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2012 CCU Competency
Heart Failure Module 1:
Medical Management Issues
Heart failure is our disease specific focus
area for 2012 competency.
 There will be 2 modules, each with a
specific focus.

◦ Medical Management Issues
◦ Nursing Driven Care
◦ Quality Outcome Assessment
Heart Failure Focus for 2012

The purpose of this module is to review
key medical management areas where
there is opportunity for improvement.

As part of the interdisciplinary team a
thorough understanding of medical
treatment goals will allow you to optimally
contribute to the treatment plan and
advocate for your patients with heart
failure.
Purpose
Stages of Heart Failure
ACC / AHA
Stage A
Stage B
Stage C
Stage D
At high risk for HF
but without structural
heart disease or
symptoms of HF.
Structural heart
disease but
without signs or
symptoms of HF
Structural heart
disease with prior
or current
symptoms of HF.
Refractory HF
requiring
specialized
interventions.
Previous MI
LV Remodeling
including LVH
and low EF
Asymptomatic
valvular disease
Known structural
disease and SOB,
fatigue, reduced
exercise tolerance.
Marked
symptoms of HF
at rest despite
maximal
medical therapy.
HTN
CAD
DM
Obesity
Metabolic syndrome
Family HX CM
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Classification of Heart Failure:
New York Heart Association
Class I
Class II
Class III
Class IV
Cardiac disease
no resulting
limitation in
physical activity.
Cardiac disease
with slight
limitation of
physical activity.
Cardiac disease
with marked
limitation on
physical activity.
Cardiac disease
resulting in
inability to carry
out any physical
activity without
discomfort.
Ordinary activity
free of fatigue,
palpitation,
dyspnea or
anginal pain.
Comfortable at
rest but ordinary
activity results in
fatigue,
palpitations,
dyspnea, or
anginal pain.
Comfortable at
rest but less than
ordinary activity
results in fatigue,
palpitations,
dyspnea, or
anginal pain.
May have
symptoms of
cardiac
insufficiency at
rest.
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Systolic Dysfunction
(Reduced EF)
Diastolic Dysfunction
(Preserved EF)
6

Although the commonly used terms are systolic
and diastolic heart failure, the current
recommended terms are heart failure with
preserved left ventricular function and heart
failure with reduced left ventricular function.

The reason for the clarification is because most
patients with “systolic heart failure” also have
some abnormalities during diastole, and patients
with “diastolic heart failure”, although their
overall EF is normal do not have completely
normal systolic function.
Heart failure with preserved or
reduced left ventricular function.

There are evidence based guidelines for the
management of patients with heart failure
with reduced LV function.
◦
◦
◦
◦
ACE-I (or ARB)
Beta blocker
Aldosterone antagonists (NYHA Class III or IV HF)
Hydralazine / Nitrate combination (for African Americans
- in addition to standard therapy)
◦ Cardiac resynchronization therapy if BBB (especially
LBBB) and EF < 35%
◦ Referral for ICD therapy if EF < 35%
Evidence Based Guidelines for
Heart Failure with Reduced LV
Function

There are only three beta-blockers that are
recommended for use in patients with reduced
LVEF (<40%)

These are considered evidence based beta
blockers
◦ Carvedilol (Coreg)
◦ Metoprolol succinate (long acting metoprolol) (ToprolXL)
◦ Bisprolol (Zebeta)

This is the reason you may see patient’s
switched from Lopressor, which is metoprolol
tartrate (short acting metoprolol)
Quality Indicator: In 2011 evidence based beta
blockers were only prescribed 84.7% of the time.
More on Beta-Blockers
In HF patients with preserved LVEF (diastolic
dysfunction) the focus is on managing the patient’s
comorbid conditions. This means rate control in
atrial fibrillation, treatment of hypertension, and
diagnosis and treatment of obstructive sleep apnea.
Note:
There are no clear evidence based guidelines for
patients with preserved LVEF.

Our quality data indicates that only 60-65%
of potentially eligible patients have
documentation regarding counseling or
referral for cardiac resynchronization therapy
and / or ICD.

When caring for a heart failure patient
with an EF < 35% ask / discuss during
rounds if this patient is a candidate for
CRT and / or ICD therapy.
Focus areas to improve outcomes.
Cardiac Resynchronization
Therapy (CRT)

Treatment modality for heart failure not just pacing
◦ Used in patients with dysynchrony (QRS > 120 msec)


Used in conjunction with optimal drug therapy
In addition to the atrial lead there are two
ventricular leads
◦ RV Apex
◦ LV lateral wall



Goal: Force biventricular pacing
Goal: Ventricular Pacing 90% of time or greater
Anticipated Outcomes:
◦ Improve hemodynamics by restoring synchrony of ventricular
contraction
◦ Improve quality of life
◦ Decrease mortality and morbidity
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Implantable Cardiovertor
Defibrillator - Indications
 Secondary
Prevention
(Class IA Recommendation)
◦ Symptoms of HF
◦ History of cardiac arrest, VF, or hemodynamically
destabilizing VT
 Primary
◦
◦
◦
◦
Prevention
(Class IA Recommendation)
Non-ischemic dilated myopathy or ischemic heart disease >
40 days post-MI or > 90 days post intervention
EF < 35%
NYHA class II or III in optimal medical therapy
Not recommended in Stage D
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Recognizing Potential Obstructive Sleep Apnea
Another Important Opportunity for Improvement







Approximately 1 in 5 adults: mild
Approximately 1 in 15 adults: moderate
/ severe
15 million Americans
> 85% have not been diagnosed
Adverse consequences may be greater
in those < 50 years.
High prevalence of pathological daytime
sleepiness in OSA
Almost all with OSA snore but not all
snorers have OSA
Obstructive Sleep Apnea
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Reflex muscle • Airway narrowing or
collapse
activity is
reduced /
lost
Apnea or
hypoapnea
occurs
• Hypoxia and
hypercapnea stimulate
ventilatory effort and
arousal occurs
During Sleep
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Hemodynamic
Instability
Increased
negative
intrathoracic
pressure
Increased
transmural
gradient
Increased
Afterload
Increased
atrial size
Autonomic
Instability
Aortic
dilation
Diastolic
dysfucntion
Ventricular
Dysfunction
Physiological Impact of Obstruction
17

The prevalence of sleep apnea in heart failure
has been reported to be approximately 50%.
◦ This includes both obstructive and central sleep
apnea.


In this study of 30,719 Medicare HF patients
only 2% were tested for sleep apnea.
Those who were tested, diagnosed and
treated had improved survival compared to
those who were not.
Source:
Javaheri, et al. (2011). American
Journal of Respiratory Critical Care Medicine,
183, 539-546.
Answer each of the following yes or no:
1. Do you SNORE loudly (louder than talking or loud enough to be
heard through closed doors)?
2. Do you often feel TIRED, fatigued, or sleepy during daytime?
3. Has anyone OBSERVED you stop breathing during your sleep?
4. Do you have or are you being treated for high blood PRESSURE?
5. BMI more than 35?
6. AGE over 50 years old?
7. NECK circumference > 15.75 inches?
8. Male GENDER?
≥3 yes answers: High-risk for OSA
<3 yes answers: Low-risk for OSA
The STOP-BANG Screening Tool
for Obstructive Sleep Apnea.

Our focus is linking knowledge to practice and
practice to patient outcomes. For this module we
want to increase awareness of our practice
patterns in the care of HF patients.

Find one patient in CCU admitted with HF
with a reduced LVEF:
◦ Does the patient have a LVEF of < 35%
 If yes - does the patient have an ICD? If not – is there a
notation regarding contraindication?
◦ Does the patient have a LBBB and a LVEF of < 35%
 If yes – does the patient have a CRT device? If not is
there a notation regarding contraindication?
◦ What is the patient’s STOP BANG Score?
 Is the patient being treated for sleep apnea?
 If not has the patient ever had a sleep study?
To Complete this Module: Document the answers to the
above patient questions in QUIA. Put the date, room
number and initials of the patient you assessed.
For your Portfolio.
Please include any examples of your input into rounding
or collaborative discussion where you have identified
potential candidates for ICD/CRT or sleep apnea testing.
Thank you.
Your commitment to excellence makes a difference!