1. Dr. Jon Salisbury Visiting Physician Services A Member of VNA Health Group No Disclosures May 14, 2015 1:40PM – 2:00PM ©AAHCM

2. “I haven’t sent a heart failure patient to the hospital in over 5 years” ©AAHCM

3.  Pathophysiologic: Inability of heart to deliver blood and oxygen  Clinical: Breathlessness and fatigue associated with cardiac disease  Associated by: Fluid retention, edema, elevated venous pressure  Clinical assessment seeks to answer to questions: ◦ Are the symptoms cardiac of non-cardiac in origin? ◦ If cardiac, what is the precise problem? ©AAHCM

4. Suspected Heart Failure? Dyspnea Fatigue Edema Seek evidence of heart failure 1. Clinical History2. Clinical Exam3. Investigation Dyspnea & fatigue Previous MI Angina Hypertension Valvular disease Palpitations (arrhythmia?) Smoking, alcohol abuse, family history Tachycardia Rales Raised J.V.P. Murmur Edema 3 rd heart sound EKG CXR Echocardiogram CBC, CMP, BNP Thyroid Panel

5. ©AAHCM Etiology Systolic LV dysfunction (most common) Diastolic LV dysfunction Valvular disease Rhythm / conduction disturbance Pericardial / endocardial disease Congenital heart disease Heart Failure Confirmed

6. ©AAHCM NYHA Class 1NYHA Class 2NYHA Class 3NYHA Class 4 No limitations of physical activity Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation or dyspnea Unable to perform any physical activity without discomfort – symptoms of cardiac insufficiency at rest ACE B-Blockers Hydralazine + isosorbide in African Americans Aldosterone antagonist (K+<5.0, Cr.<2.5) Loop Diuretics Loop diuretics Digoxin ARB can be used of ACE are not tolerated Consider digoxin ICD, CRT-P,+ transplantation don’t generally pertain to our patients

7.  ACE Inhibitors: ◦ Enalapril: 10mg BID ◦ Lisinopril: 20 – 40mg QD ◦ Captopril: 100 – 150mg daily (3 times daily dosing)  B-Blockers: ◦ Carvedilol: 3.125 BID x 2 weeks, then double every 2 weeks to highest level tolerated (dizziness) to max 25mg BID ◦ Metoprolol succinate: 25mg QD (severe HF, start 12.5mg BID) ◦ Bisoprolol: 1.25mg/day, max 5mg/day  Hydralazine: 300mg/day (divided doses)  Isorbide dinitrate: 30 – 160 mg/day ©AAHCM

8.  Loop Diuretics: ◦ Furosemide: 20 – 80mg/day ◦ Bumetanide:.5 – 2mg/day ◦ Metolazone: 2.5 – 5mg/day (often 3X/week)  Aldosterone Antagonists: ◦ Spironolactone: 25 – 50mg/day ◦ Eplerenone: 25 – 50mg/day  Digoxin:.125 -.25mg/day  ARB’s ◦ Valsartan: 40mg/BID (start), 80 – 60mg/BID maintenance ◦ Candesartan: 4mg/day start, target 32/day ◦ Losartan: (not approved but beneficial) 50mg/day ©AAHCM

9.  Diet: weight reduction, nutritional status, Na+ intake  Fluid Intake: about 2 liters/day  Smoking: stop or reduce  Exercise: regular moderate physical activity should be encouraged  Alcohol: in moderation  Vaccinations: influenza and pneumococcal ©AAHCM

10.  Education, education, education!  Patient and family involvement and decision making  Assess the patient for depression and stressors  Involvement of home nursing care, PT, medications management, CHF programs  Telemonitoring ©AAHCM

11.  Explain clearly what heart failure is  Explain medications, how they work, dosing schedule, etc…  Explain how their disease may be just as easily be well managed at home  Reassure patient that the diagnosis of heart failure does not have to be a death sentence  Include family / caregivers in education process ©AAHCM

12.  Daily weights: ◦ Gain > 3lbs, take extra Lasix first, then call us!  Sliding scale of diuretics: ◦ Involve patient and family in dosing schedules  What triggers ER visits? ◦ Usually dyspnea, suggest use of pulse oximetry for reassurance ◦ Anxiety / panic: frequently will use a short acting anxiolytic ◦ Have occasionally utilized MSIR for air hunger /anxiety ◦ Treat depression  Have discussion about Palliative Care and Hospice Care ©AAHCM

13.  Heart failure can be well treated at home  Admission and readmissions can be significantly reduced  Follow treatment guidelines  Involve patient, family, and caregivers in decision making  Educate!  Discuss hospice / palliative with critical patients  Be reassuring that there can be life after diagnosis of heart failure! ©AAHCM