Vous êtes sur la page 1sur 20

Heart Failure Patients

Management and discharge


considerations
8/5/09

Heart Failure which kind?


Heart Failure (HF) or Congestive heart
failure (CHF) are inadequate descriptors
Systolic HF, Diastolic HF, or not HF
must know EF
dont call edema/effusion HF if you have
an alternate diagnosis eg. Cancer, dialysis

What is EF?
Every patient needs the actual Ejection
Fraction noted. (normal: 50%-70%)
Systolic HF: EF below 40%
Accept an EF measurement within 3-6
months, unless there has been a change
in medical events or symptoms.

Heart Failure why?


What is the etiology of the HF?
Ischemic 50% of patients
Non-ischemic hypertension in 30%
consider: drugs, alcohol, arrhythmias such
as atrial fibrillation, valve disease especially
mitral regurgitation, infection such as HIV,
viral etc.

Heart Failure functional status


What is the patients baseline functional
status? Ask specific questions
New York Heart Association (NYHA)
I no limitations
II mild limitations
III moderate limitations (hard to do ADL)
IV severe limitations (rest, nocturnal)

Heart Failure - timeline


Were symptoms gradually building up? eg.
Weight gain, shortness of breath, edema
(patients report abrupt symptoms but data
suggest 21 days of fluid accumulation
before clinical presentation)
Has this occurred before?
When was the last time patient felt well?

example
64 y/o man with ischemic CM, baseline EF
25%, normally NYHA Class II, who
presented in pulmonary edema (Class IV).
In retrospect, he acknowledged more
shortness of breath for the last two weeks.
The night before coming to the hospital, he
slept in the chair.

Comments on this patient


Description says it all etiology, EF, baselines,
mode of presentation
History, in retrospect, provides insight into this
patients ability to recognize and self manage a
chronic condition
Our task: treat the acute symptoms but then
figure out how to prevent the same scenario

HF Medications
ALL CARDIOVASCULAR patients:
aspirin (or warfarin; Plavix if stent)
beta blocker
ACE inhibitor or Angiotensin Receptor
Blocker (ARB)
cholesterol management if ischemic
aldosterone inhibitor

Medications, cont
Beta Blockers SAVE lives!!!

Dont stop, if already on them


BB dont cause decompensation in most pts
Up titrate at every opportunity
Try to use same meds as home meds
Target: carvedilol 25-50 mg BID
metoprolol SUCCINATE (long acting) 200-400
mg a day

bisoprolol 10-20 mg a day

nebivolol HTN indication, HF in Europe

Medication cont again


ACE inhibitors are first line for HF
class effect and generic
Try to use same meds as home meds
Creatinine will go up 0.3-0.5 mg/dl for the first
3 days; do NOT stop unless hyperK,
angioedema
May use in all patients (it saves kidney
function)
If cough: assess HF. If creatinine rises:
decrease diuretics.

One more medication slide


Aldosterone inhibitors
Spironolactone, Eplerenone
Spironolactone: NYHA Class III-IV
Diastolic HF: Topcat Study (x4641)
Eplerenone: post MI, EF below 40%
NB: 15% will develop hyper K (Rales, study)
check labs after starting these drugs

Medications: AA
AA HF Study:
Hydralazine and Isosorbide added to ACEI
and BB, maximal medical therapy
Survival benefit
Note dosing: both are TID and isosorbide is
the dinitrate (isordil), not mononitrate (Imdur)
Target: hydralazine 75 mg TID
Target: isosorbide 40 mg TID

Education
Cardiac Rehab can help needs a consult request. (MF). You will need to educate on weekends and holidays.
Become familiar with educational materials, resources.
Please record in chart, teach patient and reiterate at
discharge:

salt restriction

EF (know your numbers)

each medication category if the medication is


contraindicated, it must be written (including both ACE-I
and ARB as separate entries)

A few comments
Reason for decompensation:

try and understand why

anemia, atrial fibrillation top causes

troponins are up a little, not always


considered an MI
Dont blame the patient

A few comments #2
Ascertain barriers to care:

these must be addressed or the patient


will return.

CMS: never events and readmissions


may mean no payment and quality
citations

A few comments #3
Ascertain what is this patients normal
blood pressure.
If EF is poor, BP will be below 100mmHg.
Do NOT hold/stop cardiac medications!!!
rebound HF, death, MI etc. etc.
Write orders so nurses give meds.

Sudden Cardiac Death


ALL patients with EF below 35%
THINK about ICD (defibrillator)
document, ask advice, or state why the
patient is not a candidate. (They are
supposed to live a year or two to benefit
from ICD. No ICD if not on medication, if
NYHA IV)

Discharge Process
EF documented
Medications prescribed, or documented
why not : 1) BB, 2)ACE/ARB
ICD addressed
Education completed
Follow-up arranged
Dictated. (Please include consultants
names, rather than cardiology saw pt.)

Vous aimerez peut-être aussi