OUR LADY OF HOPE PROTOCOLS
CONGESTIVE HEART FAILURE
Ref: Clinical Geriatrics 2011:19(12):21-28/ AMDA: Heart Failure in the long-term care setting, revised 2010
ASSESMENT:
Step 1: provider reviews chart upon admission
LVEF: ________% - consider Echo if date assessed > 6 months ago
Secondary diagnoses (note especially presence of CAD, HTN, Hypothyroidism): _______________
__________________________________________________________________________________
Allergies/Reactions ________________________________________________________________
Step 2: initial workup
Asses patient for signs and symptoms of fluid overload and classify heart failure class:
History: dyspnea, orthopnea, fatigue, night time cough, decreased po intake, decreased functional status
Exam: look for tachycardia, S3, JVD, rales, edema, recent weight gain
CHF NYHA class ___________
Class I — symptoms of HF only at activity levels that would limit normal individuals
Class II — symptoms of HF with ordinary exertion
Class III — symptoms of HF with less than ordinary exertion
Class IV — symptoms of HF at rest
Laboratory: (if not available from hospital notes)
CBC with diff
Comprehensive Metabolic Panel or Basic Metabolic Panel
TSH
Magnesium
CXR
EKG
Consider B-natriuretic peptide level as baseline, or to evaluate if patient may be fluid overloaded
Consider Echocardiogram if diagnosis uncertain or record of EF not available
Source: AMDA Clinical Practice Guidelines: Congestive Heart Failure; Clinical Geriatrics 2011; 19(12)
TREATMENT:
provider will write these orders for all HF patients:
Diet: Low Salt
Weights: Daily for 2 weeks, then weekly if stable. Contact MD for weight gain > 5 pounds from
admission weight
Fluid restriction: consider fluid restriction of 1500 cc for those with repeated admissions for HF
Monitor for signs of fluid overload: increasing edema, increasing dyspnea, shortness of breath on lying
down.
Step 1: treat underlying condition
Address anemia (iron, B12/folate, Procrit), diabetes, cardiac arrhythmia (rate control with beta
blocker, consider cardiac consult to treat atrial fibrillation), hyperthyroidism (consider
radioablation if chronic TSH suppression <0 .1 which conveys greater risk of atrial fibrillation),
ischemic heart disease (angioplasty if appropriate, nitrates), htn (ACE and beta-blockers, first
line tx)
Step 2: Manage fluid overload if present
Diuretic: Furosemide 20-40 mg QAM
Consider metolazone 2.5 – 5mg 30 minutes before furosemide
Consider Bumex 1-2 mg qd in those that do not respond adequately to furosemide
Step 3 if depressed EF < 40%:
Step 3a:
Start afterload reducing agents: ACE-I and Beta blocker
ACE inhibitor: lisinopril 5 mg qd tirate to 10 mg qd after 2 weeks (check BMP in 1-2 weeks after each
dose change)
Use ARB for those who develop cough. Do not use ARB and ACE together (studies show decreased
survival in those who are on ACE and Beta-blockers in combination with ARBs).
Beta blocker: Metoprolol XL 12.5 mg QD, titrate up to 200 mg QD if tolerated
Carvedilol 3.125 mg bid, titrate to 12.5 mg (or 25 mg) BID if tolerated
Step 3b:
In all patients if still symptomatic:
Source: AMDA Clinical Practice Guidelines: Congestive Heart Failure; Clinical Geriatrics 2011; 19(12)
Spironolactone 25 mg once per day, may increase to 50 mg once per day if not effective. Check BMP in 1
week for hyperkalemia and renal insufficiency
Step 3c:
In those who remain symptomatic or cannot tolerate ACE/ARB therapy due to renal insufficiency:
Isosorbide dinitrate: start at 20 mg TID, increase to 40 mg TID in 2-4 weeks
Hydralazine: start 25 mg tid, increase by 25 mg per dose every 2-4 weeks to target of 75 mg TID
Step 3d:
In all patients if still symptomatic:
Digoxin: 0.125 mg qd – do not increase. No benefit shown at higher doses. Digoxin does not improve
survival, but decreases symptoms and hospitalizations. Check levels in 2-3 weeks after starting to ensure
levels are not too high.
Step 3 if preserved EF > 40%:
Diuretics, ACE-I and Beta blockers as above
Also consider calcium channel blockers: Norvasc 2.5, titrate to 5 mg per day, or Diltiazem 120, titrate to
240 mg qd
STEP 4: Monitoring
In 1-2 weeks after any change in ACE/ARB or Diuretic, check BMP and Magnesium
Check weekly weights in all CHF patients until stable. Consider weights daily for 2 weeks after any
reduction in meds
Vital signs daily for 2 weeks after any change in meds
Monitor for signs and symptoms of fluid overload
Consider BNP when stable to provide baseline or if you suspect worsening fluid overload
Source: AMDA Clinical Practice Guidelines: Congestive Heart Failure; Clinical Geriatrics 2011; 19(12)