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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. _______________________________________________________________________ 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