Heart failure guidelines can help in managing heart failure. Heart failure is a condition identified by numerous co-morbidities, poor life quality, regular hospitalization and high rates of mortality. Consequently, the management of the condition by making use of the heart failure guidelines involves a multifaceted therapeutic treatment, in addition to a multidimensional evaluation process. Knowledge concerning the treatment and pathophysiology of heart failure keeps on accumulating swiftly. This makes it difficult for autonomous specialists to adequately and readily produce new information into efficient standards of care for their patients. Even though trial data is valuable and available, it does not provide enough direction for the management of individual patients.

Heart Failure Guidelines

Heart Failure Guidelines- Diagnosis of Heart Failure

Heart failure guidelines can help in the diagnostic procedure. In the diagnosis of heart failure, the medical history of the patient is very important. For patients that have familial or personal history of peri-partum (women), chemotherapy, coronary artery disease and hypertension, the risk is higher that they have heart failure. The main symptoms of the disease include palpitations, orthnopea, body and ankle swelling, fatigue and breathlessness.

 

Heart Failure Guidelines- Descriptive Measures for Heart Failure

Heart failure guidelines can help in creating descriptive measures for heart failure. It includes:

  1. Age: Patients may be classified according to their age.
  2. Gender: Patients may be classified according to their gender.
  3. Diagnosis: The diagnosis may also be used as a mode of classification.
  4. Heart failure measure free of defects: This measures the performance of a hospital in the provision of interventions to a particular patient.
  5. Heart failure composite measure: This measures how able the hospital is to provide appropriate interventions that are based on evidence.
  6. Race: Patients may be classified by hispanic ethnicity or race.
  7. Readmission rate: This is the percentage of index occurrences in which the patient is readmitted.

Heart failure guidelines help in managing heart failure. The vision of heart failure is complex and constantly changing and there is accumulation of heart failure therapy that is based on evidence. Given these factors, the clinician cannot simply depend on observation and their personal experience to guide their decisions on which therapy to use. Heart failure is now classified as a chronic disease and this fact further frustrates the position of the clinician. The result of the decisions taken by the clinician may not be obvious for many years, owing to the chronic status of heart failure.

Heart Failure Guidelines- Descriptive Measures for Heart Failure

It is also hard to generalize cases since the prognosis and histories of each patient differ significantly. It is possible that treatment may fail to significantly alleviate the symptoms of heart failure while at the same time delaying its progression. It may also delay the occurrence of death and morose events. The evaluation of certain therapeutic results is made difficult by the possible differential effect of a variety of co-therapies.

Heart failure is a perfect subject to develop practice guidelines (Heart Failure Guidelines) for since it is highly prevalent and complex, and there are various therapeutic options.

Heart Failure Guidelines- Physical and History Examination

The American Heart Association and the American College of Cardiology Foundation highlight several Heart failure guidelines useful in managing heart failure. Patients with heart failure should undergo a rigorous physical and history test so as to discover non-cardiac or cardiac behaviors or disorders that may encourage the progression or development of heart failure. Patients suffering from idiopathic DCM (dilated cardiomyopathy) should undergo an exam to determine their family history for 3 generations so as to help in determining the verdict of familial DCM.

For each encounter with the patient, the vital signs and volume status should be evaluated. These include the existence of peripheral orthopnea or edema, approximation of pressure in the jugular vein and successive weight evaluation.

Heart Failure Guidelines- Risk Scoring

Heart failure guidelines suggest risk scoring. In the estimation of ensuing mortality risk in hospitalized or ambulatory patients suffering heart failure, it may be useful to use certified multivariable risk scores.

Heart Failure Guidelines- Diagnostic Exams

Heart failure guidelines can help in creating diagnostics exams. Preliminary diagnostic examinations for patients exhibiting symptoms of heart failure should comprise thyroid-stimulating hormone, liver function exams, fasting lipid profile, glucose, serum creatinine, blood urea nitrogen, serum electrolytes such as magnesium and calcium, urinalysis and blood count. If it has been indicated, serial monitoring should comprise renal function and serial monitoring. All patients showing symptoms of heart failure should undergo a 12-lead echocardiogram. It is also reasonable to screen for HIV or hemochromatosis. Also reasonable are diagnostic exams for pheochromocytoma, amyloidosis and rheumatologic diseases, in case the doctor suspects their presence.

Outpatients

For outpatients who have dyspnea, it would be useful to measure the NT-proBNP (N-terminal of the prohormone brain natriuretic peptide) or BNP in order to support decision making by doctors concerning heart failure diagnosis. This is especially necessary in the event that there is clinical uncertainty. Measurement of NT-proBNP is important for developing disease seriousness or prognosis in chronic heart failure. Heart failure guidelines by these tests is necessary in the achievement of GDMT optimal dosing in certain clinically euvolemic patients. This is possible if follow-up is done a heart failure management program that is well-structured.

However, the importance of successive measurement of NT-proBNP and BNP in the reduction of mortality or hospitalization of patients has not yet been properly determined. It may also be necessary to consider exams that are clinically available including fibrosis, biomarkers of myocardical wounds for preservative risk stratification in these patients.

Hospitalized Patients

In cases where diagnosis is uncertain, it is necessary to measure NT-proBNP (N-terminal of the prohormone brain natriuretic peptide) or BNP as support of clinical decision for the identification of extremely decompensated heart failure.

Noninvasive Cardiac X-Ray

An X-ray should be undertaken in patients who seem to have heart failure in order to determine pulmonary congestion and the size of the heart. The X-ray is also useful in determining whether there are other diseases that may be causing the symptoms such as pulmonary and cardiac diseases. During the patients' earlier assessment, a 2-D echocardiogram should be done with Doppler. This is necessary to evaluate ventricular function, the thickness and motion of its walls, valve function and size.

Heart Failure Guidelines- Invasive Assessment

It would also be reasonable to perform non-invasive imaging on the patients showing signs of heart failure. This is necessary to identify viability and myocardial ischemia. The evaluation of viability is also reasonable under specific conditions when setting up revascularization of patients with CAD (Coronary Artery Disease). Volume and LVEF can be examined by magnetic resonance x-rays or radionuclide ventriculography. Measuring of LV function on a routine basis should not be performed if there are no treatment interventions or clinical status changes. When evaluating scar burden or myocardial infiltrative procedures.

For patients that have respiratory distress, invasive hemodynamic observations should be done with a catheter through the pulmonary artery. This method should also be used where clinical evidence is available that points to impaired perfusion and the intra cardiac filing pressures are impossible to establish from clinical evaluation.

This monitoring is necessary for patients that exhibit unrelenting symptoms in spite of the empirical modification of standard therapies. It is also necessary for the following patients:

  • Those in need of consideration for transplantation or MCS (Mechanical Circulatory Support).
  • Those in need of parenteral vasoactive agent.
  • Those with consistently low systolic pressure, in spite of initial therapy.
  • Those with uncertain pulmonary or systemic vascular resistance, perfusion or fluid status.
  • Those whose renal action is getting worse despite therapy.

When it is apparent that a contributing factor to heart failure is ischemia, then it is reasonable for conduct a coronary arteriography for eligible patients. In case there is a specific judgment that could potentially affect therapy, then endomyocardial biopsy would be necessary.

It is not advisable to use invasive hemodynamic observation on patients that have congestion with symptomatic reaction to vasodilators and diuretics and severe decompensated heart failure. During routine assessment of heart failure patients, endomycardial biopsies must be avoided.

Management of Heart Failure

The management of heart failure is necessary for the following purposes:

  1. To extend survival
  2. To lower necessity for hospitalization
  3. To enable patients to feel better

Prevention of hospitalization of heart failure patients is beneficial to the patient, as well as the healthcare system.

Stages A to D: Treatment

Stage A Treatment

Lipid and hypertension disorders ought to be managed according to contemporary guidelines. This will help to lower the danger of heart failure. Cardiotoxic agents such as use of tobacco, diabetes mellitus and obesity ought to be avoided or managed as they can lead to heart failure.

Stage B Treatment

ACE inhibitors ought to be used in patients that have a distant history of ACS, reduced EF (Ejection Fraction) or MI (myocardial infarction). This is in order to reduce mortality and prevent symptomatic heart failure. ARBs should be used for patients that cannot tolerate ACE inhibitors. Also, in order to reduce the chances of death, beta blockers based in evidence should be used. Statins ought to be used for patients that have a distant or recent history of ACS (Acute Coronary Syndrome) in order to stop cardiovascular occurrences and symptomatic heart failure.

Patients that have structural cardiac anomalies such as LV hypertrophy should have their blood pressure monitored according to clinical practice procedures for high blood pressure. This is, also, in order to stop symptomatic heart failure. Even without a history of MI, beta blockers ought to be used to stop symptomatic heart failure in patients with reduced EF.

An ICD should be placed in patients who have ischemic cardiomyopathy without exhibiting symptoms that are 40 days beyond MI, on suitable medication, have sensible survival expectation and have 30% or less LVEF. This is in order to prevent the risk of sudden death.

Stage C Treatment

These are non-pharmacological strategies. Patients that have had heart failure ought to be taught specific ways of taking care of themselves. They are also advised to engage in exercise so as to improve their functionality. In order to limit congestive signs, patients are advised to reduce their sodium intake.

In order to improve functionality and raise LVEF of those with sleep apnea and heart failure, it may be beneficial to undertake constant positive airway pressure. In heart failure patients that are clinically stable, it may be useful to go through cardiac rehabilitation so as to improve functionality, mortality, HRQOL (Health-related quality of life) and duration of exercise.

The Pharmacological Treatment For Stage C Is As Follows:

These include diuretics, ACE inhibitors and ARBs. ARBs (Angiotensin II receptor blockers) are necessary in the reduction of mortality and morbidity. They can be used as first-line treatment instead of ACE inhibitors for patients with heart failure.

Hypertension

Hypertension or high blood pressure is linked with the danger of developing heart failure. In order to reduce this risk, it would be advisable to undergo antihypertensive therapy. It significantly reduces the chances of heart failure. The exception in this case is alpha-adrenoceptor blockers. Hypertensive patients with heart failure should not be treated with verapamil and diltiazzem (negatively inotropic CCBs). Also to be avoided in this case is moxonidine because it is linked to increased mortality. Blood pressure should be controlled with ARBs, ACEIs, diuretics, MRA. In the absence of these, the clinician can select from felodipine, amlodipine or hydralazine.

Heart Transplantation

This is acceptable as treatment in the last stages of heart failure. Despite the lack of controlled trials, there is evidence that transplants result in higher chances of survival, greater capacity to exercise, better quality of life and ability to get back to work sooner. There is, however, the challenge of shortage of donors and complications of the long term immunosuppressive therapy after the surgery. These include coronary artery vasculopathy, malignancy, renal failure, hypertension, infection and antibody rejection.

Exercise Training

There have been meta-analyses and systematic reviews that suggest that exercise training and the resulting physical condition lead to a better quality of life for patients with heart failure. It also reduces the rates of hospitalization and increases tolerance to exercise.

Multidisciplinary Programs for Management and Organization of Care

Heart failure needs to be managed using heart failure guidelines in order to offer a flawless care system that embraces the hospital, as well as the community. This ensures optimal management of all patients with heart failure, from the start to finish of their journey to recovery.

The achievement of this objective should be incorporated in the general provision for those with heart failure. Services under this provision include palliative care and cardiac rehabilitation.

There are multidisciplinary programmes of management that are essential for the delivery of this care package. These programmes are intended to improve results through prearranged follow-up with the education of patients, better access to care facilities, psychosocial support and maximization of medical treatment.

Determination of Quality and Achievement Measures

Quality and achievement heart failure guidelines are useful for the evaluation and improvement of treatment interventions for patients with heart failure. The formulation of such measures has to start with a profound understanding of heart failure guidelines which have been discussed here.

Achievement measures are useful because they increase the urgency of translation into practice of valid clinical evidence. Hospitals have to stick to achievement measures if they are to earn recognition for achievement.

Quality measures are applicable to aspect and procedures of care that have a lot of support from science. The indication of these measures, however, is not as globally specified as measures of achievement. The achievement and quality measures are set by Get with the heart failure guidelines. This is an initiative by the American Heart Association to improve quality of care for patients with heart failure.

Achievement Measures for Heart Failure

Achievement measures in heart failure guidelines include:

  • Measurement of left ventricular function- this refers to the percentage of patients with heart failure documented in the hospital to have had their LVF assessed at one point; whether before they arrived at the hospital, while they were hospitalized or will be done after they are discharged.
  • ARB/ ACEI (angiotensin-converting enzyme inhibitor) during discharge- refers to the percentage of patients with heart failure that were prescribed an ARB or ACEI when they were being discharged.
  • Appointments after discharge for patients with heart failure- refer to the percentage of patients with heart failure for whom a follow-up visit was scheduled after their discharge from the hospital.
  • Particular beta blockers (evidence-based)- this refers to the percentage of patients with heart failure that were given prescriptions for beta blockers such as Carvedilol at the time of discharge from the hospital.

Quality Measures for Heart Failure

Quality measures in heart failure guidelines include:

  • DVT prophylaxis or Deep Venous Thrombosis Prophylaxis refers to the percentage of non-ambulatory heart failure patients that get DVT prophylaxis by the second day at the hospital.
  • ICD counseling is the percentage of patients with heart failure and Left ventricular ejection fraction or LVEF, no contraindications or acknowledged intolerance that were provided with ICD counseling.
  • Aldosterone antagonist refers to the percentage of patients with heart failure that have left ventricular systolic dysfunction or LVSD and no documented intolerance or contraindications that were given prescriptions of aldosterone antagonist at the time of discharge.
  • Anticoagulation in the case of atrial flutter refers to the percentage of patients with recurrent atrial flutter that were prescribed, at the time of discharge, an anticoagulation therapy.
  • Hydralazine nitrate refers to the percentage of black patients with heart failure and LVSD with no documented intolerance or contraindications that were prescribed isosorbide dinitrate and hydralazine during discharge.
  • Vaccination for influenza in flu season.
  • Pneumococcal vaccination.
  • Follow-up within 7 days.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: May 27, 2016

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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