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

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, O 2 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. Loop Diuretic Bumetanide0.5 to 1.0 mg once or twice10 mg4 to 6 hours Furosemide20 to 40 mg once or twice600 mg6 to 8 hours Torsemide10 to 20 mg once200 mg12 - 16 hours Initial Daily Dose Maximum Daily Dose Duration of Action

20. Loop Diuretic Bumetanide0.5 to 1.0 mg once or twice10 mg4 to 6 hours Furosemide20 to 40 mg once or twice600 mg6 to 8 hours Torsemide10 to 20 mg once200 mg12 - 16 hours Initial Daily Dose Maximum Daily Dose Duration of Action

21. Thiazides Chlorothiazide250 to 500 mg once or twice1000 mg6 - 12 hours HCTZ25 mg once or twice200 mg6 - 12 hours Chlorthalidone12.5 to 25 mg once100 mg24 - 72 hours Indapamide2.5 mg once5 mg36 hours Metolazone2.5 mg once20 mg12-24 hours Initial Daily Dose Maximum Daily Dose Duration of Action

22. K + Sparing Amiloride5 mg once20 mg24 hours Spironolactone12.5 to 25 mg once50 mg2 - 3 days Triamterene50 t0 75 mg twice200 mg7 - 9 hours Initial Daily Dose Maximum Daily Dose Duration of Action

23. Sequential Nephron Blockade Metolazone2.5 to 10 mg once plus loop diuretic Hydrochlorthiazide25 to 100 mg once or twice plus loop diuretic Chlorothiazide500 to 1000 mg once plus loop diuretic

24. ACE Inhibitors Captopril6.25 mg 3x dailyMax 150 mg daily Enalapril2.5 mg twice dailyMax 40 mg daily Fosinopril5 to 10 mg once dailyMax 40 mg daily Lisinopril2.5 to 5 mg once dailyMax 40 mg daily Ramipril1.25 to 2.5 mg once dailyMax 10 mg daily

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

26. Angiotensin Receptor Blockers Candesartan4 to 8 mg once daily(Max 32 mg daily) Losartan25 to 50 mg once daily(Max 100 mg daily) Valsartan20 to 40 mg twice daily(Max 320 mg daily)

27.  -Adrenergic Receptor Blockers Bisoprolol1.25 mg once dailyMax 10 mg daily Carvedilol3.125 mg twice dailyMax 50 mg daily Metoprolol XL12.5 to 25 mg onceMax 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 Spironolactone12.5 to 25 mg once Max 50 mg daily Eplerenone25 mg once dailyMax 50 mg daily

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