heart failure management

Heart Failure Management

mgray@medsfgh.ucsf.edu

Focus on Primary Care Practice

Framingham Clinical Diagnostic Criteria

Patients considered to have validated CHF if two major criteriaor one major and two minor criteria were present concurrently.

Major Criteria:

• Paroxysmal nocturnal dyspnea• Orthopnea• Elevated jugular venous pressure• Pulmonary rales• Third heart sound• Cardiomegaly on chest radiograph• Pulmonary edema on chest radiograph

Framingham Clinical Diagnostic Criteria

Patients considered to have validated CHF if two major criteriaor one major and two minor criteria were present concurrently.

Minor Criteria:

• Peripheral edema• Night cough• Dyspnea on exertion• Hepatomegaly• Pleural effusion• Heart rate greater than 120 beats per minute

AHA: Evaluation of Heart Failure Patients

• History and physical examination to identify the cardiac and non-cardiac disorders that might cause heart failure

• Assessment of ability to perform activities of daily living

• Initial and ongoing assessment of clinical volume status

• CBC, electrolytes, BUN, creatinine, glucose, LFTs, TSH

New York Heart Association: Function

• Class I: Asymptomatic

• Class II: Symptoms with moderate activity

• Class III: Symptoms with mild activity

• Class IV: Symptoms present at rest

AHA: Evaluation of Heart Failure Patients

• Electrocardiogram. PA / lateral chest radiograph

• Echocardiogram to assess valvular morphologies and left and right ventricular contractile function

• Cardiac catheterization in patients with angina who are candidates for revascularization procedures

AHA 2009: Get With The Guidelines – HF

HF Achievement Measures

• ACEI / ARB: LV ejection fraction < 40% or narrative indicating moderate or severe LV systolic dysfunction

• Beta Blocker: LV ejection fraction < 40% or narrative indicating moderate or severe LV systolic dysfunction

AHA 2009: Get With The Guidelines – HF

HF Achievement Measures

• Instructions addressing activity level, diet, medications, weight monitoring, what to do if there are problems

• Formal evaluation of left ventricular contractile function

• Smoking cessation advice or counseling documented

AHA 2009: Get With The Guidelines – HF

HF Quality Measures

• Aldosterone Antagonist: Left ventricular dysfunction and no significant contraindications or intolerance

• Warfarin: Chronic or intermittent atrial fibrillation

AHA 2009: Get With The Guidelines – HF

HF Quality Measures

Hydralazine-Nitrate combination therapy in black patients with left ventricular systolic dysfunction and no significant contraindication or intolerance

Treatment in addition to ACEI / ARB and β blocker

AHA 2009: Get With The Guidelines – HF

HF Quality Measures

Implantable Cardiac Defibrillator (ICD) in patients with LV ejection fraction ≤ 35% and no contraindications

AHA 2009: Get With The Guidelines – HF

HF Quality Measures

Cardiac Resynchronization Therapy (CRT) with (CRT-D) or without (CRT-P) defibrillator when LV ejection fraction ≤ 35%, QRS duration ≥ 120 ms, and no contraindication

AHA 2009: Get With The Guidelines – HF

HF Reporting Measures

Influenza and pneumococcal vaccinations

Systolic BP < 140 mmHg. Diastolic BP < 90 mmHg

Diabetes teaching and treatment

Lipid-lowering medication in CAD, PVD, CVA, DM

HFSA 2006: Hospitalization Recommended

• Evidence of severely decompensated heart failure: hypotension, renal dysfunction, altered mental status

• Shortness of breath: resting tachypnea, O2 desaturation

HFSA 2006: Hospitalization Recommended

• Hemodynamically significant cardiac arrhythmias

• Acute coronary syndromes

HFSA 2006: Hospitalization Considered

• Weight gain > 5 kg, even without shortness of breath

• Pulmonary congestion, even without weight gain

• Major electrolyte disturbances

HFSA 2006: Hospitalization Considered

• Co-morbidity: pneumonia, pulmonary embolism, TIA

• Repeated firings of implantable cardiac defibrillator

• Previously undiagnosed HF with significant congestion

Professional Practice Committee (PPC) 2010

Q: When should I refer my HF patient to a cardiologist?

A: We Are Here to Help: eReferral, email, appointment

Loop Diuretic

Bumetanide 0.5 to 1.0 mg once or twice10 mg 4 to 6 hours

Furosemide 20 to 40 mg once or twice 600 mg 6 to 8 hours

Torsemide 10 to 20 mg once 200 mg 12 - 16 hours

Initial Daily Dose MaximumDaily Dose

Durationof Action

Loop Diuretic

Bumetanide 0.5 to 1.0 mg once or twice10 mg 4 to 6 hours

Furosemide 20 to 40 mg once or twice 600 mg 6 to 8 hours

Torsemide 10 to 20 mg once 200 mg 12 - 16 hours

Initial Daily Dose MaximumDaily Dose

Durationof Action

Thiazides

Chlorothiazide 250 to 500 mg once or twice 1000 mg 6 - 12 hours

HCTZ 25 mg once or twice 200 mg 6 - 12 hours

Chlorthalidone 12.5 to 25 mg once 100 mg 24 - 72 hours

Indapamide 2.5 mg once 5 mg 36 hours

Metolazone 2.5 mg once 20 mg 12-24 hours

Initial Daily Dose MaximumDaily Dose

Durationof Action

K+ Sparing

Amiloride 5 mg once 20 mg 24 hours

Spironolactone 12.5 to 25 mg once 50 mg 2 - 3 days

Triamterene 50 t0 75 mg twice 200 mg 7 - 9 hours

Initial Daily Dose MaximumDaily Dose

Durationof Action

Sequential Nephron Blockade

Metolazone 2.5 to 10 mg once plus loop diuretic

Hydrochlorthiazide 25 to 100 mg once or twice plus loop diuretic

Chlorothiazide 500 to 1000 mg once plus loop diuretic

ACE Inhibitors

• Captopril 6.25 mg 3x daily Max 150 mg daily

• Enalapril 2.5 mg twice daily Max 40 mg daily

• Fosinopril 5 to 10 mg once daily Max 40 mg daily

• Lisinopril 2.5 to 5 mg once daily Max 40 mg daily

• Ramipril 1.25 to 2.5 mg once daily Max 10 mg daily

ACE Inhibitors: Adverse Effects

• Hypotension

• Worsening Renal Function

• Hyperkalemia

• Cough

• Angioedema

Angiotensin Receptor Blockers

• Candesartan 4 to 8 mg once daily (Max 32 mg daily)

• Losartan 25 to 50 mg once daily (Max 100 mg daily)

• Valsartan 20 to 40 mg twice daily (Max 320 mg daily)

-Adrenergic Receptor Blockers

• Bisoprolol 1.25 mg once daily Max 10 mg daily

• Carvedilol 3.125 mg twice daily Max 50 mg daily

• Metoprolol XL 12.5 to 25 mg once Max 200 mg daily

Beta-Blockers: Adverse Effects

• Fluid Retention and Worsening HF

• Hypotension

• Bradycardia and Heart Block

• Bronchospasm

• Fatigue and Depression

Aldosterone Antagonists

• Spironolactone 12.5 to 25 mg once Max 50 mg daily

• Eplerenone 25 mg once daily Max 50 mg daily

Aldosterone Antagonists: Adverse Effects

• Hyperkalemia

• Gynecomastia

• Erectile Dysfunction, Testicular Atrophy