Angiotensin converting enzyme (ACE) inhibitor
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(a) See Addendum 5
b. Beta blocker
(a) See Addendum 6.
Patients with symptomatic left ventricular systolic dysfunction, the following therapy
is recommended (barring any contraindications):
a. Diuretics in patients who have evidence of fluid retention.
b. ACE inhibitors in all patients.
c. Beta blockers in all patients who are stable and have no or minimal evidence of
fluid retention.
d. Digoxin.
e. Spironolactone or eplerenone in patients with preserved renal function and
normal potassium and have moderate to severe heart failure who are on
appropriate background therapy (e.g., ACE inhibitor plus beta-blocker at or near
goals doses).
f. Angiotensin receptor blockers (ARB) in patients who cannot tolerate an ACE
inhibitor due to cough or angioedema.
g. Hydralazine and nitrates in patients who cannot tolerate ACE inhibitor or ARB
because of renal insufficiency or hyperkalemia.
h. The addition of an ARB or Hydralazine/nitrates to therapy with ACE inhibitor and
Beta-blocker who remain symptomatic or hypertensive.
i. Medications should not be held or discontinued for asymptomatic hypotension
(see Table 1).
Electrophysiology consult for possible implantable cardioverter-defibrillator
a. Patients with non-ischemic dilated cardiomyopathy or ischemic heart disease
b. at least 40 days post MI
c. LVEF less than or equal to 35%.
d. NYHA functional class II or III
e. On optimal medical therapy
f. History of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing
ventricular tachycardia
Electrophysiology consult for possible cardiac resynchronization therapy
a. Patients with LVEF less than or equal to 35%
b. Sinus Rhythm
c. NYHA functional class III or ambulatory class IV symptoms
d. Widened QRS interval ≥120ms
e. Optimal medical therapy
Avoid the following medications in patients with heart failure:
a. Class I anti-arrhythmic:
(a) Disopyramide.
(b) Procainamide.
(c) Quinidine.
(d) Flecainide.
(e) Propafenone.
b. Calcium channel blockers:
(a) Verapamil.
(b) Diltiazem.
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c. NSAIDs and Cox-2 inhibitors.
6. Dronedarone
(a) Class IV heart failure
(b) Patients who have had an episode of decompensated heart failure in the past
4 weeks
7. Treat concomitant diseases:
a. Diabetes.
b. Hypercholesterolemia.
c. Hypertension.
d. Other.
III. Patient Education
A. Education of patients with heart failure should be ongoing and incorporated into as many
patient/caregiver interactions as possible, to reinforce key points the patient needs to
understand.
B. The key education points are summarized in Table 4.
C. Suggested patient-directed educational materials can be found within the Depart Tool
and are listed in Table 5.
Emergency Department
I.
Assessment/Diagnosis
A. The initial assessment of a patient with acute decompensated heart failure (ADHF)
should include a thorough history, physical exam, laboratory assessment, chest x-ray,
and perhaps, additional assessment of left ventricular function.
1. Key elements of history salient to ADHF:
a. Past medical history.
b. Medications prior to admission.
c. Dietary compliance with sodium & water.
d. Medication adherence
e. History of weight gain.
f. History of PND, orthopnea, DOE.
2. Key elements of physical exam consistent with ADHF:
a. Vital signs with increased heart rate and either decreased or elevated BP.
b. Hypoxia.
c. Mental status changes.
d. Increased JVD.
e. + S3 or S4.
f. + Hepatojugular or Abdomino-jugular reflex:
(a) JVP increase 2 cm above baseline and remains elevated while the abdomen
is being compressed. The test should only be done if the baseline JVP is
normal. The test is helpful in assessing for occult volume overload.
g. Pulmonary congestion.
h. Pitting edema.
i. Ascites.
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3. Key laboratory & diagnostic assessments:
a. BNP level elevated above patient’s baseline
(a) Isolated elevations of BNP in the absence of physical findings suggestive of
ADHF are NOT diagnostic for ADHF.
b. BUN.
c. Cr.
d. Electrolytes (Na, K, Mg, Ca).
e. Arterial blood gas (if respiratory distress apparent).
f. EKG.
g. Cardiac enzymes.
h. PT, INR, PTT.
B. Assessment should include investigation of precipitating causes (medical or dietary
noncompliance, acute coronary syndrome, hypertensive crisis, arrhythmias, etc.) and
severity of symptoms.
C. Based on this information, patients with the diagnosis of acute decompensated heart
failure should be stratified based on the presence of symptoms consistent with volume
overload or low cardiac output. (Addendum 1).
D. Timeline for Assessment (Addendum 2): the diagnosis of ADHF should be established
within two hours after presentation to the ED.
II. Care Treatment Plan
A. Timeline for Treatment (Addendum 2).
1. Once the diagnosis of ADHF has been made, intravenous (IV) therapy for ADHF
should be initiated within two hours of establishing the diagnosis (< four hours from
the initial ED contact).
2. Within two hours of initiating IV therapy for ADHF, the patient’s response to therapy
should be assessed and additional therapy added as necessary.
3. Over the following 6 – 8 hours, reassessment of the patient’s response should
continue. Ultimately, within 12 hours of the initial ED contact, the patient’s disposition
should be determined (e.g., hospital admission or discharge home).
4. Once the patient’s disposition has been determined, transfer out of ED to the
patient’s final destination should proceed within 24 hours of the initial ED contact.
B. ADHF Treatment Algorithm (Addendum 1).
1. Treatment of ADHF is generally based on the presence or absence of pulmonary
congestion (i.e., volume overload) and an assessment of the patient’s cardiac output.
2. On the left hand side of the algorithm, treatment recommendations are given for
ADHF patients experiencing signs and symptoms of volume overload.
3. In the middle of the algorithm, treatment recommendations are given for ADHF
patients with acute pulmonary edema and/or severe hypertension.
4. The right hand side of the algorithm provides treatment recommendations for
patients with low cardiac output.
5. Although this ADHF treatment algorithm focuses on parenteral therapy during the
initial 24 hours, continuation of patients’ chronic HF medications, including chronic
beta-blocker therapy, is advised.
C. See Inpatient Care for specific treatment recommendations:
1. Treatment of ADHF Patients with Volume Overload.
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2. Treatment of ADHF patients with volume overload and acute pulmonary edema
and/or severe hypertension.
3. Treatment of ADHF Patients with Low Cardiac Output.
4. Treatment of ADHF Patients with Low Cardiac Output and Evidence of Shock.
D. Monitoring Recommendations For Patients Hospitalized with ADHF (Minimum)
1. Daily weights
a. Documentation of baseline weight in Cerner from the Emergency Department,
ideally.
2. Daily documentation of fluid intake and output
a. Documentation of fluid intake and output during the Emergency Department stay,
ideally, is helpful, particularly for patients who are hospitalized.
3. Daily Electrolytes and Renal function
a. May consider repeating assessment of electrolytes & renal function in select
patients in the Emergency Department (e.g., extended stay in the Emergency
Department, excessive diuretic response, poor diuretic response, etc.).
III. Discharge Education and Planning
A. Education of patients with heart failure should be ongoing and incorporated into as many
patient/caregiver interactions as possible, to reinforce key points the patient needs to
understand.
1. For those patients being discharged home from the Emergency Room, discharge
education should be initiated as early in the patient care process as the patient
demonstrates they are ready to process such information in order to prepare for their
own care at home. Discharge education will be provided by the nursing staff.
B. The key education points are summarized in Table 4
C. Patient directed educational material can be found within the Depart Tool in the EMR
(Table 5)
Inpatient Care
I.
Assessment/Diagnosis
A. The decision to admit patients with ADHF may be guided by the criteria proposed in
Table 3.
II. Care Treatment Plan
A. Inpatient management of ADHF mirrors the acute management in the ED.
B. Adjustments in therapy are made based on patients’ response to therapy, adverse
effects, and symptom improvement.
C. Re-initiation of patient’s previous chronic heart failure regimen, including chronic betablockers, should be done. Initiation and titration of beta-blockers in this setting should
be considered. In addition, efforts should be made at optimizing patients’ chronic heart
failure regimen, as described earlier.
D. ADHF Treatment Algorithm (Addendum 1).
1. Treatment of ADHF is generally based on the presence or absence of pulmonary
congestion (i.e., volume overload) and an assessment of the patient’s cardiac output.
2. On the left hand side of, treatment recommendations are given for ADHF patients
experiencing signs and symptoms of volume overload.
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3. In the middle of the algorithm, treatment recommendations are given for ADHF
patients with acute pulmonary edema and/or severe hypertension.
4. The right hand side of the algorithm provides treatment recommendations for
patients with low cardiac output.
5. Although this ADHF treatment algorithm focuses on parenteral therapy during the
initial 24 hours, continuation of patients’ chronic HF medications, including chronic
beta-blocker therapy, is advised.
E. Treatment of ADHF Patients with Volume Overload.
1. Diuretics.
a. Patients with volume overload (Addendum 1) should be treated with IV diuretic
therapy, typically loop diuretics (Addendum 1, box A1).
b. In patients taking oral diuretic therapy at home, the initial IV diuretic dose should
be equivalent to the total daily dose, with a maximum IV dosage of furosemide
180mg IV.
c. Patients not taking oral diuretics at home should be given an IV bolus of
furosemide 40 mg, although patients with renal insufficiency may require an even
larger dose to produce the desired effect.
d. Monitoring of diuretic use is driven by urine output goals.
(a) Initial response
(i) For patients with normal renal function, the goal urine output is > 500mL
in the first two hours (see Addendum 1).
(ii) An acceptable urine output for patients with serum creatinine greater than
2.5mg/dL is > 250mL (see Addendum 1).
(iii) Alternatively, a goal urine output of ≥ 1ml/kg/hr for the first 2 – 4 hours
may be appropriate.
(a) Daily urine output goal for patients with ADHF is a net diuresis of 1L/day
(total input – total output = -1L or more).
e. If the patient fails to attain an adequate diuresis after the initial IV bolus, several
options exist, including:
(a) Double the previous dose – ideally, within 2 – 4 hours of the first dose to
induce a more rapid diuresis.
(b) Administer as a continuous infusion
(i) Furosemide: 10 – 40mg/hr.
(ii) Bumetanide: 0.5 – 2 mg/hr.
(c) Use combination diuretics
(i) Add metolazone 2.5 – 5mg PO daily-BID
(ii) Add chlorothiazide 500 – 1000 mg IV daily-BID
f. Once an adequate diuresis has been achieved, continuation of the effective
diuretic dose is recommended.
g. Electrolyte deficiencies, particularly hypokalemia and hypomagnesemia, are the
most common adverse effects experienced with IV diuretic therapy, although
hypotension, azotemia, and renal dysfunction are also possible.
(a) A management strategy for electrolyte disturbances in this setting has been
proposed previously and is included in the standing orders (Addendum 3,
bottom of second page).
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h. Patients with an inadequate response to furosemide should also be assessed for
the presence of low cardiac output, worsening volume overload ± pulmonary
edema, and/or severe hypertension and, if necessary, additional therapy for
ADHF may be required (described below).
F. Treatment of ADHF patients with volume overload and acute pulmonary edema and/or
severe hypertension.
1. Diuretics
a. For dosing and monitoring recommendations, see above in II.C.1.
2. Vasodilators.
a. Either IV nitroglycerin or nitroprusside should be added to IV diuretics to produce
a more rapid response and more effectively relieve the signs and symptoms of
congestion in these patients.
(a) IV nitroglycerin dosing
(i) Continuous infusion at a rate of 5 – 10 g/min and increased in
increments of 10 to 20 g/min as often as every 5 minutes as necessary
(Table 2).
(ii) Doses as high as 140 – 160mcg/min may be required to achieve the
desired hemodynamic effects.
(b) If nitroprusside is used, it should be administered in the ICU, starting at a rate
of 0.3 – 0.5mcg/kg/min, and may be titrated as often as every 5 minutes as
necessary.
(c) Nitroglycerin SL 0.4mg PRN may be used to acutely relieve symptoms of
volume overload/congestion until IV therapy can be initiated if necessary.
(d) Hypotension is the most common adverse effect from both IV nitroglycerin
and nitroprusside.
(e) Medications should not be held or discontinued for asymptomatic
hypotension.
G. Treatment of ADHF Patients with Low Cardiac Output.
1. Inotropes.
a. Patients with evidence of low cardiac output should be considered for inotropic
support.
b. Drug selection may be based on several variables, including hemodynamic
stability, baseline blood pressure, and presence of concomitant beta-blocker
therapy.
(a) ADHF patients with low cardiac output and systolic blood pressure < 90
mmHg should be treated with dobutamine initially.
(i) These patients may require vasopressor support if symptomatic
hypotension develops or there is baseline evidence of shock.
(b) Patients with low cardiac output and adequate blood pressure (systolic blood
pressure > 90 mmHg) who are also taking beta-blockers chronically may be
given milrinone preferentially.
(i) If dobutamine is used in patients taking chronic beta-blockers, higher
doses of dobutamine may be necessary or a temporary reduction in betablocker dose may be considered.
c. Patients with low cardiac output and adequate blood pressure without
concomitant beta-blocker therapy may receive either dobutamine or milrinone.
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d. Dobutamine dosing
(a) Typically initiated at a rate of 2.5 g/kg/min and may be increased by
increments of up to 2.5 g/kg/min as often as every 5 – 15 minutes, if
necessary, to achieve the desired response. (Table 2)
e. Milrinone dosing
(a) Typically initiated at a rate of 0.1 – 0.375 g/kg/min (depending on renal
function and/or baseline blood pressure).
(b) To avoid hypotension, administration of an IV bolus (50 g/kg IV over 10
minutes) of milrinone is NOT recommended.
(c) Milrinone has a half-life of approximately 2 – 3 hours; therefore, dose titration
must occur slowly, no more frequently than every 4 – 6 hours. (Table 2).
Treatment of ADHF Patients with Low Cardiac Output and Evidence of Shock.
1. Typically, these patients require admission to an intensive care unit for close
monitoring and may require the placement of a pulmonary artery catheter to more
accurately assess their hemodynamics.
2. Those patients with very low cardiac output will likely require inotropic support, may
require vasopressors, and may be considered for mechanical circulatory support or
even referral for heart transplantation.
All patients hospitalized for ADHF should also be considered for the following:
1. Immunizations
a. Pneumococcal vaccination every 5 years
b. Influenza vaccination annually
2. Smoking cessation therapy, if appropriate
a. Nicotine replacement therapy
b. Buproprion during inpatient stay, if appropriate.
Monitoring Recommendations for Patients Hospitalized with ADHF (minimum)
1. Daily Weights
2. Daily documentation of fluid intake and output
3. Daily electrolytes & renal function
a. May need to be monitored more frequently in select patients (e.g., poor baseline
renal function, excessive diuretic response, poor diuretic response, etc.).
Dietary Recommendations
1. Fluid restriction (<2L/day) is recommended in patients with moderate hyponeatremia
(serum sodium <130mequ/L) and should be considered to assist in treatment of fluid
overload in other patients
2. A low sodium diet (2g daily) is recommended
Prevention of Deep Venous Thrombosis and Pulmonary Embolism
1. Refer to UIMC guidelines:
a. G-1.3 VTE/Deep Vein Thrombosis Prophylaxis Clinical Care Guideline
2. Depending on VTE risk, acceptable therapies may include:
a. Intermittent pneumatic compression device (IPCs) or sequential compression
device (SCDs)
b. Heparin 5000 units subcutaneously q8-12h.
Patients should be considered for discharge when
1. Exacerbating factors addressed
2. Near optimal volume status observed
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3. Transition for intravenous to oral diuretic successfully completed
a. No IV vasodilator or inotropic agent for 24 hours
b. Oral medication regimen stable for 24 hours
4. Near optimal pharmacologic therapy achieved
III. Discharge Education and Planning
A. Discharge education should be initiated as early in the patient care process as the
patient demonstrates they are ready to process such information in order to prepare for
their own care at home. Discharge education will be provided by the nursing staff, and
will include providing the patient or caregiver with
B. Patient directed educational material can be found within the Depart Tool in the EMR
(Table 5)
C. The key education points are summarized in Table 4
D. The nurse will document the patient discharge education in Gemini on the Patient
Education Assessment/Teaching form
E. Other Discharge Planning:
1. The discharge planner assigned to the patient will arrange for any special services
that the patient may require including home health, special equipment, etc.
2. After a hospitalization for ADHF, patients should be seen by their healthcare
practitioner (PCP, Cardiologist or Nurse Practitioner) within 1-2 weeks for close
monitoring of symptoms and up titration of medications as appropriate.
3. Patients with multiple admissions for ADHF may benefit from referral to the Heart
Failure Clinic in cardiology. These appointments can be arranged through the Heart
Center.
F. Pharmacy Discharge Patient Education
1. Whenever possible, the clinical pharmacist on the medical team or designee (e.g.,
pharmacy student or resident) will assist in the discharge education by performing
one or more of the following:
a. Work with the medical team to review and reconcile discharge medications
b. Review discharge prescriptions for correctness
c. Provide a medication list to the patient along with discharge prescriptions
d. Review with patient and/or caregiver(s) the discharge medications, including
changes from previous regimen.
e. Offer the services of the Discharge Prescription Service from the Wood Street
Pharmacy to the patient and/or caregiver.
f. Review with the patient and/or caregiver(s) pertinent patient education points
summarized in Table 4.
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Rescission Date
April 2008
July 2004
Addenda
Addendum 1: Acute Decompensated Heart Failure (ADHF) Treatment Algorithm
Addendum 2: Timeline for the Management of Acute Decompensated Heart Failure (ADHF) in
the Emergency Department/Observation Unit
Addendum 3: Congestive Heart Failure Order Set – ED Order Sheet
Addendum 4: Digoxin Dosing Nomogram for Chronic Dosing in Heart Failure
Addendum 5: Angiotensin-converting enzyme inhibitor (ACEi)/Angiotensin Receptor Blocker
(ARB) Treatment Algorithm
Addendum 6: Beta Blocker Treatment Algorithm
Addendum 7: Aldsosterone Antagonist Treatment Algorithm
Tables
Table 1: Medications Used in Heart Failure
Table 2: Monitoring Parameters for Medications Used to Treat Acute Decompensated Heart
Failure.
Table 3: Disposition Criteria
Table 4: Key Patient Education Points
Table 5: Patient- Directed Educational Materials Found in Cerner
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References
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DiDomenico RJ, Park H, Southworth MR, Eyrich HE, Lewis RK, Finley JM, Schumock GT. Guidelines
for acute decompensated heart failure. Ann Pharmacother 2004;38:649-60.
Aghababian RV. Acutely decompensated heart failure: opportunities to improve care and outcomes in
the emergency department. Rev Cardiovasc Med 2002; 3:S3-9.
Lindenfeld J, Albert NM, Boehmer JP, et al. HFSA 2010 Comprehensive Heart Failure Practice
Guideline. J Card Fail. Jun 2010;16(6):e1-194.
Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005
Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American
College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am
Coll Cardiol. Apr 14 2009;53(15):e1-e90.
Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and
Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with
the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive
Care Medicine (ESICM). Eur Heart J. Oct 2008;29(19):2388-2442.
Stevenson LW. Tailored therapy to hemodynamic goals for advanced heart failure. Eur J Heart Fail
1999;1:251-7.
Nohria A, Lewis E, Stevenson LW. Medical management of advanced heart failure. JAMA
2002;287:628-40.
Fonarow GC. Pharmacologic therapies for acutely decompensated heart failure. Rev Cardiovasc Med
2002;2:S18-S27.
Fonarow GC, et al. Improving the use of evidence-based heart failure therapies in the outpatient
setting: the IMPROVE-HF performance improvement registry. Am Heart J 2007;154:12-38.
Peacock WFt, Albert NM. Observation unit management of heart failure. Emerg Med Clin North Am
2001;19:209-32.
Ellison DH. Diuretic therapy and resistance in congestive heart failure. Cardiology 2001;96:132-43.
Wood AJJ. Diuretic therapy. New Engl J Med 1998;339:387-95.
Maisel AS, Krishnaswamy P, Nowak, McCord J, Hollander JE, Duc P, et al. Rapid measurement of btype natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002;347:161-7.
Kruger S, Graf J, Kunz D, Stickel T, Hanrath P, Janssens U. Brain natriuretic peptide levels predict
functional capacity in patients with chronic heart failure. J Am Coll Cardiol 2002;40:718-22.
Berger R, Huelsman M, Strecker K, Bojic A, Moser P, Stanek B, et al. B-type natriuretic peptide
predicts sudden death in patients with chronic heart failure. Circulation 2002;105:2392-7.
Emerman CL, Peacock WF, Fonarow GC. Effect of emergency department initiation of vasoactive
infusion therapy on heart failure length of stay [abstr]. Ann Emerg Med 2002;40(suppl):S46.
Francis GS, Siegel RM, Goldsmith SR, Olivari MT, Levine TB, Cohn JN. Acute vasoconstrictor
response to intravenous furosemide in patients with chronic congestive heart failure: activation of the
neurohormonal axis. Ann Intern Med 1985;103:1-6.
Ikram H, Chan W, Espiner A, Nicholls MG. Haemodynamic and hormone responses to acute and
chronic frusemide therapy in congestive heart failure. Clin Science 1980;59:443-449.
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o
o
o
o
o
o
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Dormans TP, van Meyel JJ, Gerlag PG, Tan Y, Russel FG, Smits P. Diuretic efficacy of high dose
furosemide in severe heart failure: bolus injection versus continuous infusion. J Am Coll Cardiol
1996;28:376-82.
Channer KS, McLean KA, Lawson-Matthew P, Richardson M. Combination diuretic treatment in
severe heart failure: a randomized controlled trial. Br Heart J. 1994 Feb;71:146-50.
Jain P, Massie BM, Gattis WA, Klein L, Gheorghiade M. Current medical treatment for the
exacerbation of chronic heart failure resulting in hospitalization. Am Heart J 2003;145(suppl):S3-S17.
Steimle AE, Stevenson LW, Chelimsky-Fallick C, Fonarow GC, Hamilton MA, Moriguchi JD, et al.
Sustained hemodynamic efficacy of therapy tailored to reduce filling pressures in survivors with
advanced heart failure. Circulation 1997; 96:1165-72.
Dupuis J, Lalonde G, Lebeau R, Bichet D, Rouleau JL. Sustained beneficial effect of a seventy-two
hour IV infusion of nitroglycerin in patients with severe chronic congestive heart failure Am Heart J
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Larsen AI, Goransson L, Aarsland T, Tamby JF, Dickstein K. Comparison of the degree of
hemodynamic tolerance during IV infusion of nitroglycerin versus nicorandil in patients with
congestive heart failure. Am Heart J 1997;134:435-41.
Bayley S, Valentine H, Bennett ED. The haemodynamic responses to incremental doses of
intravenous nitroglycerin in left ventricular failure. Intensive Care Med 1984;10:139-45.
Armstrong PW, Watts DG, Moffat JA. Steady-state pharmacokinetic haemodynamic studies of
intravenous nitroglycerin in congestive cardiac failure. Br J Clin Pharmacol 1983;16:385-90.
Elkayam U, Kulick D, McIntosh N, Roth A, Hsueh W, Rahimtoola SH. Incidence of early tolerance to
hemodynamic effects of continuous infusion of nitroglycerin in patients with coronary artery disease
and heart failure. Circulation 1987;76:577-84.
Lowes BD, Tsvetkova T, Eichhorn EJ, Gilbert EM, Bristow MR. Milrinone versus dobutamine in heart
failure subjects treated chronically with carvedilol. Int J Cardiol 2001;81:141-9.
Bauman JL, DiDomenico RJ, Viana M, Fitch M. A method for determining the dose of digoxin for
heart failure in the modern era. Arch Intern Med 2006;166:2539-45.
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Addendum 1: Acute Decompensated Heart Failure (ADHF) Treatment
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Legend: Addendum 1: Acute Decompensated Heart Failure (ADHF) Treatment.
Where appropriate, guideline recommendations are provided from the Heart Failure Society of America
(HFSA), the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA),
and/or the European Society of Cardiology (ESC). For HFSA recommendations, IR = is recommended,
SBC = should be considered, MBC = may be considered. For ACCF/AHA and ESC recommendations
classifications: I=should be administered, IIa=it is reasonable to administer, IIb=may be considered.
Strength of evidence is provided parenthetically for each guideline recommendation (A=derived from
randomized, controlled, clinical trials or meta-analyses; B=derived from cohort or case-controlled studies,
posthoc or subgroup analyses, meta-analyses, or prospective observational studies/registries; C=expert
opinion, case studies, observational/epidemiological data, safety reporting). IV = intravenous, BP = blood
pressure.
*In patients who are refractory to initial therapy and/or in whom volume status and cardiac filling
pressures are unclear, invasive hemodynamic monitoring should be considered according the HFSA
guidelines (Strength of evidence = C).
Adapted from Lindenfeld J, et al. J Card Fail. Jun 2010;16(6):e1-194; Hunt SA, et al. J Am Coll Cardiol.
Apr 14 2009;53(15):e1-e90; Dickstein K, et al. Eur Heart J. Oct 2008;29(19):2388-2442.
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Addendum 2: Timeline for the Management of ADHF
Assess response to initial therapy
Add additional therapy as needed
Initiate IV ADHF therapy
Diuretic (mild-mod volume overload)
Diuretic + IV Vasodilators (mod-sev volume overload)
Inotrope (if low CO state)
Reassess response to therapy
Add additional therapy as needed
Establish ADHF
diagnosis
Transfer out of ED or
Observation Unit
Determine patient disposition
Admit (ICU vs observation unit vs floor)
or discharge home
Initial ED
contact
0
2
4
6
8
12
Time (hours) from initial ED physician evaluation
Adapted from DiDomenico RJ, et al. Ann Pharmacother 2004;38:649-60
24
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Addendum 3: Acute Decompensated Heart Failure Order Set
Step 1: Select “Order Sets”
Step 2: Select “Cardiology”
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Step 3: Select “CardCHF”
Step 4: Select/Deselect
desired orders
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Addendum 4: Digoxin Dosing Nomogram for Chronic Dosing in Heart Failure
Adapted from Bauman JL, et al. Arch Intern Med 2006;166:2539-45. To use, plot estimated creatinine
clearance (x axis) against ideal body weight (y axis) OR gender/height (z axis). The corresponding range
equates to the daily maintenance dose of digoxin.
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Addendum 5 (Note: Not all of these medications are on the UIMC formulary):
Reference: Fonarow GC et al. Am Heart J 2007;154:12-38.
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Addendum 6
Reference: Fonarow GC et al. Am Heart J 2007;154:12-38.
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Addendum 7 (From American Heart Journal July 2007):
Reference: Fonarow GC et al. Am Heart J 2007;154:12-38.
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Table 1: Medications Used in Heart Failure
Medication
Enalapril
Captopril
Lisinopril
Metoprolol Succinate
XL
Carvedilol
Furosemide
Bumetanide
Torsemide
Hydrochlorothiazide
Metolazone
Valsartan
Initiating Dose
Goal Dose
ACE inhibitors
2.5 mg q12h
10 mg q12h
6.25 mg q8h
50 mg q8h
2.5 mg DAILY
20 mg DAILY
Beta Blockers
12.5 to 25 mg DAILY
200 mg DAILY
Maximum Dose
3.125mg q12h
50mg q12h
25 q12h
Diuretics
20 – 40 mg DAILY
Patient-specific
0.5 – 1 mg DAILY
Patient-specific
10 – 10 mg DAILY
Patient-specific
25 mg DAILY
Patient-specific
2.5 mg DAILY
Patient-specific
Angiotensin Receptor Blockers
40mg q12h
160mg q12h
Vasodilators
10 mg q8h
75 mg q8h
10 mg TID
40 mg TID
20 mg q12h
150 mg q8h
40 mg DAILY
200 mg DAILY
480 mg DAILY
10mg DAILY
200mg DAILY
50 mg DAILY
10 mg BID
160mg q12h
Hydralazine
100 mg q8h
Isosorbide dinitrate
80 mg TID
(ISDN)
BiDil®
1 Tab TID
2 Tabs TID
2 Tabs TID
(ISDN 20mg /
hydralazine 37.5mg)
*If used, hydralazine should be combined with a nitrate formulation in the absence of ACE
inhibitor or Angiotensin Receptor Blocker
Aldosterone Antagonists
Spironolactone
6.25 – 12.5 mg DAILY 12.5 – 50 mg DAILY
50 mg DAILY
Eplerenone
12.5 mg DAILY
50 mg DAILY
50 mg DAILY
Other Drugs
See dosing nomogram
Digoxin
Patient-specific to
Patient-specific to
(Addendum 4)
achieve digoxin level
achieve digoxin level
Generally 0.125 mg
0.5 – 1.0 ng/mL
0.5 – 1.0 ng/mL
daily
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Table 2: Monitoring Parameters for Medications Used to Treat Acute Decompensated
Heart Failure.
Drug
Diuretics
Monitoring Parameters
 Symptom relief
 Vital Signs
 BUN, creatinine, electrolytes
 Urine output, goal:
 Normal renal function: > 500ml
within 2 hrs of IV furosemide
 Renal insufficiency: > 250ml
within 2 hrs of IV furosemide
Titration Parameters
Nitroglycerin


Symptom relief
Vital signs every 15 minutes until on
stable dose, then every 30 minutes for
1 hr, then every 4 hrs
Urine output
May require ICU stay to titrate
infusion
If pulmonary artery catheter in place,
PCWP, SVR, CI


Starting dose: 5 – 10 g/min
Dose can be increased by increments
of 10 – 20 g/min every 5 minutes if
necessary until desired response
achieved
Symptom relief
Vital signs every 15 minutes until on
stable dose, then every 30 minutes for
1 hr, then every 4 hrs
Urine output
Requires ICU stay for titration &
monitoring
If pulmonary artery catheter in place,
PCWP, SVR, CI
Evidence of cyanide and/or
thiocyanate toxicity


Starting dose: 5 – 10 g/min
Dose can be increased by increments
of 10 – 20 g/min every 5 minutes if
necessary until desired response
achieved
Telemetry
Symptom relief
Vital signs every 15 minutes until on
stable dose, then every 30 minutes for
1 hr, then every 4 hrs
Urine output
May require ICU stay to titrate
infusion
If pulmonary artery catheter in place,
PCWP, SVR, CI
Dobutamine
 Dose can be increased by increments
of up to 2.5 g/kg/min every 5 – 15
minutes if necessary until desired
response achieved



Nitroprusside






Inotropes






Milrinone
 May take several hours to reach
steady-state concentrations
 Consider 50 g/kg IV bolus over 10
minutes if immediate response
desired and BP will tolerate (SBP >
100mmHg)
 Dose titration should occur slowly
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Table 3. Disposition Criteria
Criteria for Hospital Admission
Sustained ventricular tachycardia or other
symptomatic arrhythmia
Unstable vital signs
Signs/symptoms of acute coronary
syndrome
Refractory electrolyte disturbances
Total urine output < 1000ml OR <
0.5ml/kg/hr (~30ml/hr)
Persistent dyspnea
Discharge Criteria
Symptomatic improvement
Patient ambulating
Heart rate < 100bpm at rest
Vital signs stabilized
(individualized to patient)
Total urine output > 1000ml AND >
0.5ml/kg/hr (~30ml/hr)
Normal cardiac enzymes
No complaints of chest pain
No documented arrhythmias
Normal(ized) electrolytes
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Table 4 : Key Patient Education Points
Activity Level
Medications
Weight Monitoring
Diet
Follow up
Appointments
What to do if
symptoms worsen
Smoking
Cessation
Patients should be advised of any restrictions regarding activity and in
general should be encouraged to remain as active as possible.
Patients should be advised as to the importance of never missing any
doses of their prescribed medications. (NOTE: Patients should be
provided with a list of their discharge medication, provided either by
the PharmD handout, or on the Discharge Notification Form). If the
patient has difficulty paying for his/her medications, he/she should be
referred to the Medication Assistance Program in the outpatient
pharmacy.
Patients should be advised that daily weights are required to
determine fluid status between clinic visits. They should be advised
that a weight gain of greater than 3-5 pounds which persists for 3-4
days should prompt a call to their physician’s office.
Patients should be advised to follow a low sodium diet, specifically
less than 2000 mg of sodium a day. If the patient has difficulty
understanding how to adhere to a low sodium diet, he/she should be
referred to the Nutrition and Wellness Center for dietary teaching.
The DASH diet is also appropriate for this population
(http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf ).
Patients should be advised as to the importance of regular follow up
and close monitoring due to their chronic condition. They should also
be provided with a list of their follow-up clinical appointments, or
advised to schedule a follow-up appointment within 1-2 weeks after
discharge
Patient should be advised as to the appropriate course of action if
their symptoms should worsen.
Patients who smoke should be advised to quit. If the patient exhibits
readiness to quit smoking, he/she should be referred to the smoking
cessation clinic in the Nutrition and Wellness Center. If the patient is
a former smoker (within the past year), they should be advised to
remain smoke-free.
Table 5: Suggested Patient directed educational materials found in Cerner
1. Heart Failure (required) includes JCAHO core measures
2. What is Heart Failure?
3. Heart Failure: Warning signs of a flare up.
4. Heart Failure: Medications to help your heart.
5. Heart Failure: Making changes to your diet.
6. Heart Failure: Tracking your weight.