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Download Heart Failure ACOVE Initial Visit Form Heart
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HEART FAILURE – Initial Visit Reason for Visit: New Diagnosis of HF HF Symptoms: YES NO Page 1 of 2 [sticker here] NO YES Weight gain………… , # of lbs_____ SOB………………… Patient has scale….. Chest pain/angina… , frequency ______________________ Orthopnea …………. , # of pillows _____ Edema……………… Limitations in ability to perform daily activities: __________________________________________________________________ Current medications (NOT for heart failure): List OTHER medications and dose: (Record heart failure medications under Treatment ON NEXT PAGE.) Can worsen HF: NSAIDs, antiarrhythmic drugs (other than amiodarone), calcium channel blockers (other than amlodipine or felodipine), thiazolidinediones (glitazones), cilostazol Past history NO YES NO YES Alcohol abuse…………… , _________________ Prior chemotherapy……… , _____________________ CAD/MI/revascularization , _________________ Hypertension……………... , _____________________ Diabetes…………………. , _________________ Hyperlipidemia…………… , _____________________ Thyroid disease …………. , _________________ Valvular heart disease….. , _____________________ Prior smoking……………. , pack years: _____ ICD………………………… Currently smoking………. , pack years: _____ CRT……………………….. Prior intolerance of HF meds (list and describe intolerance):__________________________________________________ Examination: P: _____ Irreg Reg R: ____ Sitting BP: ____/____ Standing BP: ____/____ General:_________________________ Lungs: NO Rales……………………… Effusion…………………… Abdominal : Hepatomegaly/ascites…... Weight (prior/current) ______/_______ YES , ____________ , ____________ Cardiovascular: NO Murmur…………………… S3…………………………. Edema…………………… JVP/hepatojugular reflux Height: ________ BMI ____ YES , _____ grade , _____ + Diagnostic Tests: (Order if not performed within prior 3 months) CXR BNP/NT-proBNP CMP LDL CBC TSH Urinalysis EKG Order or mo/yr done Nl _________ _________ _________ _________ _________ _________ _________ _________ Echocardiogram _________ Stress test _______ __ Assessment: NYHA Class: Results/Abnormalities _________________________________ _____ pg/ml __________________________________ (Including Na, K, BUN, Cr, glucose, albumin, LFT) _____mg/dL _________________________________ _________________________________ _________________________________ _________________________________ EF____%; PA systolic pressure _____ I (no physical activity limitation) II (sx with normal exertion) Comorbid conditions: Ischemic MR TR Diastolic dysfunction Order if indicated (known CAD or dyspnea) Systolic HF (ejection fraction <40%) HF with preserved systolic function (diastolic) Probable cause of HF: AS valvular Atrial fibrillation CAD CKD DM Symptomatic bradycardia Severe reactive lung disease Volume status: Euvolemic Volume overloaded Hypovolemic III (sx with < ordinary exertion) IV (sx at rest) Hypertensive Viral Other: _____________ Unknown *Candidate for ICD (≥40d post MI, LVEF ≤35%, life expectancy >1yr) *Candidate for CRT (LVEF <35%, QRS ≥12s, NYHA II-IV) *Refer to cardiology Page 1 of 2 HEART FAILURE – Initial Visit Page 2 of 2 Treatment: (If orthostatic symptoms develop, stagger timing of doses of different medications) Stage I-IV HF ACEI dose (target) current/new * OR ARB** dose (target) current/new* enalapril (10 bid) _____/_____ quinapril (20 bid) _____/______ candasartan (32 qd) _____/_____ lisinopril (20 qd) _____/_____ benazepril (40 qd) _____/_____ valsartan (80-160 bid) _____/_____ captopril (50 tid) _____/_____ ramapril (10 qd) _____/______ Intolerant/contraindicated: ________________________________________________________________________ (↑K, or hx of angioedema, or ACEI-induced renal impairment) * When starting or adjusting ACEI or ARB dose, check Basic Metabolic Panel 1-2 weeks later. **ARB if ACEI contraindicated or not tolerated and Beta blocker dose (target) current/new; titration recommendations carvedilol (25 bid) _____/_____ Initial dose 3.125 bid, then 6.25, 12.5 bid; increase at 2-8 week intervals metoprolol XL (200 qd) _____/_____ Initial dose 12.5 qd, then 25 qd, 50 qd, 100 qd,150 qd; increase at 2-8 week intervals bisoprolol (10 qd) _____/_____ Initial dose 1.25 qd, then 2.5 qd, 5 qd,; increase at 2-8 week intervals Intolerant/contraindicated: ________________________________________________________________________ (Symptomatic bradycardia, 2nd or 3rd degree block without pacer, severe reactive airway disease) Stage III-IV HF Add Aldosterone Antagonists* (target dose) current/new; titration recommendations spironolactone (25 mg qd) _____/_____ Initial dose 6.25 mg, then 12.5 mg, then 25 mg maximum eplerenone (50 mg qd) _____/_____ Initial dose 12.5 mg, then 25 mg, then 50 mg maximum Intolerant/contraindicated: __________________________________________________________________________ (Hyperkalemia is an absolute contraindication; avoid if Cr >2.5 mg/dL in men or >2.0 mg/dL in women) * Check Basic Metabolic Panel at 1 & 4 weeks Symptomatic Treatment drug/dose Loop diuretic: ___________________/_______ K+ supplementation Vasodilator: ____________________/_______ Digoxin, dose: _______ mg/dL (Target serum level is 0.5-0.8 mg/dL) For persistent NYHA class III-IV and LVEF < 40% despite optimal therapy Add hydralazine AND isosorbide dinitrate (target dose) current/new; titration recommendations hydralazine (75 mg TID) ______/______ Initial dose 25 mg TID and titrate to 75 mg TID isosorbide dinitrate (40 mg TID) ______/______ Initial dose 20 mg TID and titrate to 40 mg TID Treating comorbid conditions Atrial fibrillation: Rate controlled Warfarin (if chronic or paroxysmal) OR contraindication: ___________________ CAD: Statin: __________________________________ Aspirin Smoking cessation Alcohol reduction BP, target SBP: <140 <130 (if diabetic) _____ Other treatments Counseled re: Cardiology consult Medication use, dosage, intervals, side effects Referral to cardiac rehabilitation Dietary sodium Community exercise program Dietary fat Smoking cessation Rx: ________________ Recommended exercise Diet, 2-3 g Na Smoking cessation counseling Weight monitoring, target weight ______ lb Prognosis/end-of-life issues discussed Pneumonia vaccination Symptom management and contingency plan Flu vaccination Avoidance of NSAIDs Other:____________________________ Other: ______________________________________________________ Handouts: ___________________________________________________ Next follow-up visit: __________ Provider’s Signature_____________________________________________ Date of Visit___________________ Rev. 8-14-09
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