nw york heart as
TRANSCRIPT
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Planning
Determine Patients Clinical Status
New York Heart Association (NYHA) functional class
ACC/AHA stage
Integrate assessment findings into plan of care
When determining care plan objectives, consider
patient acuitycare setting
clinical status (e.g., co-morbidities and prognosis)
patient preferences
etiology of heart failurepsychosocial and economic factors
Prioritize implementation of the plan of care based on assessment findings
and clinical status (e.g., history, signs and symptoms, test results,pathophysiology)
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NYHA Classification
Class
I
Ordinary physical activity does not cause undue
fatigue, palpitations, dyspnea and/or angina
Class
II
Class
III
Class
IV
Ordinary physical activity does cause undue
fatigue, palpitations, dyspnea and/or angina
Less than ordinary physical activity causes undue
fatigue, palpitations, dyspnea and/or angina
Fatigue, palpitations, dyspnea and/or angina occur
at restCriteria Committee of the New York Heart Association, 1964.
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Heart Failure Population by NYHA Class
Class II
1.68 M
(35%)
Class IV
240 K(5%)
Class III1.20 M
(25%)
Class I1.68 M
(35%)
AHA Heart and Stroke Statistical Update 2001
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ACC/AHA Heart Failure Staging System
Stage Patient Description
High risk for developing heart failure
(HF)
Hypertension
Coronary artery disease
Diabetes mellitus
Family history of cardiomyopathy
Asymptomatic HF
Previous myocardial infarction
Left ventricular systolic dysfunction
Asymptomatic valvular disease
Symptomatic HF
Known structural heart disease
Shortness of breath and fatigue
Reduced exercise tolerance
Refractory end-stage HF
Marked symptoms at rest despite maximal medical therapy
(e.g., those who are recurrently hospitalized or cannot be
safely discharged from the hospital without specialized
interventions)
AA
BB
CC
DD
Hunt SA, et al. Circulation 2001;104:2996-3007.
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Recommended Therapy by Stage of Heart Failure
Hunt SA et al. ACC/AHA 2005 Guideline update for diagnosis and management of chronic heart failure in the adult. Summary Article. Circulation
2005; 112:1825-1852.
Jessup M et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation.
2009;119(14):1977-2016.
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ACC/AHA Heart Failure Staging Therapy
Stage Patient Therapy
High risk for developing heart
failure (HF)
Hypertension
Coronary artery disease Diabetes mellitus
Family history of cardiomyopathy
Asymptomatic HF
Previous myocardial infarction
Left ventricular systolic dysfunction
Asymptomatic valvular disease
Symptomatic HF
Known structural heart disease
Shortness of breath and fatigue
Reduced exercise tolerance
Refractory end-stage HF
AA
BB
CC
DD
AA
BB
CC
DD
Hunt SA, et al. Circulation 2001;104:2996-3007.
Optimal drug therapy
Aspirin, ACE inhibitors, statins, -blockers, --blockers (carvedilol) diabetic therapy
Optimize drug therapy
ICD if LV dysfunction (systolic) present
Optimize drug therapy
ICD if LV dysfunction (systolic) present
CRT (if QRS wide, LVEF
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Case Study:
Integrating Assessment and HFStaging into the Plan of Care
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HF Case Study
46 year old male
Diagnosis: idiopathic dilated cardiomyopathy, diagnosed 2006,
First admitted 9/10/10 for shortness of breath on exertion for 1 month andfound to have decreased ejection fraction (LV 30%, RV 50%)NYHA Class IV
PMH:Acute Renal FailureHypertension
HyperlipidemiaDiabetes melli tus II (recently diagnosed)Childhood asthma
FH: Positive family history of coronary heart disease and diabetes
46 year old male
Diagnosis: idiopathic dilated cardiomyopathy, diagnosed 2006,
First admitted 9/10/10 for shortness of breath on exertion for 1 month andfound to have decreased ejection fraction (LV 30%, RV 50%)NYHA Class IV
PMH:Acute Renal FailureHypertensionHyperlipidemiaDiabetes melli tus II (recently diagnosed)Childhood asthma
FH: Positive family history of coronary heart disease and diabetes
AA
BB
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HF Case Study
SH:
MarriedSmoking pack day for 20 years
No alcohol use
Occasional marijuana use and history of prior cocaine
use
Medication non-compliance due to inability to afford his
medication
Unfamiliar with checking blood sugars, low fat, low
carbohydrate diet
SH:
MarriedSmoking pack day for 20 years
No alcohol use
Occasional marijuana use and history of prior cocaine
use
Medication non-compliance due to inability to afford his
medication
Unfamiliar with checking blood sugars, low fat, low
carbohydrate diet
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HF Case Study
Symptoms improved from NYHA Class IV to IIwith diuresis and 10 pound weight loss
ACC/AHA Stage B/C
Discharged 9/13
Diabetic education
Switch to more affordable medications
Heart Failure educationReturn to clinic
Symptoms improved from NYHA Class IV to IIwith diuresis and 10 pound weight loss
ACC/AHA Stage B/C
Discharged 9/13
Diabetic education
Switch to more affordable medications
Heart Failure educationReturn to clinic
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Hospitalization Admission Dates
10/26: ED for SOB and Chest pain
11/18: ICD placed 12/4: ED for SOB which awoke him from
sleeping
12/21: Fatigue, several days of dyspnea,orthopnea and exercise intolerance
NYHA Class IV 1/26: SOB and generally not well, 25 pound
weight gain since last admission
LVAD and Transplant Team Consults
10/26: ED for SOB and Chest pain
11/18: ICD placed 12/4: ED for SOB which awoke him from
sleeping
12/21: Fatigue, several days of dyspnea,orthopnea and exercise intolerance
NYHA Class IV 1/26: SOB and generally not well, 25 pound
weight gain since last admission
LVAD and Transplant Team Consults
CC
DD
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Case Study: Assessment
Exam on 1/26 admission:
Overweight, maleSkin warm and dry
Respirations unlabored, lungs clear all f ields
JVP 13cm, 2+ LEERegular rate and rhythm, Positive S3
Functional: able to converse, dyspnea with ambulation,
sleeps on 4 pil lows
Quit smoking October (3 months ago)
Exam on 1/26 admission:
Overweight, maleSkin warm and dry
Respirations unlabored, lungs clear all f ields
JVP 13cm, 2+ LEERegular rate and rhythm, Positive S3
Functional: able to converse, dyspnea with ambulation,
sleeps on 4 pil lows
Quit smoking October (3 months ago)
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HF Case Study: Day 1 to 3
Admitted to Intensive Care Unit
Admission Labs: Na 135, K 2.9, Glucose 161, BUN
22, Cr 1.1, BNP 452
Admission Vitals: 90/70, 114, 18, 98.0, 96% O2 Sat
Administered intravenous diuretic
ACE Inhibitor held due to low BP
Echo LV 20% RV 30%
Right Heart Catheterization:
Initial - MRA 27, MPA 37, PCW 28, CI 1.5, CO 3.67
Admitted to Intensive Care Unit
Admission Labs: Na 135, K 2.9, Glucose 161, BUN
22, Cr 1.1, BNP 452
Admission Vitals: 90/70, 114, 18, 98.0, 96% O2 Sat
Administered intravenous diuretic ACE Inhibitor held due to low BP
Echo LV 20% RV 30%
Right Heart Catheterization:
Initial - MRA 27, MPA 37, PCW 28, CI 1.5, CO 3.67
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HF Case Study
Day 6: Initiated Milrinone infusions
PO diuretic
Net loss approximately 3.5L/day
Marked improvement in LEE
BP 110-120 systolic
Day 8: PO diuretic discontinued due tohypokalemia, KCL IV given
Day 6: Initiated Milrinone infusions
PO diuretic
Net loss approximately 3.5L/day
Marked improvement in LEE
BP 110-120 systolic
Day 8: PO diuretic discontinued due tohypokalemia, KCL IV given
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Repeat RHC on Day 8
Day 1 Day 8
MRA 27 18
MPA 37 39
PCW 28 31
CO 1.5 2.2
CI 3.7 5.15
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HF Case Study: Day 9 to 15
Transfer from ICU to Floor on Day 13
Functionally improved NYHA class II-IIIBP 113/70, HR 103, Sat 94%
Plan
Milrinone continued at 0.4mg/kg/min
Transplant/LVAD team consult
Transfer from ICU to Floor on Day 13
Functionally improved NYHA class II-IIIBP 113/70, HR 103, Sat 94%
Plan
Milrinone continued at 0.4mg/kg/min
Transplant/LVAD team consult
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Current Medications and Disposition
Discharge Medications:DiaBeta 2.5mg QDMetformin 850 mg BIDAspirin 81mg QD
Coreg 12.5mg BIDHydralazine 10mg TIDIsosorbide 10 mg TIDHydrochlorothiazide 25 mg QDSpironolactone 25mg QD
Torsemide 100mg BIDDigoxin 0.25mg QDLisinopril 20 mg BIDPravstatin 10 mg QDFolic Acid 1mg QD
Multi-vitamin QDPlan for home Milrinone
Finish Heart Transplant and LVAD Evaluation
Return to Advanced Heart Failure Clinic in 1 week
Patient is NYHA II/III and Stage D
Discharge Medications:
DiaBeta 2.5mg QDMetformin 850 mg BIDAspirin 81mg QD
Coreg 12.5mg BIDHydralazine 10mg TIDIsosorbide 10 mg TIDHydrochlorothiazide 25 mg QDSpironolactone 25mg QD
Torsemide 100mg BIDDigoxin 0.25mg QDLisinopril 20 mg BIDPravstatin 10 mg QDFolic Acid 1mg QD
Multi-vitamin QDPlan for home Milrinone
Finish Heart Transplant and LVAD Evaluation
Return to Advanced Heart Failure Clinic in 1 week Patient is NYHA II/III and Stage D