Heart Failure, Admission for (Order Set)
Heart Failure, Discharge for (Order Set)
Heart Failure, Emergent Orders for (Order Set)

Scope and Target Population:
The management of adult patients age 18 and older with suspected heart failure and heart failure requiring hospitalization.

Clinical Highlights and Recommendations:

• 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.
  
• After evaluation, diagnosis and initiation of pharmacologic and non-pharmacologic management of heart failure, follow-up in the ambulatory setting should focus on optimizing pharmacologic and non-pharmacologic therapy and preventing heart failure exacerbations. Patient education is central in this effort.
  
• Daily weights are critical for managing heart failure and early detection of increases in fluid retention. Patients should call their provider about a two-pound or greater weight gain overnight or a five-pound or greater weight gain in a week.
  
• Unless specific contraindications exist, treat all patients, including Class IV patients, with beta-blockers, starting with a low dose and titrating upward. Do not unnecessarily reduce or discontinue beta-blockers in severe or decompensated heart failure. After fluid overload and hypotension are corrected and when only one drug can be initiated, beta-blockers are preferred.
  
• Treat all patients with left ventricular systolic dysfunction with ACE inhibitors (or ARBs if intolerant) unless specific contraindications exist, such as intolerance or adverse reactions to ACE inhibitors, serum potassium greater than 5.5 mEq/L, symptomatic hypotension, severe renal artery stenosis or pregnancy. Gradually titrate dose up over a two- to three-month period.
  
• Consider treatment with aldosterone antagonists for Class III and IV heart failure patients with appropriate follow-up.
  
• Consider early specialty referral for patients with ischemia or those who are refractory despite optimal medical therapy.
  
• Brain natriuretic peptide (BNP) and proBNP is useful in the diagnosis and prognosis of heart failure in patients with dyspnea of unknown etiology.
  

Priority Aims:

1. Decrease the readmission rate within 30 days of discharge following hospitalization for heart failure.
   
2. Optimize the pharmacologic treatment of adult patients with heart failure.
   
3. Improve the use of diagnostic testing in order to identify and then appropriately treat adult patients with heart failure.
   
4. Improve care of adult heart failure patients by assuring comprehensive patient education and follow-up care.

Additional Background:
Facts about congestive heart failure:

1. 3,000,000 patients in the United States have HF.
   
2. 15,000,000 patients worldwide have HF.
   
3. Approximately 400,000 are diagnosed with HF each year in the United States.
   
4. It is the most common discharge diagnosis in patients age 65 and older.
   
5. Approximately 200,000 HF-related deaths occur each year in the United States.
   
6. Population demographics suggest these figures will continue to increase.

The guideline follows closely the Agency for Health Care Policy and Research (AHCPR) Heart Failure guideline. The only significant deviation is we recommend assessment of left/ventricular (LV) function earlier.