Download Key Components in Managing Heart Failure in Primary Care Target

Key Components in Managing Heart Failure in Primary Care
Target Population: 18 years of age and older
Introduction
Heart failure is a major health problem in the United States with an estimated 5 million
individuals currently diagnosed. Outpatient treatment has improved dramatically with the advent
of neuro-hormonal and device approaches, patient education, and disease management strategies.
Diagnosis
1) In the primary care setting, patients with major heart failure commonly complain of:
Dyspnea at rest or exertion; orthopnea; paroxysmal nocturnal dyspnea (PND); cough (recumbent
or exertional); abdominal or epigastria discomfort; abdominal bloating; early satiety; hemoptysis,
frothy or pink-tinged sputum; pedal/leg swelling; rapid weight gain; sleep disturbances (anxiety
or air hunger); unexplained confusion, altered mental status, or fatigue; nausea or anorexia;
dependent edema.
2) Initial Evaluation
Past and current medical history should include assessment for: CHF, MI, HTN,
Diabetes, Hyperlipidemia, Thyroid dysfunction; recently postpartum; snoring/sleep
apnea; blunt chest injury; rheumatic fever; HIV; bacterial endocarditis; claudication;
foreign travel
Assess for family history of: ischemic heart disease, CHF, congenital heart disease, risk
factors for atherosclerotic cardiovascular disease
Assess social history: alcohol (abuse screen), drug, and tobacco use
Assess dietary history: salt and daily fluid intake; balanced diet
Physical exam: Vital signs, including weight and height; assess for diaphoresis;
diminished peripheral pulse or bruit; skin color; cyanosis, pallor, jaundice; lower
extremity edema in the absence of venous insufficiency; elevated jugular venous
pressure; positive hepato-jugular reflux; heart rate: tachycardia, bradycardia or other
arrhythmias; left lateral displacement of point of maximal impulse (PMI); heart sounds:
S3,S4, or murmur; lung sounds: labored breathing, rales above the lower 25% of the lung
that do not clear with cough; abdomen: large, pulsatile, or tender liver or ascites
Initial lab test: CBC, Electrolytes (Na+, K+, BUN) and Cl, Bicarb, Ca++, MG++
( if on diuretics), Renal function (BUN, Cr), Liver function (AST, ALT,
Alk phos, Bili, T Prot, Alb), UA, TSH, PT/INR
Lab tests to consider to evaluate potential other causes: ferritin/iron/TIBC/macrocytic
anemias, lipid profile; blood culture (if endocarditis suspected); Lymes serology (if
suspect bradycardia/heart block), connective tissue disease workup, HIV
Consider Brain natriuretic peptide (BNP) and NTproBNP assay to help with HF
diagnosis in patients with dyspnea (BNP levels alone should not be used to either
diagnose CHF or to assess response to treatment and should be confined to the acute
care setting when the diagnosis of dyspnea is uncertain) See 3.1.3.2. Laboratory
Testing @:http://circ.ahajournals.org/cgi/content/full/119/14/1977
Chest X-Ray
12-Lead Electrocardiogram
Left Ventricular imaging (echocardiography or radionuclide ventriculography)
Ischemic evaluation in patient with CAD risk factors (stress test, angiography).
NOTE: Heart Failure should not be a single, stand-alone diagnosis. The etiology of heart failure
and the presence of exacerbating factors or other diseases that may have an important influence
on management should be carefully considered in all cases.
It is important to determine whether ventricular dysfunction is systolic or diastolic, because
therapies are quite different. In fact, some therapies for systolic dysfunction may even be
harmful if used to treat preserved systolic function. Ischemia is responsible for the majority of
cases of heart failure. Two-thirds of systolic heart failure is due to ischemic heart disease.
Identifying ischemia as a cause of heart failure is important, because many of these patients
could benefit from revascularization.
Treatment and Management
Medications: See Circulation, 2009 Focused Updates - Pharmacological Treatment of Heart
Failure, pg 23:
http://www.icsi.org/guidelines_and_more/gl_os_prot/cardiovascular/heart_failure_2/heart_failur
e_in_adults__guideline_.html
Non-Pharmacologic Management: dietary indiscretion is the most common cause of
exacerbation of heart failure; therefore, all patients with heart failure should receive dietary
instruction regarding sodium intake. Sodium restriction alone may provide substantial benefits
for heart failure patients. Daily weights are important for managing heart failure and early
detection of increases in fluid retention. Patients should call their provider about a two-pound or
greater weight gain overnight or a five-pound or greater weight gain in a week. All medications
should be reviewed at each visit. Consider referral to Health Plan Complex Case Management.
Address activity level. Discuss Advance Directives. Influenza and pneumococcal
immunizations are recommended for all patients with CHF in the absence of contraindications.
Advise smoking cessation.
Patient Education
Follow-up in the ambulatory setting should focus on optimizing pharmacologic and nonpharmacologic therapy and preventing heart failure exacerbations: educate and recruit the patient
as a partner in treatment; educate on the importance of follow-up appointments; what to do if
symptoms worsen; patient education should be ongoing and consistently reinforced, and family
members should be a part of this process whenever possible; provide patients with written
information for review at their own pace.
Follow-up
Follow-up in the ambulatory setting should focus on optimizing pharmacologic and nonpharmacologic therapy and preventing heart failure exacerbations.
Referral
Consider consultation with Cardiology during the initial evaluation and anytime that it is felt
appropriate in the ongoing management of HF patients. Consider early specialty referral for
patients with ischemia or those who are refractory despite optimal medical therapy.
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This information is meant to serve as a guideline only, and is not a substitute for clinical
judgment.
References
Adopted from:Institute for Clinical Systems Improvement, Heart
Failure in Adults, Eleventh Edition, August 2011. Retrieved from:
http://www.icsi.org/guidelines_and_more/gl_os_prot/cardiovascular/heart_failure_2/heart_failur
e_in_adults__guideline_.html
2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart
Failure in Adults Retrieved from: http://circ.ahajournals.org/cgi/content/full/119/14/1977
Adopted by QI Subcommittee: July 2008
Reviewed and approved by QI Subcommittee: April, 2009; Updated April 12, 2010; June 13,
2011, June 11, 2012, August 12, 2013