2009 Adult Congestive Heart Failure Clinical Guideline

Standards of Care History and Physical Examination History Frequency** Description

Initial and follow-up visits Initial and follow-up visits

Physical Examination

Review family history, CHD risk factors, symptoms, psychosocial and environmental factors, dietary history, and history of medications. Review vital signs, heart rate, respiratory rate, weight, height, examine neck veins, feet, ankles, and abdomen for swelling, blood pressure measurement and assessment of activity level should be recorded Recommended for patients to observe valve and heart wall motion. Recommended for patients to observe arrhythmias and cardiac stress. Recommended checking for enlargement of the heart and for fluid in and around the lungs. Recommended for patients without angina but high probability of CAD and candidates for revascularization. A cardiology consultation should be considered prior to or at the time of testing. When changing diuretic, recommended to check creatinine, sodium, potassium, and magnesium.

Diagnostic Tests Echocardiogram Electrocardiogram Chest X-ray (PA & Lateral) Noninvasive stress testing

As indicated Initial visit Initial visit Initial visit

Laboratory tests (CBC, electrolytes, BUN, thyroid function, liver function, urinalysis, creatinine, sodium, potassium, magnesium, and albumin) Lipid panel Assessment of NYHA Functional Class CHF-Related Preventive Care Influenza Vaccine Pneumococcal Vaccine Consultation Cardiology Consultation Referral to Disease Management

Initial visit

Initial and annually Initial and follow-up visits

Recommended to check at regular intervals until therapeutic goal achieved, then annually unless otherwise needed. Please refer to Table A.

Annually Once

If given prior to age 65 and five years have elapsed since vaccine, consider revaccination. Recommended for NYHA Class II, III and IV if not previously completed. Consider referral to Health Partners Disease Management Program if you think your patient would benefit from case management. Please contact us at

Initial visit Initial and follow-up visits

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2009 Adult Congestive Heart Failure Clinical Guideline

Standards of Care Management and Educational Counseling Pharmacological Management Nutrition and Fluid Management Counseling Weight Management Counseling Frequency** (215) 991-4252. Description

Initial and follow-up visits Within first 2 visits

ACE inhibitor therapy recommended for all patients NYHA Class I - IV unless contraindicated or not tolerated. (Refer to Table B.) Dietary sodium should be restricted to 2 grams per day. Excessive fluid intake should be discouraged. Patients should be encouraged to record weight before breakfast daily. It is recommended that provider be contacted if patients gain over 2 pounds in a day or 5 pounds in a week. Ideal weight should be discussed with patients. After cardiology clearance, moderate exercise to tolerance should be encouraged for all patients with stable NYHA Class I - III heart failure. Cardiac rehabilitation as indicated Alcohol use and smoking should be discouraged. Patients who drink alcohol should be advised to consume no more than one drink per day.

Within first 2 visits

Lifestyle changes to include: Exercise and Environmental Counseling

Within first 2 visits

Within first 2 visits

** Recommended Frequency of Follow-up visit(s) by NYHA Functional Class: Class I: Initial revisit in 2 weeks. Follow-up at 3 months (if tests normal), then annually if patient stable. Class II: Initial revisit in 2 weeks. Follow-up at 3 months, then 2 times per year. Class III: Initial revisit in 1 week. Follow-up at 2 weeks, then at 1-month intervals for three months, then at 3-month intervals. Class IV: Consider hospital admission for diagnostic work-up, referral to a cardiologist, or weekly follow-up.

Table A

New York Heart Association Functional Classification:

NYHA Class I II III IV Definition and Follow-up
Asymptomatic: Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, dyspnea, or angina. Mildly Symptomatic: Patients with cardiac disease resulting in slight limitation of physical activity. Comfortable at rest, ordinary physical activity results in fatigue, palpitation, dyspnea, or angina. Moderately symptomatic: Patients with cardiac disease resulting in marked limitation of physical activity. Comfortable at rest, less than ordinary activity causes fatigue, palpitation, dyspnea or angina. Severe/Symptoms at rest: Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of anginal syndrome may be present even at rest. Any physical activity leads to increased discomfort.

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2009 Adult Congestive Heart Failure Clinical Guideline Table B Pharmacological Management
Therapy Modality
Diuretics Angiotensin-Converting Enzyme (ACE) Inhibitor Therapy

Definition
Should be prescribed to all patients who have evidence of, and to most patients with a prior history of, fluid retention; Diuretics should generally be combined with an ACEI and a beta-blocker ACEI should be given to all patients with HF due to LV systolic dysfunction with reduced LVEF unless they have a contraindication to use or have been shown to be unable to tolerate treatment with these drugs; Treatment with ACEI should not be delayed until patient is resistant to other treatments due to survival benefits; Generally used in conjunction with a beta-blocker; ACEI should not be prescribed without diuretics in patients with current or recent history of fluid retention Can now be considered a reasonable alternative to ACEI; Evidence shown by the CHARM trial indicated that candesartan improved outcomes in patients with preserved LVEF who were intolerant of ACEI The addition of low dose aldosterone antagonists should be considered in selected patients with moderate or severe HF and recent decompensation with LV dysfunction early after MI Beta-blockers should be prescribed to all patients with stable HF due to reduced LVEF unless there is a contraindication to use or have been shown to be unable to tolerate treatment with these medications; Beta-blocker therapy is important and should not be delayed until symptoms return or disease progression is documented during treatment with other drugs Recommendations not provided on the use of calcium channel blockers in 2005 guideline update for the Diagnosis and Management of Chronic Heart Failure in the Adult May consider addition of digoxin in patients with persistent symptoms of HF during therapy with diuretics, and ACEI (or ARB), and a betablocker; Digoxin may be added to initial regimen in patients with severe symptoms who have not yet responded symptomatically during treatment with diuretics, and ACEI, and beta-blockers; Digoxin may be delayed until patients response to ACEI and beta-blockers has been defined; May be used in patients who remain symptomatic despite therapy with neurohormonal antagonists The addition of hydralazine and isosorbide dinitrate to standard therapy with an ACEI and/or beta-blocker was shown to be of significant benefit in the black population; This combination should not be used for the treatment of HF in patients who have no prior use of ACEI and should not be substituted for ACEI in patients who are tolerating ACEIs without difficulty

Angiotensin Receptor Blockers (ARBs) Aldosterone Antagonists Beta-Blockers

Calcium Channel Blockers Digoxin

Hydrazaline/Isosorbide Dinitrate Combination

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2009 Adult Congestive Heart Failure Clinical Guideline

Anticoagulants In the absence of definitive trials, it is unclear how anticoagulants should be prescribed in patients with heart failure; Anticoagulation with warfarin is most justified in patients with HF who have experienced a previous embolic event or who have paroxysmal or persistent atrial fibrillation; Anticoagulation may also be considered in patients with underlying disorders that may be associated with an increased thromboembolic risk and in patients with a familial history of dilated cardiomyopathy and a history of thromboembolism in a first-degree relative Currently under investigation as adjunctive therapy, administered on an intermittent outpatient basis, for advanced HF; Unless safety and efficacy are demonstrated, intermittent or a continuous outpatient infusion of nesiritide and other natriuretic peptides is not recommended Due to lack of evidence to support their efficacy and concerns about their toxicity, physicians should not utilize intermittent infusions of positive inotropic agents (at home, in an outpatient clinic, or in a short-stay unit) in the long-term treatment of HF, even in its advanced stages Longer-term clinical trials are under way to determine the role, if any, of vasopressin antagonists in patients with chronic HF References:
1. 2. 3. Institute for Clinical Systems Improvement, Heart Failure in Adults, Tenth Edition, August 2007. Colucci, W.S., Braunwald, E. ed. Current Medicine. Atlas of Heart Failure, Cardiac Function and Dysfunction, 2nd Edition, Philadelphia, PA, 1999. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J. Am. Coll. Cardiol. 2005; 46; 1-82, doi:10.1016/j.jacc.2005.08.022. Dutcher, Robert, Guidelines Recommend ACE Inhibitor or ARB for Heart Failure, Pharmacy Times, October 2007, www.pharmacytimes.com/issues/articles/2007-10_6979.asp (accessed 2/11/08).

Natriuretic peptides

Positive Inotropes (i.e. dobutamine, dopamine, milrinone) Vasopressin Receptor Antagonists

4.

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