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THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 1 of 28 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 2 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE NO: G-1.2 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 3 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 4 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois 2. 3. 4. 5. NO: G-1.2 DATE: May 2011 PAGE: 5 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE (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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 6 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 7 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 8 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 9 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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). THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 10 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois H. I. J. K. L. M. NO: G-1.2 DATE: May 2011 PAGE: 11 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 12 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 13 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 14 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE References o o o o o o o o o o o o o o o o o o 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 15 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE o o o o o o o o o o o 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 1990;120:625-37. 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 16 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE Addendum 1: Acute Decompensated Heart Failure (ADHF) Treatment THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 17 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 18 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 19 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE Addendum 3: Acute Decompensated Heart Failure Order Set Step 1: Select “Order Sets” Step 2: Select “Cardiology” THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 20 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE Step 3: Select “CardCHF” Step 4: Select/Deselect desired orders THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 21 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 22 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 23 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE Addendum 6 Reference: Fonarow GC et al. Am Heart J 2007;154:12-38. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 24 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE Addendum 7 (From American Heart Journal July 2007): Reference: Fonarow GC et al. Am Heart J 2007;154:12-38. THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 25 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 26 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 27 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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 THE UNIVERSITY OF ILLINOIS AT CHICAGO University of Illinois Medical Center Chicago, Illinois NO: G-1.2 DATE: May 2011 PAGE: 28 of 28 UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 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.