Transcript Major Criteria - NP/PA/CNM Professional Practice Group

Heart Failure Management
Focus on Primary Care Practice
[email protected]
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
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
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
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
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
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
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
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
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
AHA 2009: Get With The Guidelines – HF
HF Quality Measures
Implantable Cardiac Defibrillator (ICD) in patients with
LV ejection fraction ≤ 35% and no contraindications
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
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
HFSA 2006: Hospitalization Recommended
• Evidence of severely decompensated heart failure:
hypotension, renal dysfunction, altered mental status
• Shortness of breath: resting tachypnea, O2 desaturation
HFSA 2006: Hospitalization Recommended
• Hemodynamically significant cardiac arrhythmias
• Acute coronary syndromes
HFSA 2006: Hospitalization Considered
• Weight gain > 5 kg, even without shortness of breath
• Pulmonary congestion, even without weight gain
• Major electrolyte disturbances
HFSA 2006: Hospitalization Considered
• Co-morbidity: pneumonia, pulmonary embolism, TIA
• Repeated firings of implantable cardiac defibrillator
• Previously undiagnosed HF with significant congestion
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
Loop Diuretic
Initial Daily Dose
Maximum
Daily Dose
Duration
of Action
Bumetanide
0.5 to 1.0 mg once or twice
10 mg
4 to 6 hours
Furosemide
20 to 40 mg once or twice
600 mg
6 to 8 hours
Torsemide
10 to 20 mg once
200 mg
12 - 16 hours
Loop Diuretic
Initial Daily Dose
Maximum
Daily Dose
Duration
of Action
Bumetanide
0.5 to 1.0 mg once or twice
10 mg
4 to 6 hours
Furosemide
20 to 40 mg once or twice
600 mg
6 to 8 hours
Torsemide
10 to 20 mg once
200 mg
12 - 16 hours
Thiazides
Initial Daily Dose
Maximum
Daily Dose
Duration
of Action
Chlorothiazide
250 to 500 mg once or twice
1000 mg
6 - 12 hours
HCTZ
25 mg once or twice
200 mg
6 - 12 hours
Chlorthalidone
12.5 to 25 mg once
100 mg
24 - 72 hours
Indapamide
2.5 mg once
5 mg
36 hours
Metolazone
2.5 mg once
20 mg
12-24 hours
Maximum
Daily Dose
Duration
of Action
K+ Sparing
Initial Daily Dose
Amiloride
5 mg once
20 mg
24 hours
Spironolactone
12.5 to 25 mg once
50 mg
2 - 3 days
Triamterene
50 t0 75 mg twice
200 mg
7 - 9 hours
Sequential Nephron Blockade
Metolazone
2.5 to 10 mg once plus loop diuretic
Hydrochlorthiazide
25 to 100 mg once or twice plus loop diuretic
Chlorothiazide
500 to 1000 mg once plus loop diuretic
ACE Inhibitors
• Captopril
6.25 mg 3x daily
Max 150 mg daily
• Enalapril
2.5 mg twice daily
Max 40 mg daily
• Fosinopril
5 to 10 mg once daily
Max 40 mg daily
• Lisinopril
2.5 to 5 mg once daily
Max 40 mg daily
• Ramipril
1.25 to 2.5 mg once daily
Max 10 mg daily
ACE Inhibitors: Adverse Effects
• Hypotension
• Worsening Renal Function
• Hyperkalemia
• Cough
• Angioedema
Angiotensin Receptor Blockers
• Candesartan 4 to 8 mg once daily
(Max 32 mg daily)
• Losartan
25 to 50 mg once daily
(Max 100 mg daily)
• Valsartan
20 to 40 mg twice daily
(Max 320 mg daily)
-Adrenergic Receptor Blockers
• Bisoprolol
1.25 mg once daily
Max 10 mg daily
• Carvedilol
3.125 mg twice daily
Max 50 mg daily
• Metoprolol XL
12.5 to 25 mg once
Max 200 mg daily
Beta-Blockers: Adverse Effects
• Fluid Retention and Worsening HF
• Hypotension
• Bradycardia and Heart Block
• Bronchospasm
• Fatigue and Depression
Aldosterone Antagonists
• Spironolactone
12.5 to 25 mg once
Max 50 mg daily
• Eplerenone
25 mg once daily
Max 50 mg daily
Aldosterone Antagonists: Adverse Effects
• Hyperkalemia
• Gynecomastia
• Erectile Dysfunction, Testicular Atrophy