CDR Timothy Murray
CHF Clinic Manager
Internal Medicine Team
Inpatient Pharmacy Clinical Coordinator
Claremore Indian Hospital
Clinical Assistant Professor
University of Oklahoma
Primary Care Cardiology Update
April 9, 2011
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PT is a 37 yo white male whom is being consulted to the Internal
Medicine service today secondary to an CHF exacerbation. JS
presented to the ER with a 5 day history of increased shortness of
breath and 10 lb weight increase.
Symptoms started after a recent trip where a “poor” diet was
consumed.
Family Hx: DM, CAD
Social Hx: negative
PMH: HTN, CAD
Medication prior to admission:
 Atenolol 25mg BID, aspirin 81mg daily, fish oil 1000mg daily,
tamsulosin 0.4mg daily, KCL 8meq daily, furosemide 20mg daily
Vitals: BP- 152/77, HR-101, WT- 177lbs

Physical Exam:

CHEST/LUNGS:
Chest:
Nontender
Lungs:
RALES Bilateral mostly at right base, no wheezing
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CARDOVASCULAR:
Cardiac: regular rate, regular rhythm, No murmur
Pulses:
Equal, DIMINISHED Very diminished at feet.
Carotid: No bruit
JVD:
+ distended
Abd aorta: No Bruit
Lower ext: BILATERAL Edema of both legs mostly right side 3/4 and
2/4 at left.


PT is treated in the hospital for 3 days. Weight has decreased 15
lbs and he feels much better. PT is to be seen in the CHF clinic in
2weeks for medication adjustment, dietary education, and
monitoring. Completed echocardiogram reveals an ejection
fraction of 25%
PT returns to CHF clinic in 2wks with the following labs:
PNBP: 3200

Based upon the above case what type of interventions would you
have expected to have been performed? (during admission or in
clinic)
A.
B.
C.
D.
E.
Continue all medications prior to admission
Increase Atenolol, start an ace-inhibitor, & start an aldosterone antagonist
DC atenolol, start metoprolol succinate, & start an ace-inhibitor
DC atenolol, start carvedilol, & start an ace-inhibitor
Just give up and discharge patient from clinic!!!
Population
Hospital
Group
Prevalence Incidence Mortality Discharges
Cost
Total
population
$24.3
billion



1American
4,900,000
550,000
51,546
999,000
1
Heart failure (HF) is a major public health problem
resulting in substantial morbidity and mortality
Major cost-driver of HF is high incidence of
hospitalizations1,2
JCAHO has initiated HF quality care indicators for
hospitalized HF patients
Heart Association. 2003 Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; 2002.
Hospitalization
$13.6
Total Cost
$25.8 billion
53%
14%
Nursing Home
$3.5
7%
8%
8%
10%
Physicians/Other
Professionals
$1.8
Drugs/Other
Home Healthcare Medical Durables
$2.1
$2.7
Lost Productivity/
Mortality*
$2.1
*Lost future earnings of persons who will die in 2004, discounted by 3%
AHA. Heart Disease and Stroke Statistics—2004 Update
Over 2/3 of HF Hospitalizations Preventable
Diet Noncompliance
24%
16%
Inappropriate Rx
Rx Noncompliance
24%
19%
Failure to Seek
Care
Annals of Internal Medicine 122:415-21, 1995
17%
Other

Patients




Patient capture point
Have patient’s/family’s attention:
“teachable moment”
Predictor of care in community
Hospital structure



Standardized processes / protocols / teams
Accrediting bodies for standards of care
Centers for Medicare and Medicaid
Services—peer review organization
Benefits
Drawbacks
• Improved use of evidence•
•
•
•
based therapy
Improved symptom status
and functional capacity
Improved QOL
Reduction in
hospitalization
Decrease in total medical
costs
Usual Care
96%
Moser DK, Mann DL. Circulation. 2002;105:2810–2812.
4%
HF Disease
Management
Program

Where did our process break down and why
no reduction in hospitalizations or rehospitalizations?




Sub-optimal utilization of guidelines
No standardization of care (standing orders)
No team approach to treating CHF
No increase in intensity of HF care after hospital
discharge

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
National registry
Develop a treatment plan (protocol)
Utilize a team approach to treating CHF
Provide a comprehensive service to monitor & make
clinical alterations with patient’s treatment plan
Provide patient education & training to involve patients
in their treatment plan
Follow-up on patients discharged after a CHF
admission to avoid re-admission: CHF Clinic!!!!!!
Implement & utilize national standards of care for CHF
GET UP TO DATE WITH THE CHF GUIDELINES!
Document – Document - Document!

Center of Medicaid & Medicare Services


Compliance rates for discharging CHF pts
Joint Commission/ACC/AHA

CHF Performance Measures

CHF Core Measures

1. Documentation of discharge instructions

2. Left ventricular function assessment

3. Use of ACE-I or ARB in pts with left ventricular
systolic failure

4. Documentation of smoking cessation

Hospitals should strongly consider
implementing a process of care to ensure
these measures are obtained and proper
documentation occurs.

The principal outcome measure of the
ADHERE Registry was to assess overall
hospital adherence to each of these measures
for participating hospitals.

CMS 2009 Documentation privileges for
pharmacists!

Electronic Health Record advantages

GIPRA Measures/Performance Improvements

2010 CMS 30 day readmission policy changes

Beta Blockers?
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Ace-Inhibitors
Beta-Blockers
Aldosterone Antagonists
ARBs
ISDN/Hydralazine
Diuretics
Digitalis
Antiplatelets
Statins
Fish Oils
Calcium Channel Blockers

CHF care driven by two sets of national
guidelines

American College of Cardiology/American Heart
Association

Heart Failure Society of America

Both organizations provide a set of detailed
treatment guidelines for practitioners in an
effort to optimize the management of chronic
CHF.

Treatment guidelines provide an approach to
practice evidence based medicine.

Heart Failure Society of America



www.hfsa.org
Last update: June 2010
American College of Cardiology/American
Heart Association


http://circ.ahajournals.org
Last update: April 2009
2009 ACC/AHA recommendation for:
“implementation of practice based guidelines
utilizing multidisciplinary disease-management
programs in efforts to assist in the treatment of
patients with CHF”.

2010 HFSA recommendation for:
“patients recently hospitalized for HF & other
patients at high risk for HF decompensation
should be considered for comprehensive HF
disease management.”

Risk Factor
Goal
Hypertension
Generally < 130/80
Diabetes
See ADA guidelines1
Hyperlipidemia
See NCEP guidelines2
Inactivity
20-30 min. aerobic 3-5 x wk.
Obesity
Weight reduction < 30 BMI
Alcohol
Men ≤ 2 drinks/day, women ≤ 1
Smoking
Cessation
Dietary Sodium
Maximum 2-3 g/day
Journal of Cardiac Failure Vol. 16 No. 6 2010

ACE inhibitors are recommended for prevention of HF
in patients at high risk for this syndrome, including
those with:
 Coronary artery disease
 Peripheral vascular disease
 Stroke
 Diabetes and another major risk factor
Strength of Evidence = A

ACE inhibitors and beta blockers are recommended for
all patients with prior MI.
Strength of Evidence = A
Journal of Cardiac Failure Vol. 16 No. 6 2010

Treatment with
ACE inhibitors
decreases the risk
of CV death, MI,
stroke, or cardiac
arrest.
Placebo
HOPE
20
15
% MI,
Stroke, 10
CV Death
Ramipril
5
0
0
22%
rel.3 risk red.
p < .001
2
4
1
Years
15
EUROPA
% MI, 12
CV Death, 9
Cardiac 6
Arrest
3
Placebo
Perindopril
0
0
NEJM 2000;342:145-53 (HOPE)
Lancet 2003;362:782-8 (EUROPA)
1
2
3
20%
Years
4
5
rel. risk red. p = .0003

SAVE Study
All-cause mortality
↓19%
 CV mortality ↓21%
 HF development ↓37%
 Recurrent MI ↓25%

0.3
Mortality
Rate
Placebo
0.2
Captopril
0.1
19% rel. risk reduction
p = 0.019
0
0
0.5
1
1.5
2
2.5
3
3.5
4
Years
Pfeffer et al. NEJM 1992;327:669-77

ACE inhibitors are recommended for symptomatic and
asymptomatic patients with an LVEF ≤ 40%.
Strength of Evidence = A

ACE inhibitors should be titrated to doses used in clinical
trials (as tolerated during uptitration of other medications,
such as beta blockers).
Strength of Evidence = C

ACE inhibitors are recommended as routine therapy for
asymptomatic patients with an LVEF ≤ 40%.


Post MI
Non Post-MI
Strength of Evidence = B
Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
SOLVD Prevention
(Asymptomatic LVD)


20%
29%
death or HF hosp.
death or new HF
CONSENSUS
(Severe Heart Failure)



40%
31%
27%
mortality at 6 mos.
mortality at 1 year
mortality at end of
study
SOLVD Treatment
(Chronic Heart Failure)
16%
mortality
SOLVD Investigators. N Engl J Med 1992;327:685-91
SOLVD Investigators. N Engl J Med 1991;325:293-302
CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35
Generic
Name
Trade Name
Initial
Daily Dose
Target Dose
Mean Dose in
Clinical Trials
Captopril
Capoten
6.25 mg tid
50 mg tid
122.7 mg/day
Enalapril
Vasotec
2.5 mg bid
10 mg bid
16.6 mg/day
Fosinopril
Monopril
5-10 mg qd
80 mg qd
N/A
Lisinopril
Zestril,
Prinivil
2.5-5 mg qd
20 mg qd
4.5 mg/day,
33.2 mg/day*
Quinapril
Accupril
5 mg bid
80 mg qd
N/A
Ramipril
Altace
1.25-2.5 mg qd
10 mg qd
N/A
Trandolapril
Mavik
1 mg qd
4 mg qd
N/A
*No mortality difference between high and low dose
groups, but 12% lower risk of death or hospitalization
in high dose group vs. low dose group.

It is recommended that other therapy be substituted for ACE
inhibitors in the following circumstances:

In patients who cannot tolerate ACE inhibitors due to cough,
ARBs are recommended.
Strength of Evidence = A

The combination of hydralazine and an oral nitrate
may be considered in such patients not tolerating ARBs.
Strength of Evidence = C

Patients intolerant to ACE inhibitors from hyperkalemia or
renal insufficiency are likely to experience the same side
effects with ARBs. In these cases, the combination of
hydralazine and an oral nitrate should be considered.
Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010

Beta blockers shown to be effective in clinical
trials are recommended for symptomatic and
asymptomatic patients with an LVEF ≤ 40%.
Strength of Evidence = A

Beta blockers are recommended as routine
therapy for asymptomatic patients with an LVEF
≤ 40%.
Post MI
 Non Post-MI

Strength of Evidence = B
Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
HF
Severity
Target
Dose (mg)
Outcome
Study
Drug
US Carvedilol1
carvedilol
mild/
moderate
6.2525 BID
↓48% disease progression
(p= .007)
CIBIS-II2
bisoprolol
moderate/
severe
10 QD
↓34% mortality (p <.0001)
MERIT-HF3
metoprolol
succinate
mild/
moderate
200 QD
↓34% mortality (p = .0062)
COPERNICUS4
carvedilol
severe
25 BID
↓35% mortality (p = .0014)
CAPRICORN5
carvedilol
post-MI
LVD
25 BID
↓23% mortality (p =.031)
1Colucci
WS et al. Circulation 1196;94:2800-6. 2CIBIS II Investigators. Lancet 1999;353:9-13.
Study Group. Lancet 1999;353:2001-7. 4Packer M et al. N Engl J Med 2001;344
1651-8. 5The CAPRICORN Investigators. Lancet 2001;357:1385-90.
3MERIT-HF

Beta blocker therapy is recommended for
patients with a recent decompensation of HF
after optimization of volume status and
successful discontinuation of IV diuretics
and vasoactive agents.

Whenever possible, beta blocker therapy
should be initiated in the hospital at a low
dose prior to discharge of stable patients.
Strength of Evidence = B
Journal of Cardiac Failure Vol. 16 No. 6 2010

Continuation of beta blocker therapy is recommended
in most patients experiencing a symptomatic
exacerbation of HF during chronic maintenance
treatment, unless they develop cardiogenic shock,
refractory volume overload, or symptomatic
bradycardia.
Strength of Evidence = C




Temporary dose reduction may be considered
Avoid abrupt discontinuation
Reinstate or gradually increase prior to discharge
Titrate dose to previously tolerated dose as soon as
possible
Journal of Cardiac Failure Vol. 16 No. 6 2010
Improvement
100%
91%
73%
75%
Patients
18%
P <.0001
50%
25%
0%
Carvedilol
Predischarge Initiation
(n=185)
Physician Discretion
Postdischarge Initiation*
(n=178)
Gattis WA et al. JACC 2004;43:1534-41
CONCOMITANT DISEASE

Beta blocker therapy is recommended in the great
majority of patients with HF and reduced LVEF—even if
there is concomitant diabetes, chronic obstructive lung
disease or peripheral vascular disease.

Use with caution in patients with:

Diabetes with recurrent hypoglycemia
 Asthma or resting limb ischemia.
 Use with considerable caution in patients with marked
bradycardia (<55 bpm) or marked hypotension (SBP < 80
mmHg).
 Not recommended in patients with asthma with active
bronchospasm.
Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
COPERNICUS (carvedilol)1
With diabetes
Without diabetes
MERIT-HF (ER metoprolol succinate)2
With diabetes
Without diabetes
0
0.5
1.0
1.5
2.0
Mohacsi. Circulation. 2001;104(17):abstr 3551.
Hjalmarson. JAMA. 2000;283(10):1295.
PRESERVED LVEF

Beta blocker treatment is recommended in patients with HF and
preserved LVEF who have:



Prior MI
Strength of Evidence = A
Hypertension
Strength of Evidence = B
Atrial fib. requiring control of ventricular rate
Strength of Evidence = B
THE ELDERLY

Beta-blocker and ACE inhibitor therapy is recommended as
standard therapy in all elderly patients with HF due to LV
systolic dysfunction.
Strength of Evidence = B

In the absence of contraindications, these therapies are also
recommended in the very elderly (age > 80 years).
Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010
General
considerations
Initiate at low doses
Up-titrate gradually, generally no sooner than at 2 week
intervals
Use target doses shown to be effective in clinical trials
Aim to achieve target dose in 8-12 weeks
Maintain at maximum tolerated dose
If symptoms worsen
or other side effects
appear
Adjust dose of diuretic or concomitant vasoactive med.
If up-titration
continues to be
difficult
Prolong titration interval
Continue titration to target after symptoms return to
baseline
Reduce target dose
Consider referral to a HF specialist
Journal of Cardiac Failure Vol. 16 No. 6 2010
Generic
Name
Trade Name
Initial
Daily Dose
Target Dose
Mean Dose in
Clinical Trials
Bisoprolol
Zebeta
1.25 mg qd
10 mg qd
8.6 mg/day
Carvedilol
Coreg
3.125 mg bid
25 mg bid
37 mg/day
Carvedilol
Coreg CR
10 mg qd
80 mg qd
Metoprolol
succinate
CR/XL
Toprol XL
12.5-25 mg qd
200 mg qd
159 mg/day


ARBs are recommended for routine
administration to symptomatic and
asymptomatic patients with an
LVEF ≤ 40% who are intolerant to
ACE inhibitors for reasons other than
hyperkalemia or renal insufficiency.
Strength of Evidence = A
Journal of Cardiac Failure Vol. 16 No. 6 2010
Val-HeFT
CHARM-Alternative
50
CV Death or HF Hosp %
100
Survival %

Valsartan
90
80
Placebo
70
60
Placebo
40
30
Candesartan
20
10
p = 0.017
HR 0.77, p = 0.0004
50
0
0
3
6
9
12
15
Months
18
21
24
27
0
9
18
27
Months
36
Maggioni AP et al. JACC 2002;40:1422-4
Granger CB et al. Lancet 2003;362:772-6
Generic
Name
Trade Name
Initial
Daily Dose
Target Dose
Mean Dose in
Clinical Trials
Candesartan
Atacand
4-8 mg qd
32 mg qd
24 mg/day
Losartan
Cozaar
12.5-25 mg qd
150 mg qd
129 mg/day
Valsartan
Diovan
40 mg bid
160 mg bid
254 mg/day

An aldosterone antagonist is recommended
for patients on standard therapy, including
diuretics, who have:

NYHA class IV HF (or class III, previously class IV) HF from
reduced LVEF (≤ 35%)

One should be considered in patients post-MI
with clinical HF or diabetes and an LVEF <
40% who are on standard therapy, including
an ACE inhibitor (or ARB) and a beta blocker.
Strength of Evidence = A
Journal of Cardiac Failure Vol. 16 No. 6 2010
EPHESUS (Post-MI)
RALES (Advanced HF)
Probability of Survival

1.00
1.00
0.90
0.90
0.80
Spironolactone
0.70
Eplerenone
0.80
Placebo
0.70
0.60
0.60
Placebo
0.50
0.50
RR = 0.70
P < 0.001
0.40
RR = 0.85
P < 0.008
0.40
0
3
6
9
12 15 18 21 24 27 30 33 36
0
3
6
9
12 15 18 21 24 27 30 33 36
Months
Pitt B. N Engl J Med 1999;341:709-17
Pitt B. N Engl J Med 2003;348:1309-21

Aldosterone antagonists are not recommended
when:



Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
Serum potassium> 5.0 mmol/L
Therapy includes other potassium-sparing diuretics
Strength of Evidence = A

It is recommended that potassium be measured at
baseline, then 1 week, 1 month, and every 3 months
Strength of Evidence = A

Supplemental potassium is not recommended unless
potassium is < 4.0 mmol/L
Strength of Evidence = A
Journal of Cardiac Failure Vol. 16 No. 6 2010

Trial of 2737 patients with NYHA class 2 heart failure and an
ejection fraction of no more than 35%.

Patients were randomized to eplerenone (up to 50mg daily) or
placebo in addition to recommended therapy.

Measured outcomes included: cardiovascular death/heart-failure
hospitalization, cardiovascular death, heart-failure hospitalization,
and hospitalization for hyperkalemia.

Trial was stopped early at 21months.

EMPHASIS-HF Major results
Outcome


Eplerenone (%)
Placebo (%)
Adjusted hazard
ratio (95% CI)
P
Cardiovascular
death/heartfailure
hospitalization
18.3
25.9
0.63 (0.54-0.74)
< 0.001
Cardiovascular
death
10.8
13.5
0.76 (0.61-0.94)
0.01
Heart-failure
hospitalization
12.0
18.4
0.58 (0.47-0.70)
< 0.001
Hospitalization
for hyperkalemia
0.3
0.2
1.15 (0.25-5.31)
0.85
Results in a 37% reduction in the primary end point of the
composite of death from cardiovascular causes or
hospitalization for heart failure!!
Hyperkalemia occurring in 11.8% of eplerenone patients vs
7.2% of those in placebo group!!!

A combination of hydralazine and
isosorbide dinitrate is recommended as
part of standard therapy, in addition to
beta-blockers and ACE-inhibitors, for
African Americans with HF and reduced
LVEF:


NYHA III or IV HF
NYHA II HF
Strength of Evidence = A
Strength of Evidence = B
Journal of Cardiac Failure Vol. 16 No. 6 2010
End point
Primary end point
composite score
ISDN-HDZN Placebo
(n=518)
(n=532)
p
-0.1
-0.5
0.01
6.2
10.2
0.02
1st HF hospitalization (%)
16.4
24.4
0.001
Change in quality-of-life
score at 6 months**
-5.5
-2.7
0.02
All-cause mortality (%)
Taylor AL et al. N Engl J Med 2004; 351;2049-57
43% Decrease in Mortality
100
Survival %
Fixed Dose ISDN/HDZN
95
90
Placebo
P = 0.01
85
0
100
200
300
400
500
600
Days Since Baseline Visit
Taylor AL et al. N Engl J Med 2004;351:2049-57

Diuretic therapy is recommended to restore
and maintain normal volume status in patients
with clinical evidence of fluid overload,
generally manifested by:
 Congestive symptoms
 Signs of elevated filling pressures
Strength of Evidence = A

Loop diuretics rather than thiazide-type
diuretics are typically necessary to restore
normal volume status in patients with HF.
Strength of Evidence = B
Journal of Cardiac Failure Vol. 16 No. 6 2010
Restoration of normal volume status may require multiple
adjustments.
 Once a diuretic effect is achieved with short-acting loop
diuretics, increase frequency to 2-3 times a day if
necessary, rather than increasing a single dose.

Strength of Evidence = B
Oral torsemide may be considered in patients exhibiting
poor absorption of oral medication or erratic diuretic
effect.
Strength of Evidence = C
 IV administration of diuretics may be necessary.

Strength of Evidence = A

Diuretic refractoriness may represent patient
nonadherence, a direct effect of diuretic use on the
kidney, or progression of underlying dysfunction.
Journal of Cardiac Failure Vol. 16 No. 6 2010

Prophylactic ICD placement should be considered in
patients with an LVEF ≤35% and mild to moderate HF
symptoms:


Ischemic etiology
Non-ischemic etiology

In patients who are undergoing implantation of a
biventricular pacing device, use of a device that provides
defibrillation should be considered.
Strength of Evidence = A
Strength of Evidence = B
Strength of Evidence = B

Decisions should be made in light of functional status and
prognosis based on severity of underlying HF and
comorbid conditions, ideally after 3-6 mos. of optimal
medical therapy.
Strength of Evidence = C
Journal of Cardiac Failure Vol. 16 No. 6 2010





Fluid and sodium restriction
Diuretics, especially loop diuretics
Ultrafiltration/renal replacement therapy
(in selected patients only)
Parenteral vasodilators *
(nitroglycerin, nitroprusside, nesiritide)
Inotropes * (milrinone or dobutamine)
Journal of Cardiac Failure Vol. 16 No. 6 2010

Recommended prior to discharge for all patients with
HF:






Exacerbating factors addressed
Near optimum fluid status and pharmacologic therapy achieved
Transition from IV to oral diuretic completed
Patient education completed with clear discharge instructions
Follow-up clinic visit scheduled, usually 7-10 days
Should be considered prior to discharge for patients
with advanced HF or a history of recurrent admissions:





Oral regimen stable for 24 hours
No IV inotrope or vasodilator for 24 hours
Ambulation before discharge to assess functional capacity
Plans for post-discharge management
Referral for disease management, if available Strength of Evidence =C
Journal of Cardiac Failure Vol. 16 No. 6 2010


Classification and Regression Tree (CART) analysis of
ADHERE data shows:
Three variables are the strongest predictors of mortality in
hospitalized ADHF patients:
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dL
Fonarow GC et al. JAMA 2005;293:572-80
It is recommended that patients with HF and
their family members or caregivers receive
individualized education and counseling
that emphasizes self-care.
 This education and counseling should be
delivered by providers using a team
approach.
 Teaching should include skill building and
target behaviors.


Strength of Evidence = B
Journal of Cardiac Failure Vol. 16 No. 6 2010
Control Volume
Diuretics
Renal Replacement
Therapy*
Improve Clinical Outcomes
Aldosterone
ACEI
-Blocker Antagonist
or ARB
or ARB
CRT 
an ICD*
HDZN/ISDN*
*In selected patients
Treat Residual Symptoms
Digoxin

For years the discussion has been which
antiplatelet regimen is ideal for CHF pts?
ASA
 Warfarin
 Plavix



WASH Trial
WATCH Trial

CHADS2
Congestive Heart Failure
Hypertension
Age > 75
Diabetes
Stroke or TIA (2 points)

CHA2DS2-VAS
Congestive heart failure/LV
dysfunction
Hypertension
Age > 75 years
Diabetes mellitus
Stroke/TIA
Vascular disease (prior MI, peripheral
vascular disease)
Age 65-75 years
Female sex
Score
1
1
2
1
2
1
1
1
Patient Factors
ASA
Plavix
Myocardial
Infarction
<12months ago
X
X
Stent <12months
ago
X
X
Warfarin
Atrial Fibrillation X
(CHADS2 score 01)
Atrial Fibrillation
(CHADS2 score
>2)
X or Dabigatran
Diabetes
X
BYPASS Hx
X
Patient Factors
ASA
Plavix
EF% < 30%
X
Systolic Failure
w/ EF% >30%
X
Diastolic Failure
X
Severe CAD (no
surgery option)
X
X
LVAD
X
X
Warfarin
X
New Recommendation
VTE prophylaxsis with low dose unfractionated
heparin, LMWH, or fondaparinux to prevent
proximal deep venous thrombosis and pulmonary
embolism is recommended for patients who are
admitted to the hospital with ADHF and who are
not already anticoagulated & have no
contraindication.
(Strength of Evidence=B)


IMPROVE-HF


Omega-3 (PUFAs)


Massie b, Carson P, et al. Irbesartan in Patients with Heart Failure & Preserved Ejection Fraction
(I-Preserve Trial). NEJM. 2008;359(23):2456-2467
HFSA “The Heart Failure Clinic A Consensus Statement”


Zebrack J, Munger M, MacGregor J, et al. B-Receptor Selectivity of Carvedilol and Metoprolol
Succinate in Patients with Heart Failure (SELECT Trial): A randomized Dose-Ranging Trial.
Pharmacotherapy. 2009;29(8):883-890.
Irbesartan


Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of n-3 polyunsaturated fatty acids in patients with
chronic heart failure (the GISSI-HF trial): a randomized, double-blind, placebo-controlled trial.
Lancet 2008;372:1231-1239.
SELECT Trial


Yancy CW, Fonarow GC, Albert NM, et al. Influence of patient age and sex on delivery of
guideline-recommended heart failure care in the outpatient cardiology practice setting: Findings
from IMPROVE HF. American Heart Journal. 2009;157:754-762.
J Card Fail. 2008;14:801-815.
Centers for Medicare and Medicaid Services 30 day congestive heart failure readmission
rates.

http://www.hospitalcompare.hhs.gov
No significant differences in the patients’ global assessment of symptoms or in changes from baseline
renal function with either bolus as compared with continuous infusion of intravenous furosemide or
with a low-dose strategy as compared with a highdose strategy.





Teaching tool to utilize with CHF patients
Provides 5yr survival rate for patients based
upon clinical history and no intervention as
compared to rate after intervention.
User friendly
Internet based
http://depts.washington.edu/shfm/

Based upon the above case what type of interventions would you
have expected to have been performed? (during admission or in
clinic)
A.
B.
C.
D.
E.
Continue all medications prior to admission
Increase Atenolol, start an ace-inhibitor, & start an aldosterone antagonist
DC atenolol, start metoprolol succinate, & start an ace-inhibitor
DC atenolol, start carvedilol, & start an ace-inhibitor
Just give up and discharge patient from clinic!!!
Questions???
Timothy.murray@ihs.gov