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Heart Failure
A Concise Clinical Guideline for Providers

THESE GUIDELINES ARE NOT INTENDED TO SUBSTITUTE CLINICAL JUDGMENT

STAGE: NEW YORK HEART ASSOCIATION CLASSIFICATION

Class II:
Class III:
Symptoms with less than ordinary activity Class IV:
CHF DISCHARGES
Follow up within 7 days
KEY ASSESSMENT PARAMETERS
Clinical
Medications (prescription/OTC) and compliance, diet, weight, and BMI Laboratory:
CBC, electrolytes, BUN/creatinine, fasting glucose, glycohemoglobin, lipid profile, liver and thyroid function tests, urinalysis, HIV and Ferritin, NT pro BNP on admission, discharge and then only
if indicated to assist in assessment of fluid volume
Imaging / other:
Echocardiogram, electrocardiogram, chest x-ray (PA/lateral). Monitor for symptoms of
depression. Evaluation for CAD/ischemia as indicated. Consider cardiopulmonary exercise
testing for baseline, to discriminate between pulmonary vs cardiac dyspnea or timing for
LVAD or OHT.
KEY COUNSELING AND EDUCATIONAL INTERVENTIONS
Activity level:
Aerobic exercise is to be encouraged as tolerated, 30 minutes, 3-5 times per week. Weight training, exercise during exacerbations, should be discouraged. Emphasize salt restriction. Provide examples of foods with high and low salt content. Encourage label reading and < 2000 mg sodium per day. Fluid restriction should be considered in setting of hyponatremia or diuretic resistance. Follow up:
Patients should keep appointments, even when feeling well, and have a number to be able to Medications:
Encourage compliance, even when feeling well. Patients should bring medications to healthcare appointments and encounters. Encourage patients to call if experiencing any side effects (do
not stop on own). Automatic Brown Bag Clinic appointment for all HF discharges.
Signs and
Patients should call you for increased shortness of breath, chest pain, syncope, a 3 pound weight
symptoms:
increase within 3 days, an increase in ankle swelling, or abdominal bloating.
If applicable, smokers should be advised to quit. NY State Quitline: 1-866-NYQUITS (1-866-697- cessation:
Patients should monitor their weight daily and bring a record to appointments. Identify an ideal monitoring:
KEY PREVENTIVE INTERVENTIONS
Influenza vaccine:
Pneumococcal vaccine:
Control hypertension and hyperlipidemia, avoid alcohol/illicit drugs INDICATIONS FOR CONSIDERATION OF REFERRAL
Cardiology
Defibrillator* candidate: History of ventricular fibrillation/tachycardia, or Class II/III with EF < 35% on optimal therapy Cardiac resynchronization* candidate: EKG QRS > 0.12 seconds, EF < 35%, and NYHA functional class III or ambulatory class IV symptoms despite recommended, optimal medical therapy, or for patients chronically RV pacer dependent. Patients with LBBB, QRS >150ms,
NYHA II.
Marked symptoms at rest despite optimal therapy: may be candidate for inotropic therapy,
mechanical circulatory support, or heart transplantation. Hypotension limiting medication titration
or having to back off on medications, worsening renal function, more than one admission for acute decompensate Heart Failure in a year. Home Care
Medical factors: Multiple medications, multiple medical problems, dementia, psychiatric history, substance abuse Functional factors: Needs assistance with activities of daily living, history of non-compliance, poor
MEDICAL THERAPY (Not an exhaustive list)
For classes of agents below shown to improve survival (*), the goal is to achieve the maximal daily dose, as
tolerated

GENERIC
TRADE
INITIAL DOSE
TARGET TOTAL DAILY DOSE
Angiotensin
Indication:
Converting Enzyme
Inhibitors* (ACE-I)
Beta-Blockers*
Indication:
Initiate and titrate when clinically stable. Titrate every 4-8 weeks. 25 mg twice per day (50mg bid for wt>
85kg)
80mg once per day
Toprol XL
Aldosterone
Indication:
NYHA Class II, III and IV patients with decreased left ventricular EF Antagonists*
Start after ACE-I and beta-blocker. Use only if creatinine < 2 and potassium < 5. Closely follow creatinine/potassium. Diuretics
Indication:
Angiotensin II
Indication:
ACE-I intolerant with decreased left ventricular EF Receptor Blockers*
If patient is receiving an ARB for other indications, it may be used as first line Other Agents
Indicated for atrial fibrillation, consider if EF < 30% or large LV 75 mg three times per day 40 mg three times per day useful in AA patients already on ACE-I and BB or any patient intolerant to ACE-I Calcium channel blockers (Those
with negative inotropic effects)
*Intervention has been shown to improve survival in HF patients with LV systolic dysfunction
Adapted from:
Diagnosis and Management of Chronic Heart Failure in the Adult. American College of Cardiology and American Heart Association. August 2009.
Executive Summary: Heart Failure Society of America 2010 Comprehensive Heart Failure Practice Guideline. 2010

Source: http://www.cmocares.org/documents/diagnostic-guidelines/stroke-and-heart/2013HFClinical-guidelines_Pharm-doc_final.pdf