Deborah Crawford APRN-CNS
Clinical Supervisor HF CARE Center
Oklahoma Heart Institute
PEARLS OF HF MANAGEMENT
AND REDUCTION OF HOSPITAL
READMISSIONS
Disclosures
 None Related to this Presentation
Heart Failure Background
 Prevalence of HF:
 5,100,000
 Incidence of HF:
 825,000
 Mortality:
 50% at 5 yrs
 Hospital discharges:
 1,023,000
 Cost: $30.7 billion
» Heart Failure (HF) is a
major public health
problem resulting in
substantial morbidity, and
healthcare expenditures
» Major cost-driver of HF
is high incidence of
hospitalizations
» Despite treatment
advances large number of
eligible patients are not
receiving one or more
evidence-based HF
therapies
American Heart Association. 2014 Heart and Stroke Update Dallas, TX: AHA; 2014
Heart Failure Definition
» Systolic Heart
Failure
New Definition:
» Heart Failure with
Reduced Ejection
Fraction (HFrEF)
» LVEF < 40%
ACC/AHA Heart Failure Guidelines 2013.
Yancy, C, Jessup, M.
Types of Cardiomyopathy
» Idopathic dilated:
the cause is
unknown
» Ischemic: coronary
artery disease,
decreased blood
supply to the heart
muscle.
Heart Failure Definition
 Diastolic Heart
Failure
New Definition:
 Heart Failure with
Preserved Ejection
Fraction (HFpEF)
 LVEF > 50%
ACC/AHA Heart Failure Guidelines 2013.
Yancy, C, Jessup, M.
J Am Coll Cardiol. 2013; 62:1495-1538
Acute Decompensated Heart Failure
(ADHF)
Heart Failure:
 Complex clinical
syndrome,
Cardinal symptoms:
 fatigue
 dyspnea
 Can result from any
structural or functional
cardiac disorder that
impairs ability of
ventricle to fill with or
eject blood.
Hunt SA et al. Circulation. 2001;104:2996
Clinical signs:
 fluid retention
 exercise intolerance
Pathophysiology of ADHF
Myocardial Injury
Fall in LV Performance
Activation of RAAS and SNS
(endothelin, AVP, cytokines)
Myocardial Toxicity
Change in Gene Expression
Morbidity and
Mortality
ANP
BNP
Remodeling and
Progressive
Worsening of
LV Function
Shah M et al. Rev Cardiovasc Med. 2001;2(suppl 2):S2
Peripheral Vasoconstriction
Sodium/Water Retention
HF Symptoms
Therapies in the Hospitalized HF Patient
 Treated with IV diuretics:
 Loop diuretics dose greater than or
equal to chronic oral daily dose, the
serially adjusted
 Monitor electrolytes, BUN, Creat.
Measured during titration of HF
medications and IV diuresis
 Initiation of beta blocker at a low
dose recommended after
optimization of volume status and
discontinuation of IV agents
ACC/AHA Heart Failure Guidelines 2013. Yancy, C, Jessup, M.
J Am Coll Cardiol. 2013; 62:1495-1538
Therapies in the Hospitalized HF
Patient (Cont)
 Ultrafiltration may be considered for patients
with obvious volume overload and refractory
congestion
 IV Nitroglycerin, Nitroprusside of Nesiritide
may be considered an adjunvant to diuretic
therapy for stable patients with HF
 Patients with volume overload and severe
hyponatremia, vasopressin antagonists may
be considered.
ACC/AHA Heart Failure Guidelines 2013. Yancy, C, Jessup, M.
NYHA Functional
Classifications in
patients with HF
 Class I: No limitations
 Class II: Slight limitations
of physical activity
 Class III: Marked limitation
of physical activity
 Class IV: Symptoms at rest
Unable to carry on any
physical activity without
discomfort.
Stages of Heart
Failure
 Stage A: At risk for
developing HF
 Stage B: Structural heart
disease associated with HF
but asymptomatic
 Stage C: Known systolic
heart failure & current or
prior symptoms
 Stage D: Systolic heart
failure and presence of
advanced symptoms after
receiving optimal care
Pharmacological Treatment of Heart
Failure
 ACE Inhibitors: Inhibit renin-angiotensin system in all HF
patients with LV dysfunction
 ARB: Recommended to patients with LVEF <40% intolerant
of ACE -I
 Beta Blockers: Shown effective in patients with HF with
LVEF < 40% (start when euvolemic)
 Aldosterone blockade: Recommended in
patients with NYHA class III or IV,
LVEF <35% while receiving standard therapy
Dosing ACE/ARB
 Start with low dose ie:
 Lisinopril/Enalapril 2.5mg BID
 Stagger away from Beta Blocker dose
 Avoid Orthostatic Hypotension
 Usually Lunch and Bedtime
 “Stair step” the dosing when up titrating
 Monitor Renal function
 Can use in mild, stable renal insufficiency
Dosing Beta Blockers
 Carvedilol and Metoprolol Succinate are the Beta
Blockers that have an indication for Heart Failure
 Start low dose and titirate up slowly
 Stagger away from ACE I/ARB
 Start or up titrate when the patient is euvolemic
 “Stair step” the dosing when up titrating
 Titrate one drug at a time.
Dosing Aldosterone Blockers
 Spironolactone, Eplerenone
 Helpful in the setting of Hypertension for
better BP control
 Monitor Renal function : can use in mild,
stable renal insufficiency
 Does have mortality benefit in patients
with LVEF < 35 %.
Compensated/Decompensated ?
Diuretic Therapy
Agent
Initial Daily
Dose (mg)
Furosemide 20-40mg qd
Maximum
Total Daily
Dose (mg)
Duration of
Action (hr)
600mg
4-6
or bid
Bumetanide
0.5-1mg
qd or bid
10mg
6-8
Torsemide
10-20mg qd
200mg
12-16
Metalozone
(thiazide)
2.5mg qd
20mg
12-24
Equivalent doses: Furosemide 40mg=bumetanide 1mg=torsemide 20mg
Dosing Thiazide Diuretic
Metolazone (Zaroxlyn)
 Usually 2.5 – 5mg
Hydrochlorothiazide
 Usually 25mg
Usually give 30 min prior to the Loop Diuretic
More effective and increases the diuretic effect of the Loop
Dosing Potassium and Magnesium
Potassium:
Goal 4.0 – 5.0
Magnesium:
Goal 2.0 – 2.5
 Usually 10-20mEq /
 Usually 250mg BID for
Furosemide 40mg dose
equivelent.
 Usually will double the
Potassium dose when you
double the Loop diuretic
dose
 Depending on renal
function of the patient
1 week then once a day
 Check the Mg level in 1
month after starting
Mg supplement
Use of Devices in Heart Failure
 Prophylatic ICD
considered LVEF <30%
Ischemic or
Nonischemic
 Biventricular (CRT-D)
considered for patients
with SR, QRS >120ms,
LVEF < 35% with
persistent, moderate
to severe HF (NYHA IIIII) despite medical
therapy
Patient Compliance
» Low sodium diet
* 2 gm Na restriction
» Fluid restriction
* < 2 liters / day
» Medication
compliance
» Daily weight
* Call if 2 - 3 pound weight
gain overnight.
* Diuretic adjustment
Don’t Let this Happen to Your
Patient
Alternative treatment in Diuretic
resisitant patients
Ultrafiltration
What Is Diuretic Resistance ?


10 lbs or more over
dry weight
>
Previous
hospitalizations with
ineffective diuretic
effect

Patient cannot achieve
a goal of -2 liters at 24
hrs

No significant
difference in patient’s
global assessment of
symptoms in 24 hrs
 Non-significant
symptom improvement
noted after escalating
to high-dosing strategy

Worsening renal
function during diuretic
therapy

Post-operative fluid
overload

Peri-operative fluid
overload
Ultrafiltration
 Indicated for patients with Heart Failure not
responding to diuretic therapy
 24 hour diuretic dose >80mg Furosemide or
equivalent
 Removes excess salt and water from patients
with fluid overload
 Need to monitor Renal function closely esp.
during inpatient ultrafiltration
 Fluid removal rate should not exceed
200ml/hr (inpatient) or 350ml/hr (outpatient
for 8 hrs)
Goals of Ultrafiltration
 Reduction in hospital readmission:
 Prevent patients from being discharged when they
are still “wet”
 Reduction of Length of Stay:
 If ultrafiltration is started early (< 24 hr of
admission).
 Stable renal function during treatment:
 Monitor BMP every 12 hours while on ultrafiltration
to prevent worsening renal function. Can reduce
rate of fluid removal as needed.
Pearls after Ultrafiltration

Hold diuretic while on ultrafiltration
 Restart diuretic after ultrafiltration
completed usually the next day at a
lower dose

May respond better to diuretics after
ultrafiltration due to reduction of “gut
edema”
SAFE AND EFFECTIVE VOLUME
REMOVAL AND REDUCTION IN
THIRTY-DAY READMISSION FOR
DIURETIC RESISTANT PATIENTS
IN THE OUTPATIENT SETTING
Deborah J. Crawford, MS, APRN-CNS
Alan M. Kaneshige, MD, FACC
Poster Presentation 16th Annual Scientific Meeting Heart Failure Society of
America Sept. 18,2012, Seattle, WA
Abstract
Hypothesis:
Introduction:
 Many times, effective
fluid removal is difficult
despite aggressive
diuresis. Ultrafiltration
provides another method
for effective fluid
removal for patients
with volume overload.
 Ultrafiltration safely and
effectively removes excess
water and salt from patients
who are volume overloaded,
and resistant to diuretic
therapy.
Methods:
 Data were reviewed and
extracted during a
retrospective chart review
of patients receiving
outpatient ultrafiltration in
a hospital based heart
failure clinic setting.
All Cause and HF Hospital
Readmissions
% of readmits
25.00%
Reduction of
9.3% in 30 day
readmissions
20.00%
15.00%
10.00%
% of readmits
5.00%
0.00%
All Cause
Heart Failure
30 day
Hospital
readmits
19.9 %
30 day HF
readmits
10.6%
Conclusions
 Ultrafiltration in an outpatient
heart failure clinic setting was
found to be both clinically and
cost effective method for fluid
removal in patients with diuretic
resistance and experiencing
volume overload.
Oklahoma Heart Institute Heart Failure CARE Center
Outpatient Ultrafiltration Algorithm
Ultrafiltration
Pre-treatment
Day of treatment:
1. Obtain IV access:
a. 6Fr. Dual lumen ELC venous access catheter with stainless
steel coil reinforcement. (CHF Solutions)
2. Obtain Laboratory: CMP or BMP, Mg CBC, PT/INR (if on Coumadin)
3. Obtain Aquadex Flexflow pump
(Prime the filter / circuit with the Normal Saline)
4. Obtain UF 500 Circuit set and 10ml syringe
5. Heparin 20,000units/500ml D5W
Anticoagulation:
a. Heparin infusion 1000-1200 units/hour
b. Infuse Heparin through the infusion port of the Aquadex filter
c. Heparin bolus 2000 units IV bolus for selected patients
d. Start 30min prior to starting Ultrafiltration.
Aquadex FlexFlow Monitoring:
Patient
Treatment
1.
Patient check In
2
Obtain patient's weight
1. Evaluate for signs of clotting:
a. Frequent alarms, withdrawal occlusion,
infusion occlusion, or infusion disconnect.
2. Monitor for Pressure changes:
Normal Ranges:
Pw (withdrawal) -300 to -20
Pu (UF pressure) -250 to +200
Pi (Infusion) +20 to +300
3. Obtain sitting & standing
BP and HR for baseline
4. Place on cardiac monitor
(telemetry)
5. Assess patency of
catheter. Flush & withdraw
each port 10ml in 10 sec.
If does not infuse or
withdraw may reposition the
catheter or use 2mg of
Cathflo (Activase) per
protocol to open up line.
3. Follow Aquadex Flex Flow User's Guide to
trouble shoot alarms.
1. Heparin infusion: 1000 -1200
units/hour. Start 30min prior to
starting Ultrafiltration.
2. Vital Signs monitoring:
Every 15 min x 1 hour then,
Every 30 - 60 min for the remainder of
the treatment.
3. Strict intake and output while on the
treatment. (IV, ultra filtrate bag emptying,
and po fluids only)
4. Fluid restriction 2000ml/24 hours
5. Cardiac telemetry while on
Aquapheresis
Completion of Treatment:
1.Disconnect patient from Aquadex Flex Flow,
flush and cap catheters per hospital policy.
2. Patient achieved euvolemia or 8 hours of
outpatient therapy is completed.
3. Discuss therapy completion with prescribing
cardiologist:
a. Remove IV catheter/hospital policy
6. Pre and post treatment weight
b. If euvolemia is achieved, schedule F/U
appointment. In the next 1-2 weeks
7. Assess Catheter site hourly during
treatment.
c. If euvolemia, not yet achieved , schedule f/u
Ultrafiltration appointment in 1 week
8. Max outpatient treatment time is 8
hours.
4. Obtain weight prior to discharge.
5 Have patient call their weight in the AM after
Ultrafiltration.
Discharge Criteria for Patients
with Heart Failure
 Exacerbating factors addressed
 At least near optimal volume status
achieved
 Transition from IV to oral diuretic
therapy completed (stable for 24
hours)
 Optimization of chronic oral HF
therapy
 Follow up clinic visit scheduled
(7 – 14 days) and/or telephone f/u within 3
days of hospital discharge.
 Plans for post discharge management
(scale present in home, HF teaching
completed
ACC/AHA Heart Failure Guidelines 2013. Yancy, C., Jessup, M.
J Am Coll Cardiol. 2013; 62:1495-1538
Thank You !!