Download Congestive Heart Failure

 CONGESTIVE HEART FAILURE CLINICAL PRACTICE GUIDELINE The following guideline is applicable for patients 18 and older who have a diagnosis of Congestive Heart Failure (CHF). For these patients, their medical record will contain documentation of the following: I.
Diagnosis: The classic symptom of CHF is breathlessness (dyspnea) and is an indicator of this diagnosis. Evaluation of cardiac structure and function by objective test such as and echocardiogram is necessary to confirm diagnosis, determine the cause of symptoms, and to evaluate the degree of underlying cardiac pathology. II.
Classification: Disease classification based on the New York Heart Association (NYHA) Functional Classifications: 1. Class I, No Limitations: Ordinary physical activity does not cause undue fatigue, dyspnea or palpations (i.e. patient is able to do all normal activities of daily living without any symptoms, and only becomes symptomatic after significant exertion. Can walk more than two blocks, and can easily climb a flight of stairs without dyspnea) 2. Class II, Slight Limitation of Physical Activity: Such patients are comfortable at rest, ordinary activity results in fatigue, palpations, dyspnea or angina ( i.e. patients can walk one level block but not two, and can climb stairs but are winded after one flight of stairs) 3. Class III, Marked Limitation of Physical Activity: Patients are comfortable at rest, less than ordinary activity will lead to symptoms (i.e. less than ordinary activity causes symptoms and patients are unable to climb stairs at a normal rate or must stop before the top. Patients cannot walk one level block without dyspnea) 4. Class IV, Inability to Carry On Any Physical Activity without Discomfort: Symptoms of congestive failure are present even at rest. With any physical activity, increased discomfort is experienced (i.e. symptoms occur with minimal activity and/or at rest) III.
Assessment: a. Assessment of risk factors: Hypertension, Diabetes, and Coronary Artery Disease. Treatment to be provided if clinically indicated b.
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BNP levels should be assessed in patients suspected of having CHF if diagnosis is uncertain Baseline measurement of LVEF and follow‐up measurement as clinically indicated Electrocardiogram Evaluation for ischemia in patients who develop new‐onset LV systolic dysfunction Treatment: A. For patients with a LVEF < 40%, the treatment plan will include: 1. ACE Inhibitor or ARB. If ACE Inhibitor or ARB are not used, document reason (e.g. angioedema) 2. Beta Blockers, as appropriate. For LV systolic dyfunction, only carvedilol, metropolol succinate, or bisoprolol should be used because they have shown to reduce the risk of death. If Beta Blockers are not used, document reason (e.g. reactive airway disease) 3. For African Americans, use of combination of hydralazine plus nitrates recommended for patients with moderate‐severe symptoms on optimal therapy with ACE inhibitors, Beta‐ Blockers, and Diuretics B. For patients with preserved LVEF, the treatment plan will include: 1. ACE Inhibitor for symptomatic atherosclerotic cardiovascular disease or diabetes and one additional risk factor. ARB’s can be considered if intolerant to ACE Inhibitors 3. Beta blocker in patients with prior myocardial infarction, hypertension, or atrial fibrillation requiring control of ventricular rate 4. Calcium channel blocker in patients with atrial fibrillation requiring control of ventricular rate and intolerant to beta blockers, symptom‐limiting angina, or hypertension C. Influenza vaccine administered on an annual basis D. Pneumococcal vaccine: 1. Administered PPSV23 to i. All patients age 19‐64 with a history of heart disease with no known or unknown history of prior receipt of the PPSV23 ii. All
adults 65 years or older 2. Adults who are 65 years or older and who have not previously received PCV13, should also receive a dose of PCV13 first, followed 6 to 12 months later by a dose of PPSV23. If patient has already received one or more doses of PPSV23, the dose of PCV13 should be given at least 1 year after most recent dose of PPSV23. V.
Preventive Measures: Patient Education including information and instruction about: 1.
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Signs and symptoms of worsening CHF Self‐management strategies to minimize dyspnea and fatigue Daily self‐assessment of weights Dietary restrictions (e.g. salt or fluid intake) Smoking cessation counseling if appropriate Remaining active with regular physical activity as tolerated Carrying up‐to‐date medication list Rationale for prescribed medications and their proper usage CHF Disease Management to be considered for long term patients Advanced directives and end‐of‐life decisions when appropriate Original: 01/2000 Reviewed and Revised: 03/04/2011, 04/08/2013, 6/12/2015 Stages of Heart Failure (Documentation not required but may be included in a patient’s medical record) 1. Stage A‐At high risk for heart failure, but without structural heart disease or symptoms of heart failure 2. Stage B‐Structural heart disease but without signs or symptoms of heart failure 3. Stage C‐Structural heart disease with prior of current symptoms of heart failure 4. Stage D‐Refractory heart failure requiring specialized interventions Sources: Circulation/AHA‐ Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults (Circulation 2009;1977‐2016) HFSA‐Evaluation and management of patients with heart failure and preserved left ventricular ejection fractions: HFSA 2010 comprehensive heart failure practice guideline. (J Card Fail 2010 Jun; 16 (6):e126‐
33) Journal of the American College of Cardiology‐2009 Focused Update Incorporated Into the ACC/AHA 2005 Guideline 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 NGC: Guideline synthesis: Diagnosis and evaluation of chronic heart failure (CHF): ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008; Evaluation of patients for ventricular dysfunction and heart failure: HFSA 2010 comprehensive heart failure practice guidelines; Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2011; Management of chronic heart failure. A national clinical guideline, 2007 Reviewed by Lehigh Valley Physician Hospital Organization Physician Advisory Com