Guideline Summary

Revision Date: July 2013
Thirteenth Edition

Scope and Target Population

The scope and target population of this document focuses on the adult patient age 18 years and older with suspected heart failure. This includes the diagnosis and outpatient management of the patient. Consideration will also be made to reducing all-cause readmission rates to the hospital for patients who had been previously hospitalized with an exacerbation of heart failure.

Aims

1. Decrease the readmission rate for patients 18 years and older with heart failure diagnosis, within 30 days of discharge following hospitalization for heart failure.
2. Increase the rate of heart failure patients 18 years and older who receive optimum evidence-based pharmacologic treatment with heart failure.
3. Improve the use of diagnostic testing in order to identify and then appropriately treat adult patients with heart failure.
4. Increase the rate of heart failure patients age 18 years or older who have comprehensive patient education and follow-up care.

Clinical Highlights

• Evaluate patients presenting with heart failure for exacerbating and underlying causes, including coronary artery disease, hypertension, valvular disease and other cardiac and non-cardiac causes.
• Studies show that the distinction between systolic dysfunction and preserved systolic function is important, because the choice of therapy may be quite different and some therapies for systolic dysfunction may be detrimental if used to treat preserved systolic function.
• Daily weights are critical for managing heart failure and early detection of increases in fluid retention. Patients should call their clinician about a two-pound or greater weight gain overnight or a five-pound or greater weight gain in a week. Patients can expect the clinician to assess symptoms, adjust diuretics if appropriate, discuss dietary sodium compliance/restriction, review treatment plan, and recommend appropriate level of care (office visit, ER, etc.)
• Unless specific contraindications exist, treat all patients with beta-blockers, starting with a low dose and titrating upward.
• Treat all patients with left ventricular systolic dysfunction with ACE inhibitors (or ARBs if intolerant) unless specific contraindications exist.
• Consider early specialty referral for patients with ischemia or those who are refractory despite optimal medical therapy.
• Brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NTproBNP) are useful in the diagnosis and prognosis of heart failure in patients with dyspnea of unknown etiology.
• For patients self-described as African Americans who have moderate-to-severe symptoms on optimal therapy with ACE inhibitors, beta-blockers and diuretics, the combination of hydralazine and nitrates is recommended because the combination has resulted in significant benefit to the group in randomized controlled trials.