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6/16/2016 1 1 Heart Failure Review Course Part 4 Connie M. Lewis MSN, ACNP-C, NP-C, CCRN, CHFN, FHFSA Vanderbilt University Medical Center June 2016 Objectives Discuss heart failure disease management. Describe transition of care Review professionalism Case Study 1 Myocarditis, Spironolactone, Research Study-consent, Obesity 36 year old Caucasian firefighter from 220 miles, 2 states away from main campus referred for transplant evaluation Myocarditis, diagnosed with nonischemic cardiomyopathy PMH: hyperlipidemia, hypertension, obesity (BMI 38) ECHO: LVEF: 20-25%. LVEDD: 6.3 cm. Mild MR and TR Cardiopulmonary exercise test: SVO2: 24.3 ml/kg/min. RQ: 1.02 ml/kg/min Medications VanderbiltHeart.com Carvedilol 6.25 mg bid Furosemide 40 mg bid

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6/16/2016

1

1

Heart Failure Review Course

Part 4

Connie M. LewisMSN, ACNP-C, NP-C, CCRN, CHFN, FHFSA

Vanderbilt University Medical Center

June 2016

Objectives

♥ Discuss heart failure disease management.

♥ Describe transition of care

♥ Review professionalism

Case Study 1 Myocarditis, Spironolactone,

Research Study-consent, Obesity

36 year old Caucasian firefighter from 220 miles, 2 states

away from main campus referred for transplant evaluation

Myocarditis, diagnosed with nonischemic

cardiomyopathy

PMH: hyperlipidemia, hypertension, obesity (BMI 38)

ECHO: LVEF: 20-25%. LVEDD: 6.3 cm. Mild MR and TR

Cardiopulmonary exercise test: SVO2: 24.3 ml/kg/min.

RQ: 1.02 ml/kg/min

Medications

VanderbiltHeart.com

Carvedilol 6.25 mg bid

Furosemide 40 mg bid

6/16/2016

2

Obesity

Prevalence of overweight (BMI 25-29.9 kg/m2) and

obesity (BMI >30 kg/m2) is increasing

Elevated BMI alone is an independent risk factor for

development of HF

Obesity paradox - Higher BMI associated with better

outcomes in HF

Lavie CJ. JACC. 2013;1(2):93-102

Case Study 1

Myocarditis, Spironolactone, Research Study-consent, Obesity

Review of Symptoms

Fatigue

Short of breath with walking < one block on level ground

Cough

No chest pain, palpitations, syncope, near syncope,

PND, or orthopnea

Physical Exam

104/70, HR 56, BMI 38

JVD 10 cm, + HJR, 2+ LE edema

VanderbiltHeart.com

Case Study 1

Myocarditis, Spironolactone, Research Study-consent, Obesity

• ACCF/AHA stage C, NYHA class III

Hemodynamic Profile Assessment?

VanderbiltHeart.com

ACCF/AHA stage?

NYHA class?

6/16/2016

3

Case Study 1

Plan

Enroll in HF Disease Management Program

VanderbiltHeart.com

HF Disease Management Programs

(HFDMP) HFDMP provide specialty and individualized care (eg, extensive education,

symptom management, financial and social assistance, dietary referrals and consultation, laboratory and other diagnostic testing, pharmacology management)

Recommended components of a HFDMP:– Comprehensive education and counseling individualized to patient

needs– Promotion of self-care and engagement, including self-adjustment of

diuretic therapy in appropriate patients (or with family member/caregiver assistance)

– Emphasis on behavioral strategies to increase adherence– Vigilant follow-up after hospital discharge or prolonged periods of

instability – Coordination of care between the primary care physician and HF care

specialists and other agencies (eg, home health, cardiac rehabilitation) Patients recently hospitalized for HF and those at high risk for HF

decompensation should be considered for a referral to a HFDMP.

HF Nursing Certification: Core Curriculum Review 2nd Edition

Heart Failure Disease Management

Effective collaboration that prevents lapses in care and services for patients when transitioning from hospital to home include:

– Familiarity with one another’s practice and backgrounds

– Clear delineation of roles, responsibilities, and expectations related to individual cases

– Forums for ongoing communication and follow-up

– Recognizing that responsibility for certain aspects of the discharge planning process may

be shared but that one individual is in charge

6/16/2016

4

Patients May Be Discharged From the HFDMP

Program If: Patient or their family/caregiver demonstrate independence in

following prescribed treatment plan

Adequate or improved adherence to treatment guidelines

Improved functional capacity or cardiac function

Symptom stability

*Patients experiencing increased episodes of exacerbation or

demonstrate instability after discharge should be referred again to

the service

Pharmacologic Treatment for Stage C HFrEFHFrEF Stage C

NYHA Class I – IV

Treatment:

For NYHA class II-IV patients.

Provided estimated creatinine

>30 mL/min and K+ <5.0 mEq/dL

For persistently symptomatic

African Americans,

NYHA class III-IV

Class I, LOE A

ACEI or ARB AND

Beta Blocker

Class I, LOE C

Loop Diuretics

Class I, LOE A

Hydral-Nitrates

Class I, LOE A

Aldosterone

Antagonist

AddAdd Add

For all volume overload,

NYHA class II-IV patients

ACCF/AHA Guidelines for the Management of Heart Failure.

Circulation.2013

Case Study 1

VanderbiltHeart.com

Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL orless in women (or estimated glomerular filtration rate >30 mL/min/1.73 m2), and potassium should be less than 5.0 mEq/L. Careful monitoring of potassium, renal

function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency

ACCF/AHA Guidelines for the Management of Heart Failure.

Circulation.2013

6/16/2016

5

Case Study 1

Already on carvedilol and furosemide

What would medication would you add next?

A. ACE-I/ARB (RAAS)

B. Aldosterone antagonist

C. Statin

D. Digoxin

Lisinopril 2.5 mg daily

Spironolactone 25 mg daily

VanderbiltHeart.com

A. ACE-I/ARB first

Medication Management

Strategies

Use once-daily dosing whenever possible

Tailor medications to patients’ daily schedules

Consider providing pre-prepared pill dispensers

Pill bottles should be labeled in large print with drug name and

dosing regimen

Provide updated medication list and written instructions for

medication changes at every visit

Ask about over-the-counter medications

Check with the patient about how they are tolerating their

medications; do not assume they are taking them as prescribed

Case Study 1

Medication were maximized

♥ Carvedilol 25 mg bid

♥ Lisinopril 20 mg daily

♥ Spironolactone 25 mg

♥ Repeat ECHO after 3 months of GDMT: LVEF 30%

♥ ACCF/AHA stage C, NYHA class II

♥ EKG: QRS 120 ms

VanderbiltHeart.com

Next Steps????

6/16/2016

6

Case Study 1

Plan

♥ Refer for ICD

♥ Enroll in research study

VanderbiltHeart.com

ICD Device Therapy for Stage C HFrEF

Recommendations COR LOE

ICD therapy is indicated in patients who are survivors of cardiac arrest due to VF or

hemodynamically unstable sustained VT after evaluation to define the cause of the

event and to exclude any completely reversible causes.

I A

ICD therapy is indicated in patients with structural heart disease and spontaneous

sustained VT, whether hemodynamically stable or unstable. (Level of Evidence: B) I B

ICD therapy is indicated in patients with syncope of undetermined origin with

clinically relevant, hemodynamically significant sustained VT or VF induced at

electrophysiological study.

I B

ICD therapy is indicated in patients with LVEF less than or equal to 35% due to prior

MI who are at least 40 days post-MI and are in NYHA functional Class II or III. I A

ICD therapy is indicated in patients with nonischemic DCM who have an LVEF less

than or equal to 35% and who are in NYHA functional Class II or III. I

B

ICD therapy is indicated in patients with LV dysfunction due to prior MI who are at

least 40 days post-MI, have an LVEF less than or equal to 30%, and are in NYHA

functional Class I. I A

ICD therapy is indicated in patients with nonsustained VT due to prior MI, LVEF less

than or equal to 40%, and inducible VF or sustained VT at electrophysiological

study. I B

ACCF/AHA Guidelines for the Management of Heart Failure.

Circulation.2013

CRT Device Therapy for Stage C HFrEF

Recommendations COR LOE

CRT is indicated for patients who have LVEF ≤35%, sinus rhythm, LBBB with a

QRS ≥150 msI

A (NYHA class

III/IV)

B (NYHA class

II)

CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB

pattern with a QRS ≥150 ms, and NYHA class III/ambulatory class IV symptoms on

GDMT.

IIa A

CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, LBBB with a

QRS 120 to 149 ms, and NYHA class II, III or ambulatory IV symptoms on GDMT

IIaB

CRT can be useful in patients with AF and LVEF ≤35% on GDMT if a) the patient

requires ventricular pacing or otherwise meets CRT criteria and b) AV nodal ablation

or rate control allows near 100% ventricular pacing with CRT

IIa B

ACCF/AHA Guidelines for the Management of Heart Failure.

Circulation.2013

6/16/2016

7

Legal Principles

Health Insurance Portability and Accountability Act (HIPPA)

– Provides federal protection for privacy of personal health information (PHI).

– Allows PHI to be shared for patient care and claims submissions

– Reasonable and appropriate safeguards must be in place for written communication to maintain privacy. Email should be encrypted or have a mechanism in place to

send securely Fax transmission should be sent to a secure location with a

privacy notice on the cover sheet

HF Nursing Certification: Core Curriculum Review 2nd Edition

Legal Principles

Consent Informed:

– An individual understands the risks and benefitsassociated with the course of treatment.

Implied: – Inferred from inaction or circumstances of the situation – Unconscious patient– Language barrier– Cognitive impairment

Expressed: – Written or verbal agreement from an individual to proceed with treatment

HF Nursing Certification: Core Curriculum Review 2nd Edition

Case Study 1

The rest of the story: now 38

ECHO 6/2015: LVEF 40-45%. LVIDd 4.66 cm. Mild-moderate concentric LVH. LA 3.74 cm.

Trace MR and TR

Cardiopulmonary Test 10/2015: VO2 24.2 mL/kg/min. RQ 1.11. VE/VCO2 slope is 20.3

Continues to call and/or send message with changes

Emails symptoms, weights and blood pressures every other month, seen in clinic every three

months

VanderbiltHeart.com

6/16/2016

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Definitions of HFrEF and HFpEF

Classification EF (%) Description

I. Heart failure withreduced ejection fraction(HFrEF)

≤40 Also referred to as systolic HF. Randomized clinical trials have mainlyenrolled patients with HFrEF, and it is only in these patients thatefficacious therapies have been demonstrated to date.

II. Heart failure withpreserved ejection fraction(HFpEF)

≥50 Also referred to as diastolic HF. Several different criteria have beenused to further define HFpEF. The diagnosis of HFpEF is challengingbecause it is largely one of excluding other potential noncardiac causesof symptoms suggestive of HF. To date, efficacious therapies have notbeen identified.

a. HFpEF, borderline 41 to 49 These patients fall into a borderline or intermediate group. Theircharacteristics, treatment patterns, and outcomes appear similar tothose of patients with HFpEF.

b. HFpEF, improved >40 It has been recognized that a subset of patients with HFpEF previouslyhad HFrEF. These patients with improvement or recovery in EF maybe clinically distinct from those with persistently preserved or reducedEF. Further research is needed to better characterize these patients.

ACCF/AHA Guidelines for the Management of Heart Failure.

Circulation.2013

Cardiorenal Syndrone

Case Study 2

65 year old male ischemic cardiomyopathy, HFrEF, and chronic

kidney disease. Two HF admissions in past 6 months

HF symptoms: Cough, fatigue, shortness of breath walking 50 feet,

LE edema, early satiety, weight gain

Medications: Lisinopril 5 mg daily, carvedilol 12.5 mg bid, torsemide

50 mg bid, Kcl 20 meq bid, spironolactone 25 mg

Vital signs: BP 94/50, HR 90, weight 160

PE: S3, JVD 12 cm, + HJR, 2+ LE edema, bibasilar crackles

Labs: Na 135, K 4.3, BUN 47, creatinine 3.08 BNP 2985

Cardiorenal Syndrone

Case Study 2

10 pound weight gain above dry weight

Unresponsive to usual daily diuretic doses

Metolazone 5 mg, 30 minutes prior to PM torsemide 100 mg with

additional Kcl 20 meq

6/16/2016

9

Case Study 2

Cardiorenal Syndrone, diuretic resistance

9 lb weight loss

Cardiorenal Syndrome of

Heart Failure

VanderbiltHeart.com

Decreased cardiac output

Neurohormonal activation

Diminished blood flow

Decreased renal perfusion

Decreased cardiacPerformance: right and left

Increased sodium and water retention

Decreased renalfunction

Renal congestion:Increased renal venous pressure

Chronic kidney disease

UpToDate 2016

Cardiorenal Syndrome

Cardio renal syndrome occurs when reduction in cardiac output results in disproportionate reduction in renal perfusion

Leads to diminished glomerular filtration rate (GFR) and increased serum creatinine levels

Worsening renal function:

– Change in serum creatinine >0.3 mg/dL or >25% over baseline (normal range: adult male: 0.8 to 1.4 mg/dL; adult female: 0.6 –1.4 mg/dL)

– >70% of patients will experience increase in creatinine during hospitalization

– 20% to 30% of patients experience increase of >0.3 mg/dL

– Any increase of >0.3 mg/dL is associated with longer LOS and increased mortality

Ronco C. JACC 2008;52(19):1527-1539

6/16/2016

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Diuretic Resistance

Diuretic Resistance is the persistence of congestion despite diuretic

therapy

– May result from renal under-perfusion

– Distal tubules develop hypertrophy

– There is enhanced sodium reuptake downstream from loop

diuretic site of action

– Oral absorption of loop diuretics is impaired in the setting of gut

hypoperfusion and edema

Treatments

– Restricting NA intake

– Change timing of dose

– Use of combination diuretic therapies

– Ultrafiltration and hemodialysis

Case Study 3

Depression, Fatigue, Family Care-Giver Awareness

42 year old gentleman with ischemic cardiomyopathy, chronic heart failure,

diabetes, HTN, hyperlipidemia, obesity, and depression

He looks sad and doesn't smile. His wife also has health issues also. She is

working 3 jobs to help support the family and they have 2 teenage daughters

that are a challenge at times. He has a poor appetite and has lost >30

pounds since last fall

Complains of fatigue, positional dizziness, and a poor appetite.

Depression in HF Patients

Depression prevalence- 3 times more likely after myocardial infarction

More common in women

More common in HF patients

– 11-48% of outpatients

– 35-70% of inpatients

Severity of depression is linearly related to short and long-term mortality

rates

Heart failure patients with severe depression are four times more likely to die

within 2 years than those non-depressed.

HF Nursing Certification: Core Curriculum Review 2nd Edition

6/16/2016

11

Family/Caregiver Awareness & Involvement

in Care Planning and Delivery

Advocacy is a process in which a healthcare professional provides a

patient with the information needed to make decisions about some

aspect of his/her health care

Respect cultural and spiritual beliefs

Include family and support systems in care planning

and delivery

Identify a proxy if patient is unable to advocate for him/herself.

Caregiver awareness Be aware of signs and symptoms of worsening HF HF follows a chronic illness trajectory with a poor prognosis Understand the physical, mental and emotional aspects of HF care

Caregiver health Should not neglect their own physical, mental and emotional needs Research indicates all caregivers report mild to significant decline in their

own health including: sleep deprivation, weight loss/gain, depression and anxiety.

Seek opportunities for respite care

Case Study 4

Readmissions, Hospital Discharge,Transitions of Care,

62 year old gentleman with ischemic cardiomyopathy,

chronic systolic and diastolic dysfunction, HTN, CKD,

and nonalcoholic fatty liver disease

Admitted with acute on chronic heart failure, altered

mental status, and hepatic encephalopathy

Discharged to Skilled Nursing Facility (SNF)

Readmitted 5 days later with dehydration, weight loss

was attributed to lactulose and excessive bowel

movements, >10/day.

Hospital Readmissions

Represent a significant clinical and economic burden

Healthcare costs for HF in 2009 were > $37 billion with over one million hospital discharges; most costly expense for Medicare (> $4.5 billion annually)

Nearly 1/3 of ALL patients with diagnosis of HF are admitted within 30 days following discharge

Nearly 30% of Medicare HF patients readmitted within 30 days following discharge

HF readmissions could be prevented in at least 40% of cases

6/16/2016

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Heart Failure Readmissions

Retrospective analyses have shown a markedly increased risk of death in the

first month following discharge; the absolute increase in risk was clearly

related to the number of previous admissions:

Failure to identify precipitant for HF decompensation

Under-treatment of excess volume prior to discharge

Underutilization of evidence-based guidelines for drug and device

therapies

Lack of cardiac specialist consultations

Therapies in the Hospitalized HF Patient

Recommendation COR LOE

HF patients hospitalized with fluid overload should be treated with

intravenous diureticsI B

HF patients receiving loop diuretic therapy, should receive an initial

parenteral dose greater than or equal to their chronic oral daily

dose, then should be serially adjusted

I B

HFrEF patients requiring HF hospitalization on GDMT should

continue GDMT unless hemodynamic instability or contraindicationsI B

Initiation of beta-blocker therapy at a low dose is recommended

after optimization of volume status and discontinuation of

intravenous agents

I B

Thrombosis/thromboembolism prophylaxis is recommended for

patients hospitalized with HFI B

Serum electrolytes, urea nitrogen, and creatinine should be

measured during the titration of HF medications, including diureticsI C

ACCF/AHA 2013 HF Guideline

Address Conditions That May

Cause Increased Heart Failure Symptoms

♥ Ischemia

♥ Anemia

♥ Irregular heart rhythms (Afib,

increased PVC burden)

♥ Electrolyte imbalances

♥ Sleep disordered breathing

♥ COPD

♥ Uncontrolled high blood pressure

♥ Too low or too high thyroid levels

♥ Depression and anxiety

6/16/2016

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Oral medication regimen stable for 24 hours

No intravenous vasodilator or inotropic agent needed

during previous 24 hours

Ambulation before discharge to assess functional

capacity

Plans for post-discharge management

are initiated (eg, scales to weigh in next care site, visiting

nurse or phone call follow-up within 3 days of discharge)

Heart failure education complete

Criteria that Should be Considered for

Patients with Advanced HF and

Recurrent Readmissions

Hospital DischargeRecommendation or Indication COR LOE

Performance improvement systems in the hospital and early post discharge

outpatient setting to identify HF for GDMTI B

Before hospital discharge, at the first post discharge visit, and in subsequent follow-

up visits, the following should be addressed:

initiation of GDMT if not done or contraindicated

causes of HF, barriers to care, and limitations in support

assessment of volume status and blood pressure with adjustment of HF

therapy

optimization of chronic oral HF therapy

renal function and electrolytes

management of comorbid conditions

HF education, self-care, emergency plans, and adherence; and

palliative or hospice care.

I B

Multidisciplinary HF disease-management programs for patients at high risk for

hospital readmission are recommended I B

A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of

hospital discharge is reasonableIIa B

Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients

is reasonableIIa B

ACCF/AHA 2013 HF Guideline

Quality Metrics/Performance

Measures

Guideline for HF

6/16/2016

14

ACCF/AHA/AMA-PCPI 2011 HF

Performance Measurement Set

Measure Description* Care

Setting

Level of

Measurement

1. LVEF

assessment

Percentage of patients aged ≥18 y with a diagnosis of HF for whom the

quantitative or qualitative results of a recent or prior (any time in the

past) LVEF assessment is documented within a 12 mo period

Outpatient Individual

practitioner

2. LVEF

assessment

Percentage of patients aged ≥18 y with a principal discharge diagnosis

of HF with documentation in the hospital record of the results of an

LVEF assessment that was performed either before arrival or during

hospitalization, OR documentation in the hospital record that LVEF

assessment is planned for after discharge

Inpatient Individual

practitioner

Facility

3. Symptom

and activity

assessment

Percentage of patient visits for those patients aged ≥18 y with a

diagnosis of HF with quantitative results of an evaluation of both

current level of activity and clinical symptoms documented

Outpatien

t

Individual

practitioner

*Please refer to the complete measures for comprehensive information, including measure exception.

Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.

ACCF/AHA/AMA-PCPI 2011 HF Performance

Measurement Set (cont.)Measure Description* Care

Setting

Level of

Measuremen

t

4. Symptom

management†

Percentage of patient visits for those patients aged ≥18 y with a

diagnosis of HF and with quantitative results of an evaluation of both

level of activity AND clinical symptoms documented in which patient

symptoms have improved or remained consistent with treatment goals

since last assessment OR patient symptoms have demonstrated

clinically important deterioration since last assessment with a

documented plan of care

Outpatient Individual

practitioner

5. Patient self-

care education†‡

Percentage of patients aged ≥18 y with a diagnosis of HF who were

provided with self-care education on ≥3 elements of education during ≥1

visits within a 12 mo period

Outpatient Individual

practitioner

6. Beta-blocker

therapy for LVSD

(outpatient and

inpatient setting)

Percentage of patients aged ≥18 y with a diagnosis of HF with a current

or prior LVEF <40% who were prescribed beta-blocker therapy with

bisoprolol, carvedilol, or sustained release metoprolol succinate either

within a 12 mo period when seen in the outpatient setting or at hospital

discharge

Inpatient

and

Outpatient

Individual

practitioner

Facility

*Please refer to the complete measures for comprehensive information, including measure exception.

†Test measure designated for use in internal quality improvement programs only. These measures are not appropriate for any

other purpose, e.g., pay for performance, physician ranking or public reporting programs.

‡New measure.

Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.

ACCF/AHA/AMA-PCPI 2011 HF Performance Measurement

Set (cont.)

Measure Description* Care Setting Level of

Measurement

7. ACE Inhibitor or

ARB Therapy for

LVSD (outpatient and

inpatient setting)

Percentage of patients aged ≥18 y with a diagnosis of HF with a

current or prior LVEF <40% who were prescribed ACE inhibitor or

ARB therapy either within a 12 mo period when seen in the outpatient

setting or at hospital discharge

Inpatient

and

Outpatient

Individual

practitioner

Facility

8. Counseling

regarding ICD

implantation for

patients with LVSD

on combination

medical therapy†‡

Percentage of patients aged ≥18 y with a diagnosis of HF with current

LVEF ≤35% despite ACE inhibitor/ARB and beta-blocker therapy for at

least 3 mo who were counseled regarding ICD implantation as a

treatment option for the prophylaxis of sudden death

Outpatient Individual

practitioner

9. Post-discharge

appointment for heart

failure patients

Percentage of patients, regardless of age, discharged from an

inpatient facility to ambulatory care or home health care with a

principal discharge diagnosis of HF for whom a follow-up appointment

was scheduled and documented including location, date and time for

a follow-up office visit, or home health visit (as specified)

Inpatient Facility

*Please refer to the complete measures for comprehensive information, including measure exception.

†Test measure designated for use in internal quality improvement programs only. These measures are not appropriate for any o ther

purpose, e.g., pay for performance, physician ranking or public reporting programs.

‡New measure.

Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.

6/16/2016

15

Transitional CareBreaking the Cycle of Readmission

Transitional Care

Transitional Care: set of actions designed to ensure coordination and continuity of

health care as patients transfer between different

locations or different levels of care

Hospital Discharge Discharge

Planning

Follow upHospitalization

andTreatment

Admission

Transition of Care Recommendations for Clinical Practice

Recommendations Considerations for Implementation of Recommendation

Systematically implement principles of transition of care programs in high-risk patients with chronic HF.

Include*Medication reconciliation*Very early postdischarge contact and communication with patient and/or care provider*Early office follow-up within first week of discharge*Patient education on chronic HF self-care, including skills for recognizing early warning signs of worsening *HF and independently completing HF self-carebehaviors *Communication of patient health record with patient and postdischarge healthcare providers*Integrated, interdisciplinary collaboration and coordination*A framework that ensures that education is initiated in the hospital before the day of discharge and continues during initial community-based care

Albert et al Transitions of Care in Heart Failure. Circulation Heart

Failure. 2015

Transition of Care Recommendations for Clinical Practice

Recommendations Considerations for Implementation of Recommendation

Routinely assess patients for high-risk characteristics that may be associatedwith poor post-discharge clinical outcomes.

Exemplars include cognitive difficulties, impaired learning capabilities, non–Englishspeaking, and long travel time to healthcare providers

Ensure that qualified and trained HF nurse or other healthcare providers of clinical HF provide care services.

Assess healthcare provider knowledge and comfort in delivering patient education and interdisciplinary care coordination services

Allot adequate time in the hospital and postacutesetting to deliver complex chronic HF interventions and to assess patient and caregiver responsiveness

Incorporate time to complete high-level interventions into care plans, including patients’ ability to understand HF self-management interventions and to complete skills and expectations independently

Albert et al Transitions of Care in Heart Failure. Circulation Heart

Failure. 2015

6/16/2016

16

Transition of Care Recommendations for Clinical Practice

Recommendations Considerations for Implementation of Recommendation

Implement handoff procedures at hospital or post–acute care discharge

*Provide patient health records with key details of the hospital/postacute experience (medications used, discharge medications, procedures, treatments, postdischarge care expectations, planned rehospitalization and/or follow-up services, knownpsychosocial issues, and medication reconciliation)*Ensure that handoff documents are transmitted to postdischarge care providers ina timely manner

Albert et al Transitions of Care in Heart Failure. Circulation Heart

Failure. 2015

Transition of Care Recommendations for Clinical Practice

Recommendations Considerations for Implementation of Recommendation

Develop, monitor, and ensure transparency of results of quality measures using a structure, process, and outcome framework.

*Promote fidelity of the program and consistent application by healthcare providers*Ensure leadership and administrative support, including clinical leaders (navigators, advocates, etc)

Consider patients’ perceptions of QOL as a surrogate for physical, psychological, and social concerns that require support during the transition of care process.

Provide bridging for specific patient support needs

Albert et al Transitions of Care in Heart Failure. Circulation Heart

Failure. 2015

Transition of Care Recommendations for Clinical Practice

Recommendations Considerations for Implementation of Recommendation

Ensure availability of transition of care component details in writing (eg, a training manual)

Promote fidelity of the program and consistent application by healthcare providersEnsure leadership and administrative support, including clinical leaders (navigators, advocates, etc)

Use health informatics technology to assist with program sustainability. Informatics should be patient and healthcare provider centric.

Evaluate data for applicability and completeness in facilitating patient communication and care coordination, quality metrics, research, and financialAnalyses

Albert et al Transitions of Care in Heart Failure. Circulation Heart Failure. 2015

6/16/2016

17

Improving Transition

Nurses play a key role in inpatient and outpatient management and improving patient outcomes using a comprehensive, integrated system to manage patients

Nurse-coordinated outpatient care has been shown to reduce HF hospitalizations by more than 60%

Studies have found that specifically trained HF nurses are one crucial element found in HF multidisciplinary management models (eg, clinic visits, pt education, medication titration, device management, research, support groups)

Case Study 5 Professionalism

40 year old with nonischemic cardiomyopathy, chronic heart failure, morbid obesity,

hypertension, with a recent admission for atrial fibrillation with rapid ventricular response. He

has been a “no-show” or canceled multiple visits. He has not refilled any of his medications,

he is only taking a baby aspirin a day

He comes to the clinic with an offensive odor and dirty clothing

BP 170/110, heart rate 100

Professionalism

Reflects the values and behaviors of the nurse caring for patients demonstrated by:

Following ethical principles

Advocating for the patient and his/her family

Keeping abreast of research

Using evidence to guide clinical practice

6/16/2016

18

Ethical/Legal Principles

Preventing Health Care Disparities Disparities are the differences in health outcomes which occur even when

patient preferences, access and clinical factors are controlled

The United States demographics continue to change with increasing numbers of Hispanics, Asians and African Americans

Including under-represented individuals in quality improvement activities and clinical research will promote understanding of differences and potentially reduce disparities

Scope of practice Determines who can legally perform specific duties in the care of a patient Nurses are responsible for the delivery of nursing care and are accountable

for activities delegated to others including but not limited to licensed practical nurses, certified nursing assistants and certified medical technologists

Nurses act as a liaison with other medical professionals

Advance practice nurses scope of practice is determined by the state in which they are licensed

Ethical Principles

• Respect for Persons – Respect is both a behavior and an act

– Demonstrates honor to another individual

– Address patient with proper surname and

avoid terms of endearment

• Autonomy refers to the ability to make decisions– May be compromised due to illness or cognitive disorder

– May need to appoint someone else as proxy

• Individual rights – Right to privacy

– Right treatment

– Right to be informed

• Justice refers to being fair, not necessarily equitable – Seeks to focus on the common good

– May be in conflict with respect for persons

HF Nursing Certification: Core Curriculum Review 2nd Edition

Ethical/Legal Principles

Beneficence The state or quality of being kind, charitable, or beneficial in action that is done for the

benefit of others. Doing good.

Resuscitating a drowning victim, providing vaccinations for the general population,

encouraging a patient to quit smoking and start an exercise program, talking to the

community about STD prevention.

Non-Maleficence “Do no harm.” we must refrain from providing ineffective treatments or acting with malice

toward patients. Maximize benefits and minimize harm

– Stopping a medication that is shown to be harmful, refusing to provide a treatment that has not been shown to be effective.

HF Nursing Certification: Core Curriculum Review 2nd Edition

6/16/2016

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Case Study 5 Professionalism

Provide quality care for the patient !

EKG shows sinus rhythm, medications resumed

Individual follow up plan was agreed upon: text and 8:30 AM clinic visits

Beneficence: providing health benefits to the patient, active promotion of good.

Legal Principles

Negligence

A lack of care and vigilance demanded by the situation

Results in harm to an individual

Malpractice

An omission or negligence by act as a result of deviating from the standard of practice which results in harm to an individual

HF Nursing Certification:

Core Curriculum Review 2nd

Edition

Case Study 6

Ethical Principles

56 year old female with metastatic cancer and heart failure

She has now been treated for 1.5 years with chemotherapy. Worsening LVEF, 20%. After

extensive discussions with cardiologist and oncologist, she decides that she no longer

desires curative cancer treatment. She would rather live remaining days with Hospice Care.

This is an example of impeding which ethical principle?

A. Justice

B. Respect for Persons

C. Beneficence

D. Maleficence

B. Respect for persons

*She has the right to make an informed

decision*Further chemotherapy may not prolong life.

*She prefers quality of life over quantity.

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Test Taking Strategies

Test Taking Strategies

• Write down information you’re worried about remembering (ICD

criteria, wedge pressure)

• Read each question all the way through before looking at the

answer choices.

• Try to solve each problem before looking at the answer alternatives

to avoid being thrown off by the choices given.

• Make educated guesses; eliminate the obvious incorrect answer

choices right away and use reasoning to find the best possible

answer choice through the process of elimination.

• Pick answers that honor the patient first

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Test Taking Strategies

• Determine precisely what the question is asking; one solution will plainly be the best choice, so read through all answer choices since the best answer could be the last choice in the list.

• Do not spend too much time on any one question; skip more difficult questions and go back to those once all other questions have been answered.

• Do not change an answer-unless the question was misread; the first answer selected is usually the correct choice.

• Do not stay up all night studying; get a good night’s sleep.

Test Taking Strategies

• When it seems like more than one answer is correct there are some strategies for narrowing

down the choices in order to find the right choice.

• Examine the answer being considered and determine whether it is only partly true when

addressing the question, or if it would only be true under certain circumstances. If this is the

case, it is probably not the correct answer.

• Take each question at face value; do not assume the instructor has created any “trick”

questions. Avoid reading too much into a question.

CHFN or CHFN-K: Is in YOUR Future

6/16/2016

22

For Your InformationNot on 2016 CHFN/CHFN-K Test

Guideline-Directed Evaluation and Management

(GDEM)

• Refers to ACC/AHA Class I recommendations

Yancy CW, et al Heart Failure Focused Update

on Pharmacological Therapy 2016

6/16/2016

23

ACC/AHA Recommended System 2015 update

ACE-I/ARB

ARNI

Drugs Commonly Used for HFrEF

(Stage C HF)Drug Initial Daily Dose(s) Maximum Doses(s)

Mean Doses Achieved in

Clinical Trials

ACE Inhibitors

Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/d (421)

Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg/d (412)

Fosinopril 5 to 10 mg once 40 mg once ---------

Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg/d (444)

Perindopril 2 mg once 8 to 16 mg once ---------

Quinapril 5 mg twice 20 mg twice ---------

Ramipril 1.25 to 2.5 mg once 10 mg once ---------

Trandolapril 1 mg once 4 mg once ---------

ARNI

Sacubitril/valsartan 24 mg/26 mg bid 49 mg/51 mg bid 97 mg/103 mg bid

ARBs

Candesartan 4 to 8 mg once 32 mg once 24 mg/d (419)

Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/d (420)

Valsartan 20 to 40 mg twice 160 mg twice 254 mg/d (109)

Aldosterone Antagonists

Spironolactone 12.5 to 25 mg once 25 mg once or twice 26 mg/d (424)

Eplerenone 25 mg once 50 mg once 42.6 mg/d (445)

Yancy C et al. Circulation 2013;128:e240-e327

Yancy C.et al. JACC 2016; 05.011

ARNIWhen compared to enalapril:

Reduced cardiovascular death by 20%

Reduced HF hospitalizations by 20%

May lead to angioedema

Caution with low BP and renal insufficiency

Although the use of an ARNI in lieu of an ACE inhibitor

for HFrEF has been found to be superior, for those

patients for whom ARNI is not appropriate, continued

use of an ACE inhibitor for all classes of HFrEF remains

strongly advisedYancy CW, et al Heart Failure Focused Update on

Pharmacological Therapy 2016

6/16/2016

24

ARNI Should not be administered within 36 hours of switching

from or to an ACE-I

Concern for angioedema and significant morbidity

Should not be administered to patients with a history of

angioedema

Yancy CW, et al Heart Failure Focused Update on

Pharmacological Therapy 2016

Drugs Commonly Used for HFrEF

(Stage C HF) (cont.)

Drug Initial Daily Dose(s) Maximum Doses(s)Mean Doses Achieved in

Clinical Trials

Beta Blockers

Bisoprolol 1.25 mg once 10 mg once 8.6 mg/d (118)

Carvedilol 3.125 mg twice 50 mg twice 37 mg/d (446)

Carvedilol CR 10 mg once 80 mg once ---------

Metoprolol succinate

extended release

(metoprolol CR/XL)

12.5 to 25 mg once 200 mg once 159 mg/d (447)

Sinoatrial node modulator

Ivabradine 2.5 mg twice 5 mg twice 7.5 mg twiceHydralazine & Isosorbide Dinitrate

Fixed dose combination

(423)

37.5 mg hydralazine/

20 mg isosorbide

dinitrate 3 times daily

75 mg hydralazine/

40 mg isosorbide

dinitrate 3 times daily

~175 mg hydralazine/90 mg

isosorbide dinitrate daily

Hydralazine and

isosorbide dinitrate (448)

Hydralazine: 25 to 50

mg, 3 or 4 times daily

and isorsorbide dinitrate:

20 to 30 mg

3 or 4 times daily

Hydralazine: 300 mg

daily in divided doses

and isosorbide dinitrate

120 mg daily in

divided doses

---------

Yancy C et al. Circulation 2013;128:e240-e327 Yancy CW, et al Heart Failure Focused Update on

Pharmacological Therapy 2016

Sinoatrial node modulator

Class IIa

Level of Evidence B-R

Can be beneficial for

- NYHA class II-III stable

chronic HF

- LVEF < 35%

- On GDEM, including maximal

tolerated beta blocker

- HR 70 or greater

Benefit of ivabradine was driven by a reduction in HF hospitalization

Given the well-proven mortality benefits of beta-blocker therapy, it is

important to initiate and up titrate these agents to target doses, as

tolerated, before assessing the resting heart rate for consideration of

ivabradine initiation Yancy CW, et al Heart Failure Focused Update on

Pharmacological Therapy 2016