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Kaiser
Permanente Clinical Practice Guidelines - Heart Failure due to Left-Ventricular
Systolic Dysfunction |
Clinical
Practice Guidelines -
Heart
Failure due to
Left-Ventricular
Systolic
Dysfunction.
Endorsed
by
Regional
Chiefs of Internal
Medicine and Cardiology
Issued: May 1997
An
adaptation of a clinical
practice guideline
issued
by
the Agency for Health Care Policy and Research
Heart Failure:
Evaluation
and Care of Patients with Left-Ventricular
Systolic
Dysfunction.
The
Permanente
Medical Group Clinical Practice
Guidelines
have
been developed to assist clinicians by providing
an analytical
framework
for the evaluation and treatment of selected
common
problems
encountered in patients. These guidelines
are not
intended
to establish a protocol for all patients with
a particular
condition.
While
the guidelines provide
one approach to evaluating
a problem,
clinical
conditions may vary significantly from individual
to individual.
Therefore,
the clinician must exercise independent judgment
and
make
decisions based upon the situation presented. |
/httpdocs/cajud/heart |
|
HEART FAILURE TEAM
Rik
Smith, MD, Chair, Internal
Medicine, Harvard
Robert
Blumberg, MD,
Cardiology, Redwood City
James
Chan. Pham D. PhD, Pharmacy, Operations, Regional
Offices
Robert
Heller, MD., Cardiology. Harvard
David
Levy, MD, Internal
Medicine, Walnut Creek.
Park
Shadelands
Pam
Kotler, PhD, TPMG Department of Quality and Utilization,
Regional Offices
Valerie
McClymont, NE Cardiovascular Surgery, San
Francisco
John
Takahashi, MD, Emergency, Santa Clara
Susan
Woodier MD, Cardiology,
Santa Teresa
PROJECT MANAGEMENT
Pam
Kotler, PhD, TPMG
Department of Quality and
Utilization,
Regional Offices
Purvi
Mody Kunwar. MPH, TPMG Department of Quality and
Utilization
DESIGN AND PRODUCTION
Wendy
Jung, MA, TPMG
Department of Quality and
Utilization
ACKNOWLEDGEMENT
Jodi
Cupp. MBA, Lanna
Butler-McCoy, Kalev
Golubijatnikov,
and Anita Klein of KP Consulting,
Kaiser
Foundation Health
Plan/Hospitals
provided
additional support
for
the development and
implementation of these guidelines.
CLINICAL
REVIEW GROUP
The
following individuals reviewed this guideline and
contributed to its final form.
Henry
M. Brodkin. MD, Redwood
City
Paul
A. Feigenbaum. MD, San
Francisco
David
Gee. MD, Walnut Creek
Arthur
Klatsky, MD, Oakland
Pansy
Kwong. MD, Oakland
David
Langkammer. MD, Antioch
Eleanor
Levin. MD, Santa Clara
Roy
Meyer, MD, Santa Rosa
Jonathan
R. Rompf, MD, Santa
Teresa
Laurie
J.
Weisberg, MD, South San Francisco
David
Williams, MD, Vallejo
Copyright
1997
The
Permanente Medical Group, Inc. All rights reserved.
Please contact TPMG Department
of
Quality and Utilization at
510-987-2309 or
tie-line
8-427-2309 for permission to reprint any
portion
of this publication.
For
additional copies of
the guidelines, please call 510-987-2950
or
tie-line 8-427-2950.
Contents
- Clinical Practice Guidelines for Heart Failure
Topic
INTRODUCTION
INITIAL
EVALUATION
CLINICAL
VOLUME OVERLOAD
SCREENING
FOR ARRHYTHMIAS
ASSESSMENT
OF LEFT-VENTRICULAR
SYSTOLIC
DYSFUNCTION
DIASTOLIC
DYSFUNCTION
PHARMACOLOGICAL
MANAGEMENT/SYSTOLIC DYSFUNCTION
DIURETICS
DIGOXIN
ACE
INHIBITORS
ANTICOAGLimON
ATRIAL
FIBRILLATION
ADDITIONAL
PHARMACOLOGICAL
MANAGEMENT
GENERAL COUNSELING
ACTIVITY
DIET
MEDICATIONS
COMPLIANCE
PROGNOSIS
PREVENTION IN
ASYMPTOMATIC PATIENTS WITH LEFI-VENTRICULAR
SYSTOLIC DYSFUNCTION
HOSPITAL
MANAGEMENT
REVASCULARIZATION
No
ANGINA AND
No MI
NO
ANGINA AND
HISTORY OF MI
ANGINA
COUNSELING
AND
DECISION
CONTINUE
MEDICAL MANAGEMENT
REVASCULARIZATION
FOLLOW-UP
HEART
TRANSPLANTATION
SELECTED
REFERENCES
GUIDELINE
HIGHLIGHTS
FIGURES
AND
TABLES
Figure
1: Overview of
Evaluation
and
Care ofPatients With Heart Failure
Figure
2:
Initial Evaluation of Patients uith Heart Failure
Figure
3:
Recommended Tests for Patients with Signs or
Symptoms of Heart Failure
Table
1:
Initial Diagnostic Testing in Heart Failure
Table
2: Other
Laboratory Testing to Consider in the
Initial Evaluation of Selected Patients Who Have Been
Diagnosed
with
Heart Failure
Table
3:
Potentially Reversible Causes of Heart Failure
Table
4:
Medications Used in Heart Failure
Figure
4:
Pharmacological Managenment of Patients with
Heart Failure
Table
5:
Suggested Topics for Patient, Family and Caregiver
Education and Counseling
Figure
5:
Evaluation and Treatment of Coronary Heart
Disease in Patients with Heart Failure
Heart
failure is characterized by: signs and symptoms
of intravascular and interstitial volume overload,
including
shortness of breath,
rales, and edema
or
manifestations of inadequate tissue perfusion, such
as fatigue or poor exercise tolerance.
These
are the results of the
inability of
the heart to
meet bodily demands.
There
is a trend towards omitting the word "congestive"
with heart failure since not all patients are congested;
however,
for purposes of this
documents,
the
terms heart failure, congestive heart failure, and
left-ventricular systolic dysfunction may be considered
interchangeable.
|
|
CLINICAL
PRACTICE GUIDELINES for
HEART FAILURE
INTRODUCTION
1. signs and
symptoms of intravascular
and interstitial
volume overload, including shortness of breath, rales, and
edema
or
2.
manifestations of
inadequate
tissue perfusion,
such as fatigue or poor exercise tolerance.
These
are the results of the inability of the heart to
meet bodily demands.
The
National Heart, Lung, and Blood Institute estimates
that over 2 million Americans have heart failure with
about
200,000 deaths per year.
Approximately
400,000 new
cases are diagnosed each year
and about 1 million hospitalizations are due to heart
failure
for an estimated cost
of over $7 billion. At
Kaiser Permanente Northern California we had 3,952
hospitalizations
in
1995 for which the principle condition was heart
failure and another 2,755 hospitalizations for which heart
failure
was
an associated condition for an estimated cost of
$59,476,854 for inpatient care. Since the American population
is
aging, conditions such as
heart failure will become
more prevalent.
However,
there is evidence that changes in both inpatient
and outpatient management can have substantial impacts
on
moibiditv and mortality.
The Agency for Health
Care Policy and Research
issued
a clinical practice guideline on "Heart Failure: Management
of
Patients with
Left-Ventricular Systolic Dysfunction"
in 1994. This guideline was developed through a rigorous
evidence-based
process in
which 16 clinical experts reviewed
over 1.000 studies and developed a guideline which
primarily
addresses outpatient
management. Each recommendalion
made by the panel was graded by the level of
evidence
upon which it was
based:
A. Good evidence:
Evidence from well-conducted
randomized
controlled trials or cohort studies
B.
Fair evidence: Evidence
from other types of
studies
(case-controlled, uncontrolled)
C.
Expert Opinion
Because
heart failure is such a prevalent condition for
which changes in management can be expected to substantially
increase
positive out-comes,
the TPMG Department of Quality
and Utilization was asked by the Continuum of Care
Group
of Kaiser Foundation
Health Plan/ Hospitals to
sponsor the development of a guideline for heart failure
management.
A team of
clinicians from around Northern
California was convened as a Heart Failure Guideline Team
and
met eight times to review
the AHCPR guidelines. The
team examined each of the
recommendations
made by AHCPR
and categorized them
into
three categories:
agree;
agree with discussion: and need to see further
evidence. When further evidence was needed, a literature
search
was undertaken for new
research bearing on the
issue and the team then discussed the new evidence,
the
team did not go back and
review all the studies summarized
by AHCPR. The following work represents the
KPNCR
Heart Failure Guideline
Team's
adaptation of the
AHCPR guideline.
...there
is evidence that changes in both inpatient and
outpatient management can have substantial impacts on
mormidity
and mortality due to
heart failure.
All
patients who complain of dyspnea on exertion, paroxysmal
nocturnal dyspnea (awakening from sleep with
shortness
of breath) or
orthopnea
(shortness of breath
while lying down) should have heart failure considered
in
the initial evaluation
unless other causes for the
symptoms are clearly present.
|
|
INITIAL
EVALUATION
All
patients who complain of dyspnea on exertion, paroxysmal
nocturnal dyspnea (awakening from sleep with shortness
of
breath) or orthopnea
(shortness of breath while lying
down) should have heart failure considered in the initial
differential
diagnosis unless
other causes for the symptoms
are clearly present. Even the presence of other
explanations
for the symptom of
dyspnea does not exclude
multiple
etiologies, including heart failure.
The
physical
examination can
provide important information
about the etiology of patients' symptoms and about
appropriate
initial treatment.
However, physical signs
are not highly sensitive for detecting heart failure.
Therefore,
patients
with symptoms that are highly suggestive of
heart failure (dyspnea on exertion, paroxysmal nocturnal
dyspnea,
orthopnea) should be
evaluated in accordance
with the algorithm below.
In
addition to low
sensitivity, many physical
findings
of heart failure are not highly specific. Elevated jugular
venous
pressure, a third heart
sound and a laterally
displaced apical impulse are the most specific Findings
and
are virtually diagnostic
in patients with compatible
symptoms* Pulmonary rales or peripheral edema are
relatively
nonspecific finding
for heart failure.** The
presence of these signs does not require
measurement
of
left-ventricular ejection
fraction if
other symptoms, signs, and radiographic findings of heart
failure
are absent or if they
can be attributed to other
causes.
A
variety of conditions can mimic or provoke heart failure,
including pulmonary disease, myocardial infarction,
arrhythmias,
pulmonary emboli,
cardiac tamponade, anemia,
renal failure, nephrotic syndrome, and thyroid disease.
These
conditions should be
considered in every patient
with suspected new-onset heart failure. This guideline
does
not address the
management of patients with these
conditions. |
|
A
variety of
conditions can mimic or provoke heart
failure,
including pulmonary disease, myocardial
infarction,
arrhythmias,
pulmonary emboli,
cardiac tamponade,
anemia, renal failure, nephrotic syndrome,
and
thyroid disease.
Elevated
jugular
venous pressure, a third heart
sound
and a laterally displaced apical impulse are the most
specific
findings and are
virtually diagnostic in patients
with compatible symptoms.
Pulmonary
rules or
peripheral edema are relatively
nonspecific
findings for heart disease.
Symptoms
and signs of
volume overload include
orthopnea,
paroxysmal nocturnal dyspnea, dyspnea
on
exertion, pulomonary rales,
a third
heart sound, jugular
venous distension, ascites, peripheral edema,
and
pulmonary vascular
congestion or
pulmonary edema
on chest x-ray.
Screening
evaluation for asymptomatic arrhythmias is not
routinely warranted as part of the evaluation
of
patients with heart failure.
Measurement
of
left-ventricular performance is a critical
step in the evaluation and management of
almost
all patients with
suspected or
clinically apparent
heart failure.
|
|
Practitioners
should
perform a chest x-ray, EKG, complete
blood count, serum sodium, serum potassium, serum
BUN,
serum creatinine, and
serum glucose on all patients
with suspected or clinically evident heart failure.
A
thyroid-stimulating hormone
(TSH) level should also
be checked in all patients with heart failure and no
obvious
etiology and in
patients who have atrial fibrillation
or other signs or symptoms of thyroid disease.
See
Table I for the rationale
for these
tests.
In
addition, several other tests may be considered part
of the initial evaluation in selected circumstances
(see
Table 2).
CLINICAL
VOLUME
OVERLOAD
During
the initial evaluation,
the clinician should determine
if the patient manifests symptoms or signs of volume
overload.
Symptoms and signs
of volume overload include
orthopnea, paroxysmal nocturnal dyspnea dyspnea
on
exertion, pulmonary rales,
a third
heart sound, jugular
venous distension, hepatic engorgement, ascites,
peripheral
edema, and
pulmonary vascular congestion or
pulmonary edema on chest x-ray.
SCREENING
FOR ARRHYTHMIAS
Screening
evaluation for asymptomatic arrhythmias, such
as ambulatory electrocardiognphic (Holier)
recording,
is not routinely
warranted as
part of the
evaluation of patients with heart failure. Patients
with
known heart failure and a
history of unexplained
syncope should be discussed with a cardiologist.
ASSESSMENT
OF LEFT-VENTRICULAR FUNCTION
Patients with
suspected heart failure should
undergo
echocardiography and, if needed, radionuclide
ventritulography to
measure left-ventricular ejection
fraction (if information is not available from
previous tests).
Measurement
of
left-ventricular performance is a critical
step in the evaluation and management of almost
all
patients with suspected or
clinically
evident heart
failure. The combined use of history and physical,
chest
x-ray and
electrocardiography cannot be completely
relied upon to distinguish between the |
|
INITIAL
EVALUATION
All
patients who
complain of dyspnea on exertion, paroxysmal
nocturnal dvspnea (awakening from sleep with
shortness
of breath)
ororthopnea
(shortness of breath
while lying (town) should have heart failure considered
in
the initial differential
diagnosis unless other causes
for the symptoms are clearly present.
Even the presence of
other
explanations for the symptom
of dyspnea does not exclude multiple etiolegies,
including heart
failure.
The
physical examination can provide important information
about the etiology of patients' symptoms and
about
appropriate initial
treatment.
However, physical
signs are not highly sensitive for detecting heart failure.
Therefore,
patients with
symptoms that are highly suggestive
of heart failure (dyspnea on exertion, paroxysmal
nocturnal
dyspnea, orthopnea)
should be evaluated in
accordance with the algorithm below. In addition to low
sensitivity,
many physical
findings of heart failure
are not highly specific.
Elevated
jugular
venous pressure, a third heart
sound
and a laterally displaced apical impulse are the most
specific
findings and are
virtually diagnostic in patients
with compatible symptoms.* Pulmonary rales or
peripheral
edema are
relatively
nonspecific findings
for heart failure,** The presence of these signs does
not
require measurement of
left-ventricular ejection
fraction if other symptoms, signs, and radiographic
findings
of heart failure are
absent or if they can he
attributed to other causes.
A
variety of
conditions can mimic or provoke heart
failure,
including pulmonary disease, myocardial infarction,
arrhythmias,
pulmonary emboli,
cardiac tamponade, anemia,
renal failure, nephrotic syndrome, and thyroid
disease.
These conditions
should be
considered in every
patient with suspected new-onset heart failure.
This
guideline does not
address the
management of patients
with -
This
section just ends here without explanation.
No pages are missing in this book.
Patients
with
suspected heart failure should
undergo echocardiography
and if needed radionuclide
ventriculography
to measure
left-ventricular
ejection
fraction (if information about ventricular function
is
not available from previous
tests).
Once
left-ventricular systolic dysfunction is confirmed,
the results of the history and physical examination
should
be reviewed to search
for clues to potentially
treatable causes of heart failure.
Routine
use of
myocardial biopsy is not warranted.
Echocardiography
or
radionuclide
ventriculography can
substantially imporove diagnotic accuracy in
distinguishing
between
systolic and
diastolic dysfunction.
The
optimal treatment
of diastolic dysfunction is
not
well defined but agents used to treat systolic dysfunction
can
be deleterious in patients
with diastolic dysfunction.
Because
ischemia can produce diastolic dysfunction before
systolic dysfunction develops, physiologic testing
for
ischemia should be
considered in patients with diastolic
dysfunction, particularly when dyspnea on
exertion
is a prominent
symptom.
|
|
DIASTOLIC
DYSFUNCTION
As
many as 40% of
patients with a clinical diagnosis
of heart failure have preserved left-ventricular systolic
function
and no evidence of
valvular heart disease. Most
have left-ventricular diastolic dysflunction.
In
these cases, the left
ventricle has
increased diastolic
stiffness and cannot fill adequately abnormal
diastolic
pressures. The
elevated
pressures required
for filling result in symptoms of pulmonary
congestion.
In addition, the
reduced
left-ventricular
filling volume leads to lowered stroke volumes
and
symptoms of poor cardiac
output.
Most
diastolic
dysfunction resulls from coronary artery
disease or hypertension. Because ischemia can
produce
diastolic dysfunction
before
systolic dysfunction
develops, physiologic testing for ischemia
should
be considered in
patients with
diastolic dysfunction,
particulariy when dyspnea on exertion is a
prominent
symptom.
Hypertension is also a
common cause
of diastolic dysfunction which can develop
even
in the absence of
left-ventricular
hypertrophy.
The
optimal treatment of diastolic dysfunction is not
well defined but agents used to treat systolic
dysfunction
can be
deleterious in patients witb diastolic
dysfunction. Excessive diuresis can reduce
stroke
volume and cardiac
output. Digitalis may further
decrease left-ventricular compliance.
The
role of ACE inhibitors is
not clear.
Vasodilators
may be detrimental in diastolic function although ACE
inhibitors
may have beneficial
effects by
directly improving
ventricular relaxation and causing regression of
hypertrophy.
This
guideline does
not provide
management strategies
for diastolic dysfunction and the remainder of
the
guideline discusses heart
failure due
to left-ventricular
systolic dysfunction. Patients who are
symptomatic
from diastolic
dysfunction may
benefit from
referral to a cardiologist.
PHARMACOLOGICAL
MANAGEMENT: SYSTOLIC DYSFUNCTION
DIURETICS
Diurelics
are
extremely useful for reducing symptoms
of volume overload, including orthopnea and
paroxysmal
nocturnal dyspnea.
Patients
suspected of heart
failure with signs of significant volume overload
should
be started immediately
on a diuretic. Those with
severe volume overload should be started on a
loop
diuretic. Patients with
mild volume
overload may
be managed adequately on thiazide diuretics.
Patients
with minimal symptoms
and minimal
volume overload
should receive dietary counseling
and
may not require diuretic
therapy.
Although
initiation
of diuretics
is important in these
patients, it is also important to avoid over-diuresis
before
starting ACE
inhibitors. Volume depletion may
lead to hypotension or renal insufficiency when
ACE
inhibitors are started or
when the
doses of these
agents are increased to full therapeutic levels.
After
the ACE inhibitor is
increased to full therapeutic
levels, additional diuretic therapy may
be
necessary to optimize the
patient's status.
The
recommendations
contained in this guideline are designed
for patients with heart failure due of
left-ventricular
systolic
dysfunction,
i.e., EFs of less
than 35-49 percent.
Patients
suspected of
heart failure with signs of
significant
volume overload should be started
immediately
on a diuretic.
...it
is important to
avoid
over-diuresis before starting
ACE inhibitors.
All
patients should have their serum potassium levels
checked frequently (e.g., every 3 days until stable)
during
initiation, titration,
or modification of diuretic
or ACE inhibitor therapy and every few months
thereafter.
ACE
inhibitors may be
considered as first-line
therapy
in the subset of heart failure patients who
present
with fatigue or mild
dyspnea on
exertion and
who do not have any other signs or minimal
symptoms
of volume
overload.
Diuretics may be added
if symptoms persist.
...relatively
low
blood pressure, moderate renal
insufficiency,
and mild hyperkalemia are not
contraindictions
to ACE
inhibitors.
Potassium
depletion commonly occurs when patients are
treated chronically with diuretics. However,
ACE
inhibitors decrease renal
potassium
losses and raise
serum potassium levels, so many patients
with
heart failure who are
treated with
both agents may
not develop potassium depletion. All patients
should
have their serum
potassium levels
checked frequently
(e.g., every 3 days until stable) during
initiation,
titration, or
modification of
diuretic or
ACE inhibitor therapy and every few months thereafter.
Potassium-sparing
diuretics
should be used with great
caution, if at all, in patients taking ACE inhibitors.
DIGOXIN
Digoxin
increases the force of
ventricular
contraction
in padents with left-ventricular systolic dysfunction.
It
reduces clinical
deterioration and the need for hospitalization,
but does not reduce overall mortality
in
this group of patients.
Digoxin should
be added to
the medical regimen of patients with heart failure
who
remain symptomatic after
optimal management with
ACE inhibitors and diuretics but should be
used
with caution because of
its potential
toxicity.
ACE
INHIBITORS
Because of their
beneficial effect on mortality
and
functional status, angiotensin-converting enzyme
(ACE) inhibitors
should be prescribed for all patients
with left-ventricular systolic dysfunction
unless specific
contraindications exist: (1) history
of intolerance or adverse reactions to these
agents, (2) serum
potassium >5.5 mEq/L that cannot
be reduced or (3) symptomatic hypotension.
If
diuretic therapy
is initiated
in patients with clinical
volume overload and left-ventricular systolic
dysfunction
is confirmed as
the cause of
symptoms, an
ACE inhibitor should be added, even if the
patient
has become
asymptomatic on
diuretics. Patients
should be assessed closely for volume
depletion
before therapy is
initiated
(ortho-static hypotension,
prerenal anotemia, melabolic
alkalosis),
and if volume
depletion is evident,
diuretics
should be withheld for a brief period
(24
to 48 hours) until volume
depletion
resolves. ACE
inhibitors may be considered as first-line
therapy
in the subset of heart
failure
patients who present
with fatigue or mild dyspnea on
exertion
and who do not have
any other signs or
minimal
symptoms of volume overload.
Diuretics
may be added if
symptoms persist.
Side
effects of ACE
inhibitors, particularly relative
hypotension and renal dysfunction, have been
emphasized
making some
physicians
reluctant to use ACE
inhibitors. However, the average changes
in
blood pressure and serum
chemistries in
the SOLVD
and CONSENSUS trials were actually quite
small
such that relatively
low blood pressure, moderate
renal insufficiency, and mild hyperkalemia are not
contraindications
to ACE
inhibitors |
|
|
If
serum creatinine is 3.0 mg/dL or greater, ACE inhibitors
should be used with caution and titrated
upward
slowly, as tolerated,
to a maximum
of half the
usual maintenance dose. Patients with lesser
degrees
of renal insufficiency
also
require close follow-up
and a reduced dose if the glomeerular filtration
rate
is less than 30 mL/min.
Hyperkalemia is
considered a contraindication to
ACE inhibitor
therapy unless the serum potassium
can
be reduced.
Potassium-sparing diuretics should
be
stopped in all patients who are being started
on
ACE inhibitors, regardless
of the serum
potassium.
These
agents may be restarted if the patient remains
hypokalemic on full therapeutic doses of ACE
inhibitors.
Potassium
supplements should also be withheld unless the
serum potassium is low(<4.0 mEq/L).
Patients
with low blood pressure must also be carefully
monitoied but therapy should be continued.
In
the absence of orthostatic
hypotension, a
systolic
blood pressure of 90 mm Hg is perfectly acceptable.
Some
patients with heart
failure will feel
best with
a blood pressure below 90 mm Hg. If a physician is
uncomfortable
treating with
ACE inhibitors in the setting
of a low blood pressure, he or she should
refer
the patient to someone
with
expertise in treating
heart failure, rather than abandon attempts to use
ACE
inhibitors or other
vasodilators.
Cough
is common in patients taking ACE inhibitors, but
it is also common in patients with heart failure.
Patients
who report cough
while taking ACE inhibitois
should be evaluated to see whether this results
from
pulmonary congestion
before
considering discontinuing
ACE inhibitors. For most patients, the
cough
is a nuisance that they
are willing
lo tolerate
in exchange for the benefits of the medication,
however,
angioedema of the
oropharyngeal
region is an
absolute contraindication to further use of an
ACE
inhibitor.
Recently
angiotensin II
receptor blockers, such as
Losartan,
which avoids the side effect of cough,
have
recently become
available.
The
outcome of long-term use
of these agents in patients
with heart failure is cunently under evaluation.
Hydralazine
Isosorbide
(HYD/ISDN) is an appropriate
alternative in patients with contraindications or
intolerance
to ACE inhibitors.
Patients who are at high
risk for first-dose
hypotension
should be given a small dose of a
short-acting
agent (e.g., Caplopril 6.35 mg) and monitored
closely for 2 hours. Patients over the age of 75
may
also be at
increased risk for hypotension and may
be started on once-daily dosing. If the test dose
is
tolerated,
or if a test dose is unnecessary,
Caplopril
12.5mg TIDorLisinopril 2.5mg QD can be started.
Patients with hypertension can be started
on
Captopril 25
mg TID or Lisinopril 5 mg QD.
Patients
should have blood pressure, renal function, and
serum potassium monitored within 1 week of
/httpdocs/cajud/heart
initiation
of an ACE inhibitor.
It
is appropriate to contact
the patient by
telephone
48 hours after an ACE inhibitor is initiated to ask
about
symptoms of hypotension,
Treatment should be modified
if the patient develops (1) an increase
in
serum creatinine of 0.5
mg/dL or more,
(2) a serum
potassium of 5.5 mEq/L or higher, or
(3)
symptomatic hypotension.
Doses
of ACE inhibitors should be titrated upward over
2 to 3 weeks with the goal of reaching the
doses
comparable to those used
in
large-scale clinical
trials: Captopril 50 mg TID or Lisinopril 20mg QD.
Volume
status should be
reassessed if hypotension or
a rise in the serum creatine of 0.5 mg/dL occurs
as
the dose is increased. If
volume depletion occurs,
the dose of the ACE inhibitor should be reduced
to
the highest dose that was
previously
tolerated and
the diuretic dose reduced.
The
dose of the ACE inhibitor
should then be
increased
again. If higher doses are not toleraled despite
euvolemia,
then the lower dose
should becontinued or
a trial of HYD/ISDN instituted.
Patients
with low blood pressure must also be carefully
monitored but therapy should be continued.
Patients should have
blood pressure, renal
function, and
serum potassium monitored within 1 week
of
initiation of an ACE
inhibitor.
It
is appropriate to contact the patient by telephone
48 hours after an ACE inhibitor is initiated to
ask
about symptoms of
hypotension.
Doses of ACE inhibitors
should be titrated upward
over
2 to 3 weeks with the goal of reaching the
doses
comparable to those used
in
large-scale clinical
trials: Captopril 50 mg TID or Lisinopril 20 mg QD.
With judicious dosing
and close follow-up, almost
all
patients can tolerate these agents. The full effect
of
/httpdocs/cajud/heart
ACE
inhibitors on functional
status may not be
seen for
several months. Patients who tolerate the
preceding
doses but who remain
symptomatic may benefit
from higher doses.
If
patients remain symptomatic on a combination of a diuretic,
an ACE inhibitor, and digoxin, a
consultation
should be
obtained with a
cardiologist if
this has not been done previously.
With judicious dosing
and close follow-up, almost
all
patients can tolerate these agents.
The
full effect of ACE
inhibitor on functional
status
may not be seen for several months.
Patients
who tolerate the
preceding doses but who
remain
symptomatic may benefit from
higher
doses.
ANTICOAGULATION
Routine
anticoagulation is
controversial. Patients
with
a history of systemic or pulmonary
embolism,
atrial fibrillation
or mobile
left-ventricular
thrombi should be anticoagulated to an
International
Normalizalion
Ratio of 2.0 to
3.0.
There
has never been a controlled trial of anticoagulalion
for patients with heart failure. The risks
/httpdocs/cajud/heart
of
routine treatment, including intracranial or gastrointestinal
hemorrhage, must be balanced
against
the relatively low
reported incidence of
significant
thromboembolic events in this population.
ATRIAL
FIBRILLATION
Atrial
fibrillation is present
in 10 to 15% of
patients
with heart failure and it may occur in up to 50%
of
patients with more severe
heart failure. If atrial
fibrillalion causes sudden, severe worsening of
heart
failure, immediate
cardioversion may
be necessary.However,
most palienis can be stabilized
by
using digoxin to control
the heart rate. Once
stable,
all patients should be considered
for
cardioversion.
Patients
with less than one year history of atrial fibrillation
should be considered for cardioversion.
Patients
should be
anticoagulated to
therapeutic levels
for 3 to 5 weeks before cardioveision and for
1
to 2 months after
cardioversion.
ADDITIONAL
PHARMACOLOGICAL MANAGEMENT
If
patients remain symptomatic on a combination of a
diuretic, an ACE inhibitor, and digoxin, a
consultation
should be
obtained wilh a
cardiologist if
this has not been done previously,
Patients
with persistent volume overload despite initial
medical management may require more
aggressive
administration of
the current diuretic
(e.g.,
intravenous administration), more potent
diuretics,
or a combination of
diuretics. Salt
restriction
should be re-emphasized and compliance
assessed and
encouraged since
dietary noncompliance
is often the cause of persistent volume overload.
Patients with heart
failure and angina who will
not or
cannot undergo revascularization should be
treated
with nitrates and
aspirin.
/httpdocs/cajud/heart
Patients
with persistent dyspnea after optimal doses
of diuretics, ACE inhibitors and digoxin
should
have a Trial of
hydralazine and/or
nitrates added
to the medical regimen.
The
addition of a vasodilator
to an ACE inhibitor
may
also relieve symptoms. Direct vasodilalors
may
be particularly helpful in
patients
with hypertension
or evidence of severe mitral regurgitation.
Even
patients with blood
pressure in the
usual normal
range may benefit by reducing their blood
pressure
with direct
vasodilator.
Alternatively, if a
patient primarily has symptoms of pulmonary
congestion
or has a low
syslolic blood
pressure, nitrates
are preferred over arterial vasodilators.
Patients
who remain symptomatic or hypertensive may benefit
from more aggressive treatment.
After
maximization of
conventional therapy, beta
blockers,
calcium channel blockers, or alpha
blockers
may be employed.
However, none of these
drugs
has been approved specifically for
use
in heartfailure, although
carvedilol (Coreg),
a new
drug with combined alpha and beta blocking
activity,
has been recommended
for
approval by the Cardiovasular
and Renal Drugs Advisory
Committee.
Beta-adrenergic
receptor and calcium
channel
blocking drugs have potential negative
inotropic
effects and should
be considered
investigational
and only given after consultation with
a
practitioner who is
experienced in their
use in heart
failure./httpdocs/cajud/heart
Several
studies have demonstrated that the careful titration
of beta blockers in selected heart
failure
patients results in
improved
symptomatology,
ventricular function, and exercise tolerance.
Benefits
appear to be more
pronounced in
patients with
idiopathic dilated cardiomyopathy than
those
with coronary disease
when compared
to placebo-controlled
trials.
Three
studies have demonstrated a significant decrease
in cardiovascular events, and two
studies
to date have shown
improved survival.
Further
studies are underway.
Only a few randomized
trials of calcium channel
blochers
in heart failure patienis have been published
and
most trials have shown
either no
difference or an
increase in mortality. The results appear due to
negative
inotropic effects in
patients on nondihydropyridine
drugs such as verapamil and diltiazem.
Even
some of the
dihydropyridine drugs
such as nifedipine,
nicardipine and isradipine have resulted in
activation
of the
renin-angiotensin system
and a poor
prognosis.
However,
recent randomized studies with felodipine and
amiodipine have demonstrated improved
symptoms
and no increase in
mortality; in
fact, there
appears to be improved survival in the smaller
subgroup
of patients without
coronary
disease.
Therefore,
given the informatton currently available,
the use of calcium channel blockers in
/httpdocs/cajud/heart
heart
failure should be restricted to amlodipine or
felodipine; patients on other calcium channel
blockers should have
their therapy changed to one
of these agents or an alternative medication.
Use
of alpha blockers has not demonstrated benefit in
heart failure patients but should be considered
in
patients who remain
hypertensive after
treatment This
is especially important given that hypertension
often
predates worsening heart
failure and
a poor prognosis.
Several
studies have demonstrated that the careful titration
of beta blockers in selected heart failure
patients
results in improved
symptomatology, ventricular
function, and execise tolerance.
...given
the information currently available, the use
of calcium channel blockers in heart failure should
be
restiricted to amlodipine
or felodipine;patients on
other calcium channel blockers should have their
therapy
changed to one of
these agents or an alternative
medication.
The impact of heart
faiilure on a patient's life
may be
related as much to psychological adaptation
condition
as to impairment in
physical
functioning.
Recent
studies
show that patients with heart failure can
exercise safely, and regular exercise may
improve
functional status and decrease symptoms.
Patients
should be encouraged to keep a daily record of
their weight and to bring that record with
them
when visiting their
practitioner.
Patients
should be carefully instructed in how to change
their medical regimen on an as-needed
basis
or call for specific
instructions if
they experience
a weight gain greater than 3 to 5 pounds
since
their last clinical
evaluation.
GENERAL
COUNSELING
After
a diagnosis
of heart failure is established, all
patients should be counseled regarding the
nature
of heart failure, drug
regimens,
dietary restrictions,
symptoms of worsening heart failure,
what
to do if these symptoms
occur, and
prognosis. The
impact of heart failure on a patient's
life
may be related as much to
psychological adaptation
to the disease as to impairment in
physical
functioning. Nursing
interventions,
family involvement,
and support groups may all
help
patients cope with heart
failure.
Practitioners
should emphasize the importance of not
smoking
or chewing tobacco and
should
recommend that
patients receive vaccination against
influenza
and pneumococcal
disease.
It
is vital that patients understand their disease and
be involved in developing the plan for
their
care. In addition,
family members
and other responsible
caregivers should be included
in
counseling and
decision-making sessions.
Durable power
of attorney or other advance
directives
should be discussed
with all patients.
ACTIVTTY
Regular
exercise such as
walking or
cycling at a comfortable
pace should be encouraged for
all
patients with stable heart
failure. Even short
periods
of bed rest result in reduced exercise
/httpdocs/cajud/heart
tolerance
and aerobic capacity, muscular atrophy, and
weakness. Recent studies show that
patients
with heart failure
can exercise safely,
and
regular exercise may improve functional
status
and decrease symptoms.
An
explanation of the importance
of exercise can help prevent
patients
from becoming afraid
to perform daily
activities
that might provoke some shortness
of
breath. Patients should be
advised to stay as
active
as possible.
There is insufficient
evidence at this time to
recommend
the routine use of formal rehabilitation
programs
for patients with
heart failure.
DIET
Dietary
sodium should be
restricted to as
close to 2
grams per day as possible, especially
in
patients with evidence of
fluid
retention and/or volume
overload.
Acute ingestion of
alcohol depresses myocardial
contractility
in patients with known
cardiac
disease. This may be
clinically
significant in
patients with heart failure, although
there
are no studies that
address this
issue. Complete
abstention from alcohol is crucial for
patients
with alcohol-induced
cardiomyopathy. For patients
without a history of alco-
holism,
it is unclear whether abstinence makes a difference
in functional status or mortality
In
general alcohol use should
be discouraged. If
patients
want to continue to drink, they should
be
strongly advised to have no
more than
one drink per
day.
0ne
drink
equals 4oz.of wine, 12oz of beer, or a mixed
drink or cocktail containing no more than
1
ounce of alcohol.
Patients
with heart failure should be advised to avoid
excessive fluid intake. However, fluid
restriction
is
not advisable unless patients develop
significant hyponatremia. Patients should
be
encouraged to keep daily records of their weight and
to bring those records with
them when
visiting their practitioners. Patients should
be carefully instructed in how to change
their
medical
regimen on an as-needed basis or call for
specific instructions if they experience a
weight
change
greater than 3 to 5 pounds. |
|
Dietary
sodium should be restricted to as close to
2
grams per day as possible, especially in
patients
with
evidence of fluid retention/volume overload.
Practitioners
should empasize the importance of not smoking
or chewing tobacco...
Patients
should be advised to stay as active as possible.
Because
noncompliance is a major cause of morbidity and
unnecessary hospital admissions
in
heart failure, education
programs or support
gruops
should be a routine part of the care of
patients
with heart failure.
In
general, alcohol use should be discouraged.
Asymptomatic
patients who are found to have moderately
or severely reduced left-ventricular
systolic
function (ejection
fraction
<35 to 40 percent)
should be treated with an ACE inhibitor to
reduce
the chance of
developing clinical
heart failure.
...the
ER should be determined in most patients following
a myocardial infarction unless they
are
at low risk for
significant systolic
dysfunction,
i.e., unless they meet all of the following criteria:
1.
No previous
myocardial
infarction.
2.
Ingerior infarction.
3.
Relatively small increase in cardiac enzymes
(i.e., <2 to 4 times normal).
4.
No Q waves
develop on
electrocardiogram.
5.
Uncomplicated clinical course (e.g., no arrhythmia
or hypotension).
MEDICATIONS
Medications
are prescribed for
patients with heart
failure
for two basic reasons:
(1)
to reduce mortality
(angiotensin-converting
enzyme
[ACE] inhibitors, isosorbide
dinitrate/
hydralazine) and
(2) to reduce symptoms
and
improve ftinctional status (ACE
inhibitors,
diuretics,
digoxin). Patients should
be provided
with complete and accurate
information
concerning the
medications they are
being
asked to take, including the reasons
the
medications are being
prescribed,
dosing requirements
and possible side effects.
COMPLIANCE
Because
noncompliance is a
major cause of
morbidity and
unnecessary hospital admissions
in
heart failure, education
programs or support
groups
should be a routine part of the care
of
patients with heart
failure.
Noncompliance may reduce
life expectancy and is also a major
cause
of hospitaliations.
Practitioners should be
attuned
to the problem of noncompliance
and
its causes and should
discuss the importance
of compliance
at Follow-up visits and
assist
patients in removing
barriers to compliance.
PROGNOSIS
Heart
failure is a serious
disease and it
is important
that patients receive information concerning
their
prognosis in order to
make decisions
and plans
for the future. Prognosis can vary
considerably
depending upon
etiology, functional
class,
and response to therapy.
Studies
quote mortality rates
from 5 to 5O% per
year
depending upon these factors and there
are
indications that newer
forms of therapy have
improved
prognosis.
Practitioners should
discuss patients' decisions
regarding
resuscitation and all patients should
be
encouraged to complete a
durable power of
attorney
for health care or another form of advance
directive.
If
a patient desires resuscitation, family members should
consider learning cardio-pulmonary
resuscitation.
Such a course
should be combined
with
psychosocial support for patients and
family
members because it may
otherwise
have negative
psychological consequences.
Patients,
families, and caregivers must be provided with
the accurate information necessary to make
decisions
and plans for the
future, while
maintaining
hope and emphasizing that good quality of life
is
still possible.
PREVENTION
IN
ASYMPTOMATIC PATIENTS WITH
LEFT-VENTRICULAR
SYSTOLIC DYSFUNCTION
Asymptoniatic
patients who are found to have moderately
or severely reduced left-ventricular
systolic
function (ejection fraction <35 to 40 percent)
should be treated with an ACE inhibitor
to
reduce the
chance of developing clinical heart failure.
Probably
the
largest number of such patients will be
those who have recently sustained a
myocardial
infarction.
For
this
reason, the EF should be determined in most
patients following a myocardial infarction
unless they are
at low risk for significant systolic
dysfunction, i.e., unless they meet all of the
following
criteria:
1.
No previous myocardial infaiction.
2.
Inferior infarction.
3.
Relatively small increase in cardiac
enzymes (i.e., <2 to 4 times normal).
4.
No Q waves develop on electrocardiogram
5.
Uncomplicated clinical course (e.g
no arrhythmia or hypotension). Other
asymptomatic patients without infarctions may be
found to have reduced EF on evaluation
of
heart
murmurs or cardiomegaly. These patients should
also be treated with ACE inhibitors. |
/httpdocs/cajud/heart |
Redadmission
rates
as high as 57 percent within 90
days
have been reported in patients over the age of
70
years. Proper
discharge
planning is essential
to prevent those unnecessary readmissions.
Patients
who have
been hospitalized for heart
failure
should be contacted within 2 to 4 days of discharge...
Appropriate
laboratory tests
should also be checked within
7 days following discharge, and medication
adjusted
as necessary.
HOSPITAL
MANAGEMENT
The
presence or suspicion of clinically evident heart
failure and any of the following findings usually
indicate
a need for
observation or
hospitalization:
*
clinical or electrocaidiographic evidence of acute
myocardial ischemia,
*
moderate or severe pulmonary edema or severe respiratory
distress not responsive to treatment,
oxygpn
saturation below 90
percent (not
due to pulmonary disease),
*
severe complicating medical illness (e.g., pneumonia),
*
symptomatic hypotension or
syncope,
heart failure refractory
to outpatient therapy,
*
inability to arrange adequate social support for safe
outpatient management, or
*
new onset and poorty tolerated supraventricular tachyarrhythmias.
Occasionally,
patients with one of the above findings
may be managed at home or in an assisted
living
or nursing home setting
if the
clinician believes
it is safe to do so and adequate follow-up
can
be arranged. Heart failure
is one of
the most common
causes for recurrent admission to hospitals,
and
many of these admissions
may be
avoidable. Readmission
rates as high as 57 percent within 90
days
have been reported in
patients over the age
of 70
years. Proper discharge planning is essential
to
prevent unnecessary
readmissions.
Patients
with heart
failure
should be discharged from
the hospital only when:
*symptoms
of heart failure have been adequately controlled,
*
all reasons for admission
haw been
treated or stabilized,
*
patients and their caregivers have been educated about
medications, diet, activity, and
exercise
recommendations, and
symptoms of
worsening heart
failure, and
*
adequate outpatient support and follow-up care have
been arranged.
Patients
who have been hospitalized for heart failure
should be contacted within 2 to 4 days
of
discharge to (1) make sure
that
medications are being
taken properly, (2) assess compliance
with
reduced salt diet, (3)
ensure that
weight is stable,
(4)
adjust the dosage of diuretics and other medications
if necessary, and (5) determine that
the
patient, family, and
caregiver
understand when and
how to contact the practitioner.
Appropriate
laboratory tests should also be
checked within
7 days following discharge,
and
medication adjusted as
necessary.
This
guideline does
not address
management strategies
specific to the hospital setting
(e.g.,invasive
hemodynamic
monitoring, intravenous
dobutamine).
Refer to Inpatient Care Path.
REVASCULARIZATION
Coronary
artery disease is
currently the most
common
cause of heart failure in the US.
Some
patients may benefit from
revascularization.
In
particular, patients with
viable myocardium subserved
by substantially stenotic vessels
may
reasonably be expected to
obtain longevity
benefits
and, perhaps, improved quality of
life
if the stenosis is
successfully relieved. On
the
other hand, revascularization entails significant
morbidity
and mortality.
Before studies are initiated
to determine if patients are candidates for
revascularization
(i.e., have
viable
myocardium supplied
by stenotic arteries), it is important
to
determine first if any
conditions exist
that may preclude
intervention or that could raise the
risk
of revascularization
above any
potential benefit
These may include:
*
patient would not consider surgery or is unable to
give informed consent,
*severe
comorbid diseases, especially renal failure,
pulmonary disease, or
cerebrovascular
disease (e.g.,
severe stroke),
*
very low ejection fraction
(i.e., <20%),
*
illnesses with a projected life expectancy less than
or equal to 1 year.
These
include advanced cancer,
severe lung or
liver disease,
chronic renal disease,
advanced
diabetes mellitus,
and advanced collagen
vascular
disease, or
*technical
factors, including previous myocardial revascularization
or other cardiac
procedure,
history of chest irradiation, and diffuse
distal coronary artery atherosclerosis.
Patients
without
contraindication to
revascularization
should be advised of the possibility
of
revascularization,
including its
potential benefits
and known risks.
Three
parameters are important:
(1)
likelihood of surgically correctable lesions,
(2)
Bipedal benefits of
revascularization, and
(3)
expected risks and
potential harms of
revascularization.
These
parameters vary
depending
on several factors, including
whether clinical evidence
of
myocardial ischemia is
present and the
patient's general
state of health.
The
three major randomiad clinical trials involving revascularization
excluded patients with
marked
left ventricular
dysfunction (EF<
35% in CASS).
In addition, patients were required
to
have clinical evidence of
ischemia and
demonstrated
benefits have largely been proportionate
to
the degree of myocardium at
risk. In general,
the
presence of heart failure increases perioperative
risk
but appropriately
selected patients with heart failure
may experience substantial benefit.
Counseling
should be
based on patients' particular
characteristics,
particularly on an assessment
of
patients' risk factors for
coronary artery
disease.
Patients
can be classified into three major subgroups:
(1)
patients who have neither
angina nor a history
of
infarction, (2) patients without
significant
angina(angina that
limits exercise or
occurs
frequently at rest), but who
have
a history of MI, and (3)
patients
with
significant angina
pectoris.
Coronary
artery disease is currently the most common cause
of heart failure in the US.
Some
patients may benefit from
revascularization.
In
general, the
presence of heart failure increases perioperative
risk but appropriately /httpdocs/cajud/heart
selected
patients with heart
failure may
experience substantial
benefit.
Patients
without contraindication to revascularization
should be advised of the possibility
of
revascularization,
including its
potential benefits
and known risks.
The
likelihood of coronary disease in heart failure patients
without angina or history of
myocardial
infarction varies
depending on patient
risk
factors.
...there
is no evidence from controlled trials to show
that revascularization benefits heart
failure
patients in the
absence of
evidence of reversible
ischemia.
The
decision about whether to perform physiological tests
for ischemia or coronary
angiography
should be based on
a consideration of
patients'
risk factors for coronary
artery
disease and the
likelihood of alternative
etiologies
(e.g., alcoholic cardiomyopathy).
Patients
without
angina but with a history of MI
should
be advised to undergo an adequate
physiologic
test for
ischemia.
NO
ANGINA AND NO MI
The
likelihood of coronary
disease in
heart
failure patients
without angina or history of
myocardial
infarction varies
depending on patient
risk
factors (e.g., age, sex, smoking history,
/httpdocs/cajud/heart
hyperlipidemia,
hypertension, family history of premature
coronary artery disease, and diabetes).
Patients
should he
counseled concerning the
expected benefits
and risks of evaluation for
ischemia,
including the fact
that there is no
evidence
from controlled trials to show that
revascularization
benefits
heart failure patients
in
the absence of evidence of reversible
ischemia.
It
is unclear whether
patients who are unlikely to
have
coronary disease should be
routinely
evaluated for
ischemia.
The
decision about whether to
perform physiological tests
for ischemia or coronary
angiography
should be based on
a consideration of
patients'
risk factors for coronary
artery
disease and the
likelihood of alternative
etiologies
(e.g.,
alcoholic cardiomyopathy). If the decision is
made to proceed with an evaluation,
noninvasive
testing for
ischemia (e.g., thallium
scanning)
should be performed as the
initial
test; coronary
angiography may be
performed if
noninvasive testing
demonstrates
ischemia or is
inconclusive.
Given
that
non-invasive listing is sometimes more difficult
to interpret in patients with
cardiomyopathy,
there should
be a low threshold
for contacting
a cardiologist or considering
angiography
in patients with
significant risk
factors
for coronary disease.
NO
ANGINA AND
HISTORY OF MI
Available
evidence supports that as many as half of patients
who suffer a myocardial
infarction
have clinically
important myocardial
ischemia
in areas supplied by other coronary
arteries.
There are no data,
however, to show that
revascularization
of these areas is
beneficial,
in terms of increased life expectancy or
enhanced quality of life, in the absence
of
angina. Nevertheless,
patients with
large areas of
ischemia may possibly benefit from
revascularization.
Patients
without angina but
with a history of MI
should
be advised to undergo an adequate
physiologic
test for ischemia.
Coronary
angiography should
be considered if:
(1)
ischemic regions are detected, or (2) physiologic
test is inconclusive, or
(3)
physiologic test shows a fixed defect outside the
infarct zone. This strategy
will
miss a small number of
patients with false
negative
physiological tests. However, in
view
of the lack of evidence
that these patients
benefit
from surgery, together with a
consideration
of the morbidity, mortality, and the cost
of catheterizing all patients in this
group,
this drawback is
considered
relatively minor.
There
are a number of acceptable physiologic tests for
ischemia. Clinicians must be familiar
with
the availability,
quality, and cost
of the different
physiologic tests for ischemia and
should
use this information in
deciding what test
to
order. The most widely available and
accepted
procedure for
determining the
presence of ischemic
myocardium is myocardial /httpdocs/cajud/heart
perfusion
scintigraphy, such
as thallium
scanning, with
post-stress, redistribution, and
rest
reinjection imaging.
ANGINA
The
potential benefit of revascularization is clearest
and probably greatest in individuals
with
severe or limiting angina
or
angina-equivalent (e.g.,
recurrent acute episodes of pulmonary
edema
despite appropriate
medical
management). Available
evidence suggests that about
75
percent of heart failure
patients with
significant
concomitant angina have operable disease.
Although
the three randomized
trials of coronary
artery
bipass graft (CABG) surgery excluded
patients
with heart failure or
severe
left-ventricular
dysfunction, several cohort
studies
and registries suggest
that patients with
angina
and impaired left-ventricular function
have
improved functional
status and
survival if they
undergo bypass surgery.
Heart
failure
patients without contraindications
to revascularization
and who have
exercise-limiting
angina, angina that occurs frequently
at rest, or episodes of acute pulmonary
edema
that may be secondary to
ischemia
should be advised
to undergo coronary artery
angiography
as the initial
test for significant
coronary
lesions. Some patients may need
physiological
testing for
ischemia to interpret
the significance
of the findings from coronary
artery
angiography.
COUNSELING
AND DECISION
Based
on the
results of physiological testing and/or
cardiac catheterization, a cardiologist
should
give the patient a
refined estimate
of the risks
and benefits of revascularization.
The
patient can then decide if
he or she desires
revascularization.
No
data are available that address the question of how
much ischemia should be present
to
justify the risk of
revascularization for the
chance
of an improvement in survival.
In
general, patients with
severely depressed
ejection
fractions (EF <20 percent) should
undergo
revascularization only
if large
areas of ischemia
are detected. Patients with less
severely
depressed ejection
fractions may be
willing
to risk surgery for more modest-sized
ischemic
areas. The lack of
data in this
area makes it
difficult to justify revascularization
for
small ischemic areas,
except when
severe angina is
present.
CONTINUE
MEDICAL MANAGEMENT
The
medical therapy started
under
"Pharmacological Management"
should be continued if
(1)
a patient is not a
candidate for
revascularization,
(2) studies show insufficient evidence
of
reversible ischemia, or (3)
surgery has
been perfomied
but the patient still
has
residual left-ventricular dysfunction. As stated
previously, an assessment of compliance
is
recommended at each visit.
Use of home
health nurse
visits may be helpful for this purpose.
Coronary
angiography
should be considered if: (1)
ichemic
regions are detected, or
(2)
physiologic test is
inconclusive, or
(3)
physiologic test shows a
fixed defect outside the
infarct zone.
The
potential benefit of revascularization is clearest
and probably greatest in individuals with
severe
or limiting angina or
angina-equivalent.
Available
evidence suggests that about 75 percent of heart
failure patients with significant
concomitant
angina have
operable disease.
On
follow-up visits,
patients should be asked about the
presence of orthopnea, paroxysmal
nocturnal
dyspnea, edema, and
dyspnea on
exertion.
It is important to remember that patients
are
likely to experience
changes in
symptoms before there
is evidence of deterioration by
physical
examination.
Revascularization
Coronary
artery
bypass grafting is the only
revascularization
procedure that has been shown
to
prolong life in patients
with angina and
left-ventricular
dysfunction.
The
effect of coronary artery angioplasty on survival
of heart failure patients has not been studied,
nor
are the risks of
angioplasty in heart
failure patients
known at this time. The choice between
CABG
and angioplasty will
depend on
numerous considerations,
including multiple technical
factors
(e.g., coronary
anatomy), relative risk of
the
two procedures in individual patients, and
patient
preferences.
A
discussion of these factors
lies beyond the scope of this guideline.
Follow-up
Careful
history and
physical examination should be
major
guides to determining outcomes
and
directing
therapy. A thorough
history would
evaluate satisfaction with current lifestyle
and
include questions
regarding physical and
mental functioning
and the presence or absence
of
heart failure symptoms.
On
follow-up visits,
patients
should be asked about the
presence of orthopnea, paroxysmal
nocturnal
dyspnea, edema, and
dyspnea on
exertion.
It is important to remember that patients
are
likely to experience
changes in
symptoms before there
is evidence of deterioration by physical
examination.
Patients
should be
encouraged to keep a daily
record of
their weight and to bring that record with
them
when visiting their
practitioner. Patients
should be carefully instructed in how to change
their
medical regimen on an
as-needed
basis or call for
specific instructions if they experience a
weight
change greater than 3
to 5 pounds.
Family
members or
other caregivers can often contribute
important additional information about
the
patient's status and
compliance when
asked similar
questions. In some cases, it may be desirable
to
interview family members or
other
caregivers apart
from the patient in order to validate the patient's
report.
If
discrepancies do occur, additional measures
need to be instituted for clarification. In addition
to
questions about symptoms
and activities, providers
should ask about other aspects of patients'
health-related
quality of
life, including
sleep, sexual
function, mental health (or outlook on life), appetite,
/httpdocs/cajud/heart
and
social activities. A worsening in any of these
parameters may indicate the need to adjust therapy.
To
ensure optimal care for
heart failure, the provider
must view the disease in the broad context of the
patient's
life and see how the
patient is coping with
the disease. Consultation with psychologists,
dietitians,
health educators,
and clinical
nurse specialists
may be necessary to deal with specific problems
such
as depression,
difficulties adhering
to complicated
dietary or medical regimens, or poor
functional
status.
The
team recommends
against the
routine use of invasive
or noninvasive tests, such as
echocardiography
or
maximal exercise testing,
for
monitoring the response
of heart failure patients to treatment.
No
data exist to suggest that
the
monitoring of these
endpoints contributes information beyond
that
obtained by a careful
history and
physical examination.
However, repeat testing may be useful
in
patients with a new heart
murmur, a new
myocardial
infarction, or sudden deterioration despite
compliance
with
medications.
Repeat testing as
part of the evaluation for transplantation may also be
necessary.
Heart
Transplantation
Patients
with severe
functional limitations or repeated
hospitalizations despite aggressive
/httpdocs/cajud/heart
medical
therapy in whom revascularization is not likely
to convey benefit should be considered
for
cardiac
transplantation.
Kaiser Permanente
has a regional heart transplant program at
Santa
Teresa Kaiser where
pre-transplant
and post-transplant
care are performed.
The
transplant surgery is
performed at Stanford or
another
designated center of excellence.
The
program at Santa
Teresa is part of a Kaiser
Permanente
national transplant network
which
has standarized criteria
for transplant
candidacy.
These are available upon request
and
similar to those used
throughout the
country.
These criteria require that the patient
be
unlikely to benefit from
other therapy,
that heart
transplantation be likely to confer
benefit
and that any cormorbid
states be unlikely
to
significantly offset the expected benefit.
Patients
thought to
be candidates for cardiac
transplant
should be referred for cardiac
consultation
at the local
facility.
Subsequently,
the cardiologist can refer the patient
for
formal
evaluation. A history
and phsycial,
including details of recent attempts at improving
medical
therapy, and pertinent
study results can be sent
to the heart transplant service.
Patients
who are candidates
for heart
transplantation
will generally have a number of
poor
prognostic indicators,
such as reduced LVEF
(<20%),
markedly increased left-ventricular
size
(LVEDD>7.0 cm),
severe symptoms
(advanced NYHA Class
III or Class IV), low exercise
tolerance
(measured
objectively as maximum oxygen
consumption),
evidence of activation
of
the renin-angiotensin
system (low serum Na++),
and
a low cardiac index (<2.0) despite
aggresive
medical
therapy. In
addition to the history
and physicial, the avaluation includes a
panel
of laboratory tests
available as STR
Panel 1, a
chest x-ray, and EKG, an echocardiogram,
dietary
and psychosocial
evaluations,
pulmonary function
tests, exercise ergometry, and
right
heart
catheterization. Selected
patients
undergo carotid and peripheral arterial dopplers,
measurement
of creatinine
clearance, and abdominal ultrasound.
Emergency consults should /httpdocs/cajud/heart
be
directed to Dr. Susan
Woodley or the
cardiologist
on call through the Santa Teresa page
operator
at 8-440-7188 or
(408) 972-7188.
Patients
whose
symptoms are controlled need not be referred
for transplantation but may benefit
from
contact with the
transplant
service. Patients
ineligible for transplantation on the basis of
comorbid
conditions should be
informed of
the availiability
of experimental protocols, although
such
programs may not be an
insured benefit
available
through Kaiser Permanente.
In
summary, heart failure is a
treatable condition
which
many patients can live with comfortably.
Most
patients will sustain
substantial
benefit from education
as well as dietary and medical
management.
Such
therapies should be
maximized
prior to consideration for heart transplantation
and
experimental surgical
procedures.
This
guideline is one
component of a multi-disciplinary
approach to the treatment of heart
failure
which is designed to
maximize patient
outcomes
and potentially minimize the need
for
heroic procedures.
To
ensure
optimal care for heart failure, the provider
must view the disease in the broad
context
of the patient's life
and see how the
patient
is coping with the disease.
Consultation
with
psychologists, dietitians,
health educators,
and clinical nurse
specialists
may be necessary
to deal with specific
problems...
The
team recommends against the routine use of invasive
or noninvasive tests, such as
echocardiolography
or maximal
exercise testing,
for monitoring
the response of heart
failure
patients to treatment.
Kaiser
Permanente has
a regional
heart transplant program
at Santa Teresa Kaiser
where
pre-transplant and
post-transplant care are
performed.
In
summary, heart failure is a treable condition which
many patients can live with comfortably.
Most
patients will sustain
substantial
benefit from education
as well as dietary and medical
management.
Such
therapies should be
maximized
prior to consideration for heart transplantation
and
experimental surgical
procedures.
This
guidelines is one component of a multidisciplinary
approach to the treatment of heart failure
which
is designed to maximize
patient outcomes and
potentially
minimize the need for heroic procedures.
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