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Heart Failure Management

Heart Failure Management. Focus on Primary Care Practice. mgray@medsfgh.ucsf.edu. Framingham Clinical Diagnostic Criteria Patients considered to have validated CHF if two major criteria or one major and two minor criteria were present concurrently. Major Criteria:

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Heart Failure Management

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  1. Heart Failure Management Focus on Primary Care Practice mgray@medsfgh.ucsf.edu

  2. Framingham Clinical Diagnostic Criteria • Patients considered to have validated CHF if two major criteria • or 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

  3. Framingham Clinical Diagnostic Criteria • Patients considered to have validated CHF if two major criteria • or 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. AHA 2009: Get With The Guidelines – HF • HF Quality Measures • Implantable Cardiac Defibrillator (ICD) in patients with • LV ejection fraction ≤ 35% and no contraindications

  12. 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

  13. 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

  14. HFSA 2006: Hospitalization Recommended • Evidence of severely decompensated heart failure: • hypotension, renal dysfunction, altered mental status • Shortness of breath: resting tachypnea, O2 desaturation

  15. HFSA 2006: Hospitalization Recommended • Hemodynamically significant cardiac arrhythmias • Acute coronary syndromes

  16. HFSA 2006: Hospitalization Considered • Weight gain > 5 kg, even without shortness of breath • Pulmonary congestion, even without weight gain • Major electrolyte disturbances

  17. HFSA 2006: Hospitalization Considered • Co-morbidity: pneumonia, pulmonary embolism, TIA • Repeated firings of implantable cardiac defibrillator • Previously undiagnosed HF with significant congestion

  18. 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

  19. Maximum Daily Dose Duration of Action Loop Diuretic Bumetanide 0.5 to 1.0 mg once or twice 10 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

  20. Maximum Daily Dose Duration of Action Loop Diuretic Bumetanide 0.5 to 1.0 mg once or twice 10 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

  21. Maximum Daily Dose Duration of 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

  22. Maximum Daily Dose Duration of 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

  23. 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

  24. 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

  25. ACE Inhibitors: Adverse Effects • Hypotension • Worsening Renal Function • Hyperkalemia • Cough • Angioedema

  26. 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)

  27. -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

  28. Beta-Blockers: Adverse Effects • Fluid Retention and Worsening HF • Hypotension • Bradycardia and Heart Block • Bronchospasm • Fatigue and Depression

  29. Aldosterone Antagonists • Spironolactone 12.5 to 25 mg once Max 50 mg daily • Eplerenone 25 mg once daily Max 50 mg daily

  30. Aldosterone Antagonists: Adverse Effects • Hyperkalemia • Gynecomastia • Erectile Dysfunction, Testicular Atrophy

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