Download Heart Failure - Dr Ted Williams

Heart Failure
Guideline
Stages
CHEST Protocol
A
B
Classes
1.
2.
3.
4.
Types
Symptoms of HF
High risk , no Sx
C
Sx
No structural defects
Structural Defects
High Risk, No Sx
D
Refractory
Structural defects
Cardiac Disease without limitations of activities
Cardiac Disease with slight limitations. Ordinary activies result in fatigue,
palpitations, Dyspnea, or Angina
Cardiac Disease with marked limitations. Less than ordinary activites
result in symptoms.
Cardiac Disease with the inability to perform normal activities without
discomfort. Symptoms present even at rest.
1. Systolic (Low EF <40%)
2. Diastolic (norm EF)
1. Dyspnea
2. Cyanosis in Acute CHF
3. Orthopnea
4. Paroxysmal Nocturnal Dyspnea (PND)
5. Cardiac Asthma
6. Fatigue
7. Bilateral Edema
8. Pulmonary Rales (Crackles due to Pulmonary Edema)
9. Pleural Effusion
10. Abdominal Symptoms
o Hepatomegaly (Severe Cases)
o
o
o
Pharmacological
Treatments
Goals of Tx
Monitoring
Patient
Education
Anorexia
Nausea
Ascites (Fluid in the abdominal Cavity)
1. ACEI & BB
2. ARB, BiDil (CI D HF)
3. Diuretics
a. Loop
b. Spironolactone
4. Verapamil (CI in S HF)
1.
2.
3.
4.
Relieve uncomfortable sx
Reduce Remodeling
Improve exercise tolerance
Reduce complications
Weight
Monitoring for SE
Hypertension
Guidelines

JNC-7

NICE (National Institute of Health and Clinical Excellence)

Canadian Hypertension Education Program

Elevated Blood Pressure

Target Organ Damage
Stages
Symptoms
o Kidney Damage
o Vision Disturbances
o Angina
o TIA
Etiology
1. Kidney Disease
Most common cause of Secondary Hypertension
Aortic Coarctation
o
2.
3. Aldosteronism
Hypersecretion of Aldosterone
4. Hyperthyroidism/Parathyroid disease
5. Cushing's Syndrome
6. Pheochromocytoma
7. Sleep Apnea
8. Increase Intracranial Pressure
9. Lifestyle
10. Medications
o Stimulants
o Steroids
o Psychoactive Drugs
o NSAIDs
o Thyroid Replacement
o
Goals
TLC
Dependent upon comorbidities
1. Diabetes
2. Complicated HF
3. Uncomplicated HF
Prevent Target Organ damage
1. Cardiac
2. Cerebrovascular
3. PVD
4. Kidney
5. Retinopathy
1. Diet (DASH)
2. Weight Loss (BMI<25 or 10kg)
3. Exercise
4. Quit Smoking
5. Limited EtOh
Pharmacological
Tx
1.
2.
3.
4.
Thiazide Diuretics
ACE Inhibitors/ARBs
Calcium Channel Blockers
Beta Blockers
Monitoring



Patient
Education

BP
HR
Chem 7
o Potassium with Thiazides & ACEI
o BUN/SCr for Kidney Damage
Side Effects
o Direct
o Masking (e.g. Thiazides and Hyperglycemia)
Self Testing
o BP
o HR

Hyperlipidemia
Guidelines
Etiology
Staging/Risk
Factors
Goals
Signs & Sx
Pharmacological
Tx
TLC
Level (LDL/TLC Initiation/ Rx initiation)
Very High (70/100/130)
 ACS
 CHD +
o Diabetes
o Metabolic syndrome
o Smoking
o HTN
CHD/CHD Equiv(100/100/130)
 MI
 Angina
 PVD
 Stroke
 Diabetes
Framingham Risk factors
1. Age>45
2. Smoking
3. HTN
4. FH CHD
5. HDL< 40
2+ FRF 10-20% (130/130/130)
2+ FRF 0-10% (130/130/160)
1 FRF (160/160/190)
LDL driven by risk factors
LDL-c > Target
TG >150
TG > 500 Hypertriglyceridemia
1. Statins 40% (RASLPF 5:20:40:80:80:160)
2. Fibric Acid Derivatives (+/-)
3. Anionic Resins (15-30)
4. Niacin (5-25%)
5. Ezetimibe (15%)
6. Sitosterol
7. Omega 3 Fatty Acids
Diet
Exercise
Smoking
Weight Loss
Monitoring
Patient
Education
Myalgia 4 wks
LDL 6-8 wks
LFT 6-12 wks
CK
DI
 3A4
o Lovastatin
o Simvastatin
o Atorvastatin
 2C9
o Fluvastatin
 Renal
o Rosuvastatin
Myalgia
Diabetes
Guidelines
Etiology
Staging
Goals
Signs & Sx
ADA Guidelines
1. type 1
2. Type 2
a. Hyperglycemia
i. Drug induced
ii. Diet induced
iii. Poor compliance
b. Hypoglycemia
i. Drug Induced
None
 FBG < 100
 Post Pradial <180
 A1C < 7.0% or 6.5% if patient can tolerate
1. Hypoglycemia
a. Altered Mental Status
i. Irritability
ii. Confusion
b. Sweating
c. Shaking
d. Tachycardia
e. HA
f. Hunger
2. Hyperglycemia
a. Polydipsia
b. Polyurea
c. Polyphagia
d. Weight Loss
e. Ketoacidosis
f. Gastroparesis
3. Ketoacidosis
a. Tachycardia
b. Hypotension
c. Dehydration
d. Kussmal Sign
e. Altered Mental Status
f. Ketotic Breath
4. Lactic Acidosis
a. Dyspnea
b. Muscle Aches
c. Altered Mental Status
d. Palpitations
Pharmacological
Tx
TLC
Monitoring
Patient
Education



Compliance
Diet
Exercise
FBG QD
PPBG TID
A1C Q 3 months
SE
Hypoglycemia
 Sx
 Tx
Hyperglycemia
 Sx
 Tx
General Notes
Points to Know for each Disease State
1.
2.
3.
4.
5.
6.
7.
8.
Guidelines
Etiology
Staging
Signs & Sx
Pharmacological Tx
TLC
Monitoring
Patient Education
Points to know for each drug
1.
2.
3.
4.
Dosing Schedule
Therapeutic Range
Titration
Push Dose before switching until
a. Max effective dose
b. Intolerance
c. Excessive Risk
5. Side Effects & Monitoring of SE
Presentation
1. Introduction
a. Who am I
b. What disease state am I presenting
2. Subjective
a. Chief complaint
b. HPI
c. PMH
d. SH/FH
e. Allergies
3. Objective
a. Medication list
b. Labs
c. PE
4. Prioritized Problem List
5. Assessment
a. According to the S & O of X and Y, this patient has…
i. Stage/Severity
ii. Etiology
b. According to Guidelines they can be treated with
i. TLC
ii. 2+ medication options Pros and Cons
c. Goals of Treatment are…
6. Plan
a. Start…
b. Stop…
c. Continue…
d. Drug, Dose, Route, Schedule
7. Monitoring
a. Clinic
b. Self Monitoring
8. Patient Education
a. Monitoring instructions
b. Specific Sx to watch for
c. “Patient Verbalized understanding of…”