q1 - heart failure - hayes, dellise rev2...outpatient management of heart failure nicole dellise,...
TRANSCRIPT
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Outpatient Management of Heart Failure in Primary Care
National Nurse Practitioner Symposium July 12, 2020
Nicole Dellise, DNP, FNP-BC, CHFN K. Melissa Hayes, DNP, ANP-BC, CHFN
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Disclosures
Dr. Dellise has no disclosures.
Dr. Hayes had no disclosures.
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Objectives
DISCUSS implication of heart failure management strategies highlighting key considerations for primary care.
IDENTIFY challenges of optimization of guideline-directed medical therapy in heart failure patients.
REVIEW the appropriate adjustment of heart failure medications according to the volume status of the patient.
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Presentation Outline
~Background and significance
~Definitions; HFpEF vs HFrEF
~Cases_HFpEF ~Hospital to Home
~Cases_HFrEF ~Resources
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AHA 2017 Heart Disease & Stroke Statistics Update, Heart Disease and Stroke Statistics—2010 Update: A Report From the American Heart Association Circulation, Feb 2010; 121: e46 - e215.
The number of adults living with heart failure has increased from about 5.7 million (2009-2012) to about 6.5 million (2011-2014).
One in 5 Americans will be >65 years of age by 2050.
HF incidence increases with age, rising from approximately 20 per 1000 individuals 65 to 69 years of age to >80 per 1000 individuals among those ≥85 years of age.
960,000 new cases annually.
Hospital admissions rates have increased approximately 150% over the past 2 decades.
Half of the hospital admissions are patients with HFpEF.
Half of the hospital admissions are patients with HFrEF.
Heart Failure Facts
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The number of Americans with HF is expected to significantly worsen in the future.
(Yancy, et al., 2013)
Getty Images / tiero
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Definitions
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Heart Failure
A complex clinical syndrome resulting from any structural or functional
cardiac disorder that impairs the ability of the ventricle to FILL with blood or EJECT blood. (Yancy, et al., 2013)
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HFpEF vs HFrEFDiastolic Failure - Heart Failure with Preserved Ejection Fraction (HFpEF)
result of the inability of the heart to relax and FILL with blood (EF ≥ 45%)
Systolic Failure - Heart Failure with Reduced Ejection Fraction (HFrEF)
result of the inability of the heart to EJECT blood (EF ≤ 40%)
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Heart Failure Mid-Range EF (HFmEF)
Grey area with LVEF > 40 but no quite 50-55% HFmEF
Group treated based on symptomatology, etiology and usually end up being treated as LVEF HFrEF.
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Yancy CW, et al. Circulation. 2013;128:e240-e327.Image Source: Jessup M, Brozena SA. New Engl J Med. 2003; 348:2007-2018.
Reduced EF (HFrEF)
Normal Heart Preserved EF (HFpEF)
Heart Failure – Ejection Fraction (EF)
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Classifications of Heart Failure
Circulation 2013;128:e240-327.
Classification Ejection Fraction (EF)
Heart failure with reduced ejection fraction (HFrEF)• Formerly referred to as systolic heart failure
< 40%
Heart failure with preserved ejection fraction (HFpEF)• Formerly referred to as diastolic heart failure
> 50%
HFmEF borderline 41-49%
HFrEF improved - patients with a history of HFrEF > 40%
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Brief Pathophysiology Review
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RAS, renin-angiotensin system; SNS, sympathetic nervous system.
Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease)
Morbidity and mortalityArrhythmiasPump failure
Peripheral vasoconstriction/Increased filling pressures
Heart failure symptoms
Remodeling and progressiveworsening of LV function
Initial fall in LV performance, wall stress
Activation of RAAS and SNS
Fibrosis, apoptosis,hypertrophy,
cellular/molecular
alterations,myotoxicity
FatigueActivity altered Chest congestionEdemaShortness of breath
Neurohormonal Activation in Heart Failure
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Altered gene expression Apoptosis
Remodeling
Pathogenesis of Heart Failure
Myocardial Insult
Myocardial Dysfunction
Renin-Angiotensin-Aldosterone Activation
Sympathetic Activation
Reduced Organ Perfusion
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Pathophysiologic Progression of HF
Injury Adaptation Remodeling
Normal
Dilated and fibrotic
Compensatory hypertrophy
Architecturaldistortion
Normal
Courtesy of A. Agocha, MD.
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HFpEF
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ACC/AHA HF Stage vs NYHA Class
ACC/AHA HF Stage
High risk for developing heart failure (HF) No structural disease
Structural heart diseaseNo HF symptoms
Structural heart diseasePrior or current HF symptoms
Refractory end-stage HFrequiring special interventions
Jessup M et al. N Engl J Med. 2003;348:2007-2018. New York Heart Association/Little Brown and Company, 1964. Adapted from Farrell et al. JAMA. 2002;287:890-897.
A
B
C
D
NYHAFunctional Class
Asymptomatic
Symptomatic with moderate exertion
Symptomatic with minimal exertion
Symptomatic at rest
Class I
Class II
Class IV
Class III
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HFpEF vs HFrEF
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Etiology HFpEF HFrEF
HTN ++ +
Ischemic heart disease + +++
Obesity + +
Valve disease + +
Arrhythmias (ie a-fib, tachycardia) + +
Sleep disordered breathing ++ -
Myocarditis (ie viral, SLE, Chagas, AIDs) - +
Diabetes + +
Older age ++ -
Anemia - +
Toxic (ie ETOH, Chemo, nutritional deficiency, amphetamines)
- +
Pregnancy - +
Thyroid disease - +
Idiopathic dilated - +
Stress (Takotsubo) - +
Amyloidosis ? -
Sarcordosis ? -
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Diagnostics HFpEF HFrEF
Signs and Symptoms of HF
+ +
Diagnosis of Exclusion + -
B-Type Nauturtic Peptide - or + ↓ ↑ + ↑↑
Chest X-Ray + +
ECG + +
Transthoracic Echocardiogram
+ +
Right heart Catherization + +
Stress testing + +
Left heart catherization + +
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SymptomsHFpEF HFrEF
Dyspnea + +
Orthopnea + +
Paroxysmal nocturnal dyspnea
+ +
Fatigue + +
Reduced exercise capacity + +
Cough or Wheezing + +
Confusion/Delirium + +
GI Symptoms: early satiety, nausea, vomiting, abdominal discomfort
+ +
Sudden weight gain more than 2 pounds in one day or 5 pounds in 1 week
+ +
Chest pain + +
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Physical ExamHFpEF HFrEF
Rales ++ ++
Peripheral edema + ++
Jugular venous distension + ++
S3 + ++
S4 ++ +
Displaced point of maximal impulse - ++
Mitral regurgitation murmur + ++
Hepatomegaly and/or ascites + ++
Cool extremities + ++
Narrow pulse pressure + ++
Hypotension + ++
Tachycardia + ++
Hypertension ++ +
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Measuring JVP
https://www.youtube.com/watch?v=ATSPY-1vYKcCredit: Tom Heywood
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Goals
HFpEF HFrEF
Reduce Symptoms + +
Improve Quality of Life + +
Decrease hospitalizations + +
Reduce Mortality + +
Identification and treatment of co-morbidities
+ +
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Guideline Directed Medical Therapy
HFpEF HFrEFDiuretics ++ ↓ symptoms ++ ↓symptoms
ACE Inhibitor, ARB, or ARNI - ++ ↓ morbidity & mortality
Beta Blocker - ++ ↓ morbidity & mortality
Aldosterone Antagonist + (?) ++ ↓ morbidity & mortality
Hydralazine/isosorbide dinitrate - ++ ↓ morbidity & mortality for AA
Corlanor - ++ ↓ hospitalization
Digoxin - ++ ↓ hospitalization
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Interventions
HFpEF HFrEF
ICD Therapy - Recommended for primary prevention of SCD
CRT - Indicated for HFrEF with LBBB
Heart Transplant - Indicated for HFrEF who meet criteria
Permanent Mechanical Circulatory Support
- Indicated for HFrEF who meet criteria
Chronic Inotropes - Indicated for HFrEF who meet criteria
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Case Study
Heart Failure with Preserved Ejection
Fraction
Image Source: Jessup M, Brozena SA. New Engl J Med. 2003; 348:2007-2018.
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Case Study HFpEF: Mr. Jones
55 year old Caucasian male
Past Medical History
HFpEF
Obstructive Sleep Apnea
Hypertension
Chronic Kidney Disease, Stage 3
Uncontrolled Diabetes Type 2
TIA
Hyperlipidemia
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Case Study HFpEF: Mr. Jones
ASA 81mg Lipitor (atorvastatin) 40mg QHS Bumex (bumetanide) 4mg BID Aldactone (spironolactone) 25mg daily Cymbalta (duloxetine) 30mg daily Lyrica (pregabalin) 200mg TID Cozaar (losartan) 25mg QHS MEDICATIONS
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Case Study HFpEF: Mr. Jones
EKG 3/2020
Sinus Rhythm
Boarder line left axis deviation
Cardiac Stress Test 9/2018
Indication: Shortness of breath and Chest pain
No evidence of ischemia or infarct
LVEF greater than 70%
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Case Study HFpEF: Mr. Jones Echocardiogram 10/2019
Normal left ventricular size with mild to moderate hypertrophy.
Normal systolic function.
Stage II diastolic dysfunction.
Normal right ventricular size and function.
No significant valvular disease.
PA systolic pressure estimated at 37mmHg plus RA pressure.
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Case Study HFpEF: Mr. Jones
Heart Failure Hospitalization # 1
• Presented with progressive dyspnea on exertion. Walking 10 feet causes severe dyspnea. ADLs cause dyspnea.
• Noted gradual weight gain over 2 months (252 pounds to 288 pounds). • Not responding to Lasix (furosemide) 80 mg BID. • Admission vital signs: BP 187/90, HR 77, RR 22, oxygen 98 % RA • Admission Labs: Sodium 136, Potassium 4.9, BUN 76, Creatinine 2.6, BNP 78 • Reports he does not monitor fluid or sodium intake. • Established with heart failure clinic• Lasix (furosemide) 80 mg BID• Aldactone (spironolactone) 25 mg Qday• Cozaar (losartan) increased 50 mg QHS• Advised patient to keep blood pressure log
October
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Case Study HFpEF: Mr. JonesHeart Failure Hospitalization # 2
• Admitted following right heart catheterization demonstrating significant volume overload.•RA = 27 mean •PA = 40/31 mean = 34•PCW = a wave = 31 v wave = 33 mean = 28•SVR 23 Wood Units•PVR 1.3 Wood Units
• Admission vital signs: BP 125/82, HR 82, RR 18, oxygen 97 % RA• Admission weight 278 pounds• Admission labs: Sodium 138, potassium 4.5, BUN 66, Creatinine 2.4, BNP 67
• Lasix (furosemide) 80 mg BID• Aldactone (spironolactone) 25 mg daily• Cozaar (losartan) 50 mg QHS• HF teaching and reinforcement
November
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Case Study HFpEF: Mr. JonesHeart Failure Hospitalization # 3
• Admitted from clinic with volume overload• Symptoms: Abdominal dissension, LE edema, JVD elevated 16 cm, orthopnea.• Admission vital signs: BP 133/72, HR 72, RR 20, oxygen 97 % RA• Admission weight 282 pounds• Admission labs: Sodium 140, potassium 4.6, BUN 68, Creatinine 2.6, BNP 88
• Diuretic switched to Bumex (bumetanide) 6 mg BID• Aldactone (spironolactone) 25 mg Qday• Cozaar (losartan) 50 mg QHS• HF teaching and reinforcement• Comorbidities Contributing?• Diabetes Seen by endocrinology for uncontrolled diabetes type 2• OSA compliant w/ CPAP• HTN controlled• CKD, stage 3 kidney function stable• Medication review: ? Lyrica (pregabalin)• Socioeconomic factors?
February
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Case Study HFpEF: Mr. Jones
FOLLOW UP:
Seen in clinic for post hospital
follow up 7 days after discharge.
SUBJECTIVE:
Able to walk from home to mailbox
without limitations. Denies orthopnea.
Limiting sodium and fluid intake. Wearing CPAP nightly. Blood
glucose average 200s
EXAM:
JVD 7 cm. Trace LE edema
VITALS:
BP 126/89, HR 78, RR 16, oxygen saturation
98%
WEIGHT:
270 pounds
LABS:
Sodium 139, potassium
4.8, BUN 58, creatinine
2.2, bnp 66
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HFpEF Clinical Pearls
Management of hypertension
Management of fluid
Management of Co-Morbidities
Assess Socioeconomic
Factors
Labs:
BNP NOT always elevated w/ HFpEF
and or Obesity
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Transitioning from Hospital to Home
Follow up phone call with 72 hours of hospital discharge
• Improves outcomes• Billable via Transitional
Care Management Services CPT code
2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure
Steven M. Hollenberg, Lynne Warner Stevenson, Tariq Ahmad, Vaibhav J. Amin, Biykem Bozkurt, Javed Butler, Leslie L. Davis, Mark H. Drazner, James N. Kirkpatrick, Pamela N. Peterson, Brent N. Reed, Christopher L. Roy, Alan B. StorrowJ Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011
Image source: Hollenberg, Stevenson, Ahmad, Bozkkurt, Butler, Davis, et al. J Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011
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First post-discharge visit checklist
• History• Exam• Testing• Medication• Therapy Considerations• Patient Education• Consultations
Transitioning from Hospital to Home
Image source: Hollenberg, Stevenson, Ahmad, Bozkkurt, Butler, Davis, et al. J Am Coll Cardiol. 2019 Oct, 74 (15) 1966-2011
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Transitioning from Hospital to Home
Transitional Care Management Services
CPT Code 99495: Moderate Complexity
Communication within 2 business days of discharge
Moderate complexity medical decision making
Face to face visit within 14 days of discharge
CPT Code 99496: High Complexity
Communication within 2 business days of discharge
High complexity medical decision making
Face to face visit within 7 days of discharge
Getty Images / fcscafeine
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Co-Managing Heart Failure in Primary Care
Partner with local heart specialist or cardiologist.
Get to know the hospitalists team that takes care of the HF pts in local hospital.
Connect with community resources such as home health, medication delivery services.
Communicate any medications changes to the cardiologist or concerns for disease progression.
Knowing when to refer for advanced care.
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Case Study
Heart Failure with Reduced Ejection Fraction
Image Source: Jessup M, Brozena SA. New Engl J Med. 2003; 348:2007-2018.
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Case Study HFrEF: Mrs. Smith
HPI: Mrs. Smith is a 51 yo AA female with history of HFrEF 2/2 to hypertensive heart disease with LVEF of 20-25%. Presents today for follow up after recent hospitalization.
Current symptoms include: DOE with walking around in home and ADLs, No DOE at rest, + PND about 2 nights a week, + 2 pillow orthopnea, LE edema, and early satiety.
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Case Study HFrEF: Mrs. Smith
PMH:
Hospitalization for new onset HF symptoms
Hypertension x 20 years (non-adherent)
Type 2 DM x 10 years
Obesity
Family History:
Father with Cardiomyopathy
Social:
Stopped all ETOH 2 years ago
No illicit drugs, non-smoker
Divorced, lives with mom and son
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Case Study HFrEF: Mrs Smith
Glucophage (metformin) 500mg BID Lasix (furosemide) 80mg once a day Coreg (carvedilol)12.5mg once a day Lopressor (metoprolol) 25mg once a day Prinivil (lisinopril) 10mg once a day K-Tab (potassium chloride) 10meq QD
MEDICATIONS
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VS: Weight 245# , b/p 155/80, HR 78, o2 sat 98%, rr 16, Temp 98.6
Gen: AA female well developed, well nourished in NAD
HEENT: EOMs intact bilaterally, PERRLA bilaterally, oropharynx benign, neck supple, no carotid bruits
CV: regular rate and rhythm, S1S1, +S4 no S3, soft II/VI systolic apical murmur, PMI slightly laterally displaced. JVD 8-10 cmh20 noted pt sitting 90 degrees, no HJR
Pul: Bilat CTA
Ab: normoactive BS, non-tender, non-distended, no HJR, no heptosplenomegaly
Extremities: Bilateral LE 2+ edema to knees, 2+ bilateral LE pulses
Case Study HFrEF: Mrs. Smith
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Most RecentTesting:
ECHO: Severe depressed LV systolic function with severe global hypokinesis with LVEF est at 20-25%.
Impaired relaxation (Stage I diastolic dysfunction).
Normal right ventricular size and function.
No significant valvular disease.
RA pressure estimated at 8
Cardiac Cath: No significant coronary artery disease
LABS: Glucose 204, KCL 4.3, CL 102, Co2 28, BUN 16, Creat1.2, CA 9.6 ; BNP= 1194
Case Study HFrEF: Mrs. Smith
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Diagnosis:
HFrEF Class C, NYHA class IIIb, etiology likely hypertensive heart disease.
WET VS DRY?
Case Study HFrEF: Mrs Smith
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Plan:
WET - Needs increased diuresis (what ss = ? WET)
Has increased B/P - Good time to increase after load reduction by changing over to ARNI (STOP PRINIVIL (LISINOPRIL) x 36 hrs)
Beta blocker optimization?? (on 2 different ones) point to only be on one…which one? Coreg (carvelol) 12.5mg increase to BID after increased diuretics for a few days.
STOP Lopressor (metoprolol)
Add Aldactone (spironolactone) 25mg QD
Consider adding Digitek (digoxin) 0.125mcg
Increase diuretic to 80mg BID to lose 1-2 pounds a day….
Increase KCL to 10meq BID (KCL is on the low side)
Case Study HFrEF: Mrs. Smith
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Once optimized:
Consider Adding Bidil (isosorbide/hydralazine) slow increase to 1 tab BID-TID
Repeat ECHO and if LVEF remains < 30 % will need referral to EP for ICD for primary prevention
Case Study HFrEF: Mrs. Smith
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Follow up visit:
HOW SOON?
WHAT NEXT?
Case Study HFrEF: Mrs. Smith
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What would plan be if patient was DRY on exam?
Case Study HFrEF: Mrs. Smith
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HFrEF Clinical Pearls
When Dry increase Beta blocker (if HR & B/P allow)
When Wet increase ACE/ARB/ARNI
( if B/P & Lab allow)
36 hour wash out changing from ACE
to ARNI
Higher Creatine Higher Diuretic
Dose
Lasix (furosemide) 80mg
=
Demadex (torsemide 20mg
=
Bumex (bumetanide) 2mg
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Patient Teaching
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Patient Teaching: Key Points
Medication Review
Activity Level
Dietary and Sodium restrictions (no added salt)
Fluid restrictions (1500-2000ml/day)
Daily weight monitoring
Assessment of peripheral edema
Substance use counseling if appropriate
List of warning signs of decompensation
Bring list of medications and daily weights to each outpatient visit
Who to call for worsening symptoms or ICD discharge
Smoking Cessation
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Same time
Same scale
Notify provider for weight gain > 2 lbs. above baseline
Daily Weights
Getty Images / TerryJ
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MEDS TO AVOID
NO NSAIDS for pain
Watch for the TZDs: Actos (pioglitazone), Avandia (rosiglitazone)
Worsening renal function (all diabetic meds)
Calcium Channel Blockers in LVEF <40%
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When to Refer
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I-NEED-HELP
I: IV inotropes
N: NYHA IIIB/IV or persistently elevated natriuretic peptides
E: End-organ dysfunction
E: Ejection fraction < 35%
H: Hospitalized > 1
E: Edema despite escalating diuretics
L: Low blood pressure, High heart rate
P: Prognostic medication-progressive intolerance or down-titration of GDMT
(Yancy, et al., 2018)
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Stages, Phenotypes and Treatment of HF
or ARNI
(Yancy, et al, 2013)
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Clinician and Patient Resources American Association of Heart Failure Nurses
https://www.aahfn.org/
Heart Failure Society of America
https://hfsa.org/
American Heart Association
https://www.heart.org/en/health-topics/heart-failure
2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized with Heart Failure
http://www.onlinejacc.org/content/74/15/1966?rss=1
2013 ACCF/AHA Guideline for Management of Heart Failure
https://www.ahajournals.org/doi/full/10.1161/cir.0b013e31829e8776
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for Management of Heart Failure
https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000509
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On the Horizon
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On the Horizon for HF
“SGLT2 inhibitors have been found to significantly improve HF related outcomes, decreasing the frequency of HF related hospitalizations as well as CV related Death”
The FDA has already granted empagliflozin the fast track designation for the reduction of risk for CV death and HF hospitalization in people with chronic HF.
COVID-19 Impact (unknown)
CardioMems_Remote Hemodynamic monitoring
(Guide-HF)
Wojcik & Warden (2019) Curr Cardiol Rep. Sep 14;21(10):130. doi: 10.1007/s11886-019-1219-4.Mechanisms and Evidence for Heart Failure Benefits from SGLT2 Inhibitors.
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SUMMARY
HFpEF vs HFrEF: Goals are the same but treatment is vastly different.
Management of Co-Morbid conditions is essential for reducing Heart Failure exacerbations.
Primary Care providers are essential in co-management of the Heart Failure patient.
Collaboration and resources are readily available.
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References Axon, R. N., & Williams, M. V. (2011). Hospital readmission as an accountability measure. JAMA, 305(5), 504-505. doi:
10.1001/jama.2011.72
Buggey, J., Mentz, R. J., DeVore, A. D., & Velazquez, E. J. (2015). Angiotensin Receptor Neprilysin Inhibition in Heart Failure: Mechanistic Action and Clinical Impact. J Card Fail, 21(9), 741-750. doi: http://dx.doi.org/10.1016/j.cardfail.2015.07.008
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