OPTIMIZE-HF In-Hospital Heart Failure Management Algorithm Patient presents with symptoms of heart failure (ACC/AHA Stage C or D) History & Physical (special considerations: HTN, DM, CAD, anemia, infection) Helpful Diagnostic Findings q Elevated jugular venous pressure or positive abdominal jugular reflux q A 3rd heart sound q Laterally displaced cardiac apical impulse q Peripheral edema not due to venous insufficiency q Rales on auscultation q Positive BNP test q Abnormal chest X-ray Assess ECG: Evaluate for ischemia, arrhythmias, wide QRS Labs • Hb • Cr • Na • K Determine left ventricular functional status • BUN Systolic dysfunction Heart failure with (EF < .40) preserved systolic function Determine etiology Restrictive cardiomyopathy Valvular: CAD (angina/ischemia/ Primary previous Hx of CAD) ETOH Consider infiltrative & storage evaluate for surgery cardiomyopathy diseases, HTN, hypertrophic cardiomyopathy Evaluate for revascularization Pharmacologic Management (See “Drugs Commonly Used for Treatment of Chronic Heart Failure,” Below) Complete discharge instructions in all patients including all of the following: a) activity level, b) diet, c) complete list of discharge medications, d) follow-up appointment, e) weight monitoring, f) what to do if symptoms worsen, g) smoking cessation advice/counseling/aid for all smokers Developed by the OPTIMIZE-HF Steering Committee CRG859R0 5 mg qd 2.5 mg bid 10 mg qd 10, 20 mg qd 20 mg qd Trandolapril* 1 mg qd 2, 4 mg qd 4 mg qd *Includes documentation of improved long-term survival and clinical outcomes compared with placebo in patients with HF or PMI LVD Developed by the OPTIMIZE-HF Steering Committee CRG858R0 OPTIMIZE-HF: In-Hospital -Blocker Heart Failure Treatment Algorithm Patient With Heart Failure Diagnosis Patient Selection Criteria All patients with stable heart failure due to Patient Exclusions left ventricular systolic dysfunction, • Systolic blood pressure >85 mm Hg (Based on patient's current clinical status) including those with mild symptoms (for 80-85 mm Hg, use clinical judgment) • Not requiring intravenous therapy with • Cardiogenic or other forms of shock inotropic agents or vasodilators • Signs of systemic hypoperfusion (altered BNP may facilitate Not appropriate • No longer significantly volume mental status, narrow pulse pressure, cold diagnosis for β-blocker overloaded (stable orthopnea, or clammy skin, rising BUN/Cr) therapy until absent JVD, <1+ peripheral edema) • Systolic blood pressure <80 mm Hg exclusion no • In general β-blockers are used (for 80-85 mm Hg, use clinical judgment) longer present together with ACE inhibitors • Significant volume overload (delay initiation until adequately diuresed) • Absolute contraindications: symptomatic bradycardia, 2nd- or 3rd-degree heart block Initiation and Titration For patients who do not without pacemaker, reactive airways disease Patients will generally be started on the initial tolerate in-hospital initiation of starting dose while in the hospital and discharged β-blocker therapy, initiation on this dose.The dose is generally increased at should be re-attempted on an Continuing β-Blocker on Admission 2–4-week intervals until the target dose is achieved. outpatient basis after clinical • Patients hospitalized with decompensated HF, The first dose titration may take place stability is established already treated with β-blocker therapy on the first or second outpatient visit. prior to hospitalization, should continue on β-blocker therapy so long as they are not in cardiogenic shock and do not show signs of systemic hypoperfusion (altered mental Agent Initiation Dosage Titration Steps Target Dosage β-Blockers are status, narrow pulse pressure, cold or β-Blocker therapy should Carvedilol 3.125 mg bid 6.25, 12.5 mg bid 6.25–25 mg bid* typically titrated clammy skin, rising BUN/Cr) not be initiated while the patient Extended-release 25 mg qd a 25, 50, 100, 150 mg qd Max tolerated b on an outpatient • Patients receiving intravenous vasodilators or is receiving dopamine, dobutamine, Metoprolol† up to 200 mg qd basis (q 2 weeks) diuretics may have the β-blocker continued or milrinone infusions Bisoprolol‡ 1.25 mg qd 2.5, 5 mg qd 10 mg qd • In patients who cannot achieve target dosages of the β-blocker, the highest dose tolerated should be maintained above the initiation dosage Note: The ACC/AHA Heart Failure guidelines recommend using only those agents and doses proven to be effective in heart failure. If a patient is on another β-blocker, consider appropriate switching to one shown effective in large clinical trials. a 12.5 mg in more severe patients, one tablet cut in half. Patients with cardiogenic shock b The target labeling dose in the extended-release metoprolol prescribing information is 200 mg. or systemic hypoperfusion should * The target labeling dose in the carvedilol prescribing information is 25 mg bid. A maximum dose of 50 mg bid have the β-blocker has been administered to patients with mild-to-moderate heart failure who weigh over 85 kg (187 lb). discontinued or reduced † Extended-release metoprolol is not indicated for the reduction of mortality alone. ‡ Not FDA-approved for heart failure in US; the dosages above are the recommendation of the OPTIMIZE-HF Steering Committee. Inpatient Monitoring Inpatient/Outpatient Monitoring Blood Pressure and Heart Rate Weight Symptoms Review Concomitant Meds • Should be monitored per standard routine • Daily weights should • Most heart failure • Prescribe lowest diuretic dose that maintains • Notify physician if patient develops be obtained and patients will notice no euvolemia to minimize hypotension symptomatic hypotension and/or recorded while worsening in symptoms • Stagger administration times of hypotensive meds bradycardia patients are with β-blockers (separate administration times of ACE inhibitors) • Dose should be held for SBP <80 mm Hg hospitalized • Most common symptoms if patient experiences hypotensive symptoms (recheck in 1 hour, notify physician) • Patients should be would include increased and β-blockers by at least 4–6 hours • Dose should be held for HR <55 (and reduced instructed to measure fatigue or slight dizziness, • Avoid drugs that adversely affect renal function dose considered) or symptomatic bradycardia and record their weight gain, and and volume retention (e.g., NSAIDs) (recheck in 1 hour, notify physician) weight daily at home bradycardia/heart block • An ARB should not be used with the combination of an ACE inhibitor and β-blocker Developed by the OPTIMIZE-HF Steering Committee. CRG652R0 Pathway Name: Heart Failure Clinical Pathway MD: _________________________________________ beeper: _______ Case Manager: _________________________________ beeper: _______ _____________________________________________ ADDRESSOGRAPH Indicators ED Card/Med Unit Card/Med Unit Card/Med Unit Day 1 Day 2 Day 3 Day 4 Consult/ Heart failure service or Social worker Reassessment by HF Reassessment by HF Evals cardiology consult Dietary nurse coordinator nurse coordinator Heart failure nurse Arrhythmia service (if Ongoing eval and need coordinator indicated) for other consults Assess need for Physical additional consults, therapy/cardiac rehab i.e., renal, GI Advance Directives MD/APN H+P Change diet order per Begin formulating D/C med regimen + Initiate and/or titrate dietitian/RN discharge medication prescriptions meds recommendations regimen Follow-up with PMD/ CAD, HTN, diabetes Echo if previously not cardiology in 1 wk or assessment obtained sooner Reversible causes of Evaluate for Follow-up testing/ heart failure revascularization if consults indicated Discharge note Nursing Tx Cardiac monitor Cardiac monitor Cardiac monitor Cardiac monitor I+O totals q12h I+O I+O I+O Admit weight Daily AM weights Daily AM weights Daily AM weights Diuretics, K dosing Call MD if ↓ UO, Orthostatic BP prior to Orthostatic BP prior to plan hypertension, ambulating pt Q shift discharge arrhythmias Peripheral IV line D/C med schedule to Follow diuretic + K Medication teaching review with patient replacement protocol Patient discharge Initiate medication declaration teaching Encourage early ambulation Diet 2000-mg NA diet 2000-mg NA diet 2000-mg NA diet 2000-mg NA diet Fluid restriction for Fluid restriction for Fluid restriction for Fluid restriction for volume overload volume overload volume overload volume overload Evaluate additional Review discharge diet restrictions for ↑ chol, DM, obesity, etc. Lab/Tests Echocardiogram to Electrolytes, BUN, Cr Chemistry panel, Electrolytes, BUN/Cr document LVEF if not electrolytes, BUN, Cr PT if on warfarin previously done PT if on warfarin BNP (if indicated) CXR, EKG Electrolytes, BUN, Cr, CBC w/diff, PT, PTT, TFTs, Mg, UA, liver function tests, lipid panel Glycosylated Hb (PRN) Glucose BNP Pathway Name: Heart Failure Clinical Pathway MD: _________________________________________ beeper: _______ Case Manager: _________________________________ beeper: _______ _____________________________________________ ADDRESSOGRAPH Indicators ED Card/Med Unit Card/Med Unit Card/Med Unit Day 1 Day 2 Day 3 Day 4 Meds IV diuretics or initiate Begin or titrate ACE ACE inhibitor ACE inhibitor diuretic + K protocol inhibitor maintenance or maintenance or IV nesiritide or IV Evaluate β-blocker titration titration nitroglycerin (if dose (if on prehosp) Begin or continue β- Begin or continue β- indicated) IV diuretics blocker (if stable) blocker (if stable) Digoxin PO (if Digoxin PO (if PO diuretics PO diuretics indicated) indicated) Digoxin (if indicated) Digoxin (if indicated) Heparin 5000 SQ bid, Heparin (PRN) Aldosterone antagonist Aldosterone antagonist or enoxaparin SQ Warfarin (if indicated) (if indicated) (if indicated) Warfarin (if indicated) Antiplatelet agent (if Warfarin (if indicated) Warfarin (if indicated) Antiplatelet agent (if indicated) Antiplatelet agent (if Antiplatelet agent (if indicated) Statin (if CAD, PVD, indicated) indicated) Evaluate ACE CVD, diabetes) Statin (if CAD, PVD, Statin (if CAD, PVD, inhibitor dose (if on Nitrates (if indicated) CVD, diabetes) CVD, diabetes) prehosp) Nitrates (if indicated) Nitrates (if indicated) Evaluate β-blocker Flu shot or Pneumovax dose (if on prehosp) (if indicated) Teaching Heart failure education HF guidelines Diuretic regimen Reinforcement of HF booklet 2000-mg NA diet Exercise programs guidelines 2-qt fluid restriction Reinforcement of HF Discharge instructions Daily weights chart guidelines including activity Smoking/alcohol Formal dietary level, diet, discharge restriction instruction medications, f/u appt, D/C planning, i.e., weight monitoring, follow-up what to do if appointments symptoms worsen Blood tests Expected Verbalizes Verbalizes beginning Verbalizes Verbalizes Outcomes understanding of HF understanding of HF understanding of understanding of diagnostic procedures treatment plan, follow-up with follow-up in HF clinic and plan of care guidelines, and f/u care physicians and w/PMD Achieve relief of Anticoagulation with Written discharge symptoms warfarin if indicated instructions provided, Stable electrolytes, Stable electrolytes, containing all of the BUN, Cr BUN, Cr following: activity Begin anticoagulation Maintain stable weight level, diet, discharge w/ warfarin (if and I+O w/PO medications, f/u appt, indicated) diuretics weight monitoring, Patient and family Verbalizes what to do if aware of D/C plan understanding of 2000- symptoms worsen mg NA diet, 2-qt fluid restriction, daily weights, exercise activity and diuretic regimen Shift RN AM Admit Signature D: D: D: D: N: N: N: N: 1. Diagnosis 2. Care Manager 3. Actual LOS 4. Monitored Days VARIANCE DESCRIPTION If a variance occurs within the Clinical Path, indicate date and variance, describe nature of variance and indicate the code, what action was taken, and an explanation of why it occurred. DATE VARIANCE CODE ACTION TAKEN/EXPLANATION Code Cause Patient System P-1 Recurrent chest pain S-1 Waiting for bed to be available P-2 Arrhythmia S-2 Delay in RHC insertion (procedure room not available) P-3 Hypotension S-3 Service not available on nights P-4 ↑ Creatinine S-4 Service not available on weekend P-5 Worsening hemodynamics S-5 Waiting for test/procedure P-6 Fever/infection/line infection S-6 Waiting for test/procedure results P-7 Hemodynamic instability (requiring CCU transfer) S-7 Waiting for family for D/C P-8 Patient refusal S-8 Delayed D/C P-9 Noncompliant behaviors S-9 D/C earlier than expected Practitioner S-10 Delay in transferring patient to another facility R-1 Waiting for physician S-11 Transferring patient to CCU R-2 Delay in writing orders S-12 Other R-3 Waiting for consult S-13 Delay related to equipment problems R-4 Delay in RHC insertion R-5 Waiting for nursing staff R-6 Waiting for APN CRG652RO Adapted by the OPTIMIZE-HF Steering Committee from the UCLA Medical Center. HEART FAILURE ADMISSION CHECKLIST Patient name: Admit date: Admitting diagnosis: Admitting physician: Designated cardiologist: BRIEF HISTORY: ________________________________________________________________________________ Were the following assessments performed? Y N Initials Date Comments Performed Vital signs Weight taken History taken (for comorbidity) Physical examination (for comorbidity) Medical history taken Allergy history taken Risk stratification (good, fair, guarded) Advance directives Was the following lab work performed? Y N Initials Date Comments Performed 12-lead ECG Echocardiogram/Doppler (MUGA) Chest X-ray INR, PTT Electrolytes, BUN, Cr CBC w/diff, Platelets Cardiac Enzymes (Troponins and/or CK-MB) Liver function tests BNP TFTs, iron, TIBC, RUA (if indicated) Pulse oximetry HEART FAILURE ADMISSION CHECKLIST (PAGE 2) Was the following performed/discussed with the Cont’d D/C Initiated Not Initials Date Comments patient? as Used Before I + O totals Daily weight 2000-mg Na diet Fluid restriction (if indicated) Heart failure patient education sheet Check the appropriate box for each Cont’d D/C Initiated Not Initials Date Comments HF medication. as Used Before ACE inhibitor Angiotensin receptor blocker (if ACEI intolerant or in addition to ACEI) β-Blocker Aldosterone antagonist Loop diuretic Digoxin Supplemental oxygen Electrolyte supplement (K, Mg as needed) Warfarin (for atrial fibrillation) Antiplatelet (CAD, CVD, PVD, diabetes) Statins (CAD, CVD, PVD, diabetes) Diabetes control: Pain control: Antiarrhythmics (specific indications): Other: Other: Other: Were the following interventions or Performed Planned Not Initials Date Comments testing procedures performed/planned? Applicable Performed/ Planned Echocardiography/Doppler Stress testing – pharmacologic or exercise Angiography/catheterization for possible revascularization PCI (PTCA, balloon, stent) CABG Electrophysiology (sudden death risk assessment) • Biventricular pacing • Implantable cardioverter/defibrillator Other cardiac imaging: Were the following secondary prevention Performed Planned Not Initials Date Comments measures performed/initiated? Applicable Performed/ Planned Lipid profile (total C, HDL-C, LDL-C, triglycerides) Blood pressure control Smoker? If yes: smoking cessation booklet and refer to program Diabetic? If yes: HbA1C, glucose, sliding scale insulin Atrial fibrillation? If yes: EP consult, dietitian, anticoagulation clinic Physical therapy/Cardiac rehab Other: CRG856RO Adapted by the OPTIMIZE-HF Steering Committee from the UCLA Medical Center. STANDARD ORDERS for HEART FAILURE Date ______________ Time __________ Intern ________________________ _____________________________ ___________ LAST NAME FIRST NAME BEEPER Resident ______________________ _____________________________ ___________ LAST NAME FIRST NAME BEEPER Attending _____________________ _____________________________ ___________ LAST NAME FIRST NAME BEEPER Patient _______________________ _____________________________ ___________ LAST NAME FIRST NAME MI Etiology ______________________________________________________ Reason for admission New HF Noncompliance, meds Noncompliance, diet (Check all that apply) Volume overloaded Exacerbation of HF Refractory HF Arrhythmias Over-diuresis Other _________________ ACC/AHA Stage C D NYHA Class I II III IV Condition Good Fair Guarded Check/Initial/Date ____/____ Allergies:______________________________________________ ____/____ Diet 2000 mg Na with 1500 cc by mouth fluid restriction 2000 mg Na with 1900 cc (2 quarts) by mouth fluid restriction 2000 mg Na; low cholesterol with _____cc by mouth fluid restriction Other____________________________________________ NURSING ____/____ Vital signs (call House Officer if: SBP <80 or >150; HR <60 or >110; RR <10 or >24; T >38.5°C) ____/____ O2 _____L/min nasal cannula for CP, SOB, SaO2 <93% ____/____ Cardiac monitor ____/____ I+O totals q _____h ____/____ Daily AM weights ____/____ Encourage progressive ambulation LABS ____/____ Echocardiogram/Doppler (document LV ejection fraction) ____/____ Chest x-ray ____/____ Electrocardiogram ____/____ Electrolytes ____/____ BUN ____/____ Creatinine ____/____ CBC w/diff ____/____ PT, PTT (if treated with heparin/LMWH) ____/____ INR ____/____ TFTs (thyroid function tests) ____/____ Lipid panel ____/____ LFTs (liver function tests) ____/____ BNP (B-type natriuretic peptide) ____/____ Troponins (I/T) MEDICATIONS ____/____ IV: Heplock with 3 cc normal saline flush q12h ____/____ ACE inhibitor _________________ mg by mouth q ___ h (hold for SBP <80 mm Hg; use clinical judgment for SBP 80–85 mm Hg, SCr >3 mg/dL), consider ARB if patient is intolerant or if clinically indicated. Initiate/use in-hospital or prescribe at discharge for all patients without a confirmed contraindication (allergy or intolerance, angioedema, hyperkalemia [K >5.5 mEq/L], pregnancy, symptomatic hypotension [SBP <80 mm Hg], bilateral renal artery stenosis). Start at low doses. ____/____ ARB _________________ mg by mouth q ___ h, if clinically indicated. (Hold for SBP <80 mm Hg; use clinical judgment for SBP 80–85 mm Hg). Initiate/use in-hospital or prescribe at discharge for all patients without a confirmed contraindication (allergy or intolerance, angioedema, hyperkalemia [K >5.5 mEq/L], pregnancy, symptomatic hypotension [SBP <80 mm Hg], bilateral renal artery stenosis). Start at low doses. ____/____ β-Blocker _____________ mg by mouth q ____h (hold for SBP <80 mm Hg [use clinical judgment for SBP 80–85 mm Hg], hold for HR <55 bpm and consider reduced dose, hold for worsening volume overload). Initiate/use in-hospital or prescribe at discharge for all patients without a confirmed contraindication (cardiogenic shock, or decompensated HF requiring IV inotropes, severe bradycardia, sick sinus syndrome or 2nd or 3rd degree heart block without a pacemaker in place, reactive airways disease). Start at low HF doses. ____/____ Loop diuretic ____/____ Furosemide _________ mg IV or IVPB now; every _____ hours tabs _____ mg q ___h ____/____ Digoxin __________0.125 mg by mouth daily (if indicated) (modify for renal failure or drug interactions) _________mg by mouth daily ____/____ Aldosterone antagonist __________ mg by mouth daily if clinically indicated (start spironolactone 6.25 or 12.5 mg or eplerenone 12.5 or 25 mg). Contraindication: hyperkalemia, CrCl ≤30 mL/min. ____/____ Warfarin __________mg daily (if indicated) ____/____ KCl _______mEq IV in ________mL of D5W KCl tabs ________ mEq KCl liquid ___________mEq ____/____ Isosorbide dinitrate ________mg by mouth 3 times daily (if clinically indicated) ____/____ Enteric-coated aspirin 81–325 mg by mouth once every morning (if CAD, CVD, PVD, diabetes) ____/____ Statin __________ ___ mg by mouth daily (if CAD, CVD, PVD, diabetes) ____/____ Heparin or LMWH (for immobilized patients) ____/____ Other CONSULTS ____/____ Physical therapy/Cardiac rehabilitation ____/____ Smoking cessation ____/____ Cardiology ____/____ Medical social worker ____/____ Nutrition services ____/____ Electrophysiology CRG854RO Adapted by the OPTIMIZE-HF Steering Committee from the UCLA Medical Center HEART FAILURE DISCHARGE SUMMARY CHECKLIST Patient name: __________________________________________________________________________________________ Discharge date: _________________________________________________________________________________________ Designated cardiologist: __________________________________________________________________________________ BRIEF HISTORY: ______________________________________________________________________________________ Check duration of medication for each agent Were the following discharge Y N Agent Contraindication? Reason for Not Initials medications prescribed? Prescribed Y N Prescribing /Indicate Code Letter/Comments ACE inhibitor ARB (if ACEI intolerant or in addition to ACEI) β-Blocker Loop diuretic Thiazide diuretic Digoxin (if atrial fibrillation or refractory symptoms) Aldosterone antagonist Nitrates (specify PRN, prescribed indef., or both) Warfarin (specify INR in comments) ASA Lipid-lowering agents Other Other Other Were the following interventions and Y N Initials Date Initials Comments counseling measures addressed? Performed Treatment and adherence education Risk-modification counseling (general) Blood pressure controlled Diabetes controlled Smoking cessation recommended Dietitian/nutritionist interview Cardiac rehabilitation interview and enrollment Physical activity counseling Which follow-up services Y N Initials Date Comments were scheduled? Scheduled Cardiologist follow-up Primary care follow-up Cardiac rehabilitation Begins: Stress test follow-up Electrophysiology follow-up Lipid profile follow-up Anticoagulation service follow-up Other Clinical summary and patient education record faxed to appropriate physicians Reasons for Nonprescription of Heart Failure Medicine Code Letter Reason for Not Prescribing A. Creatinine >3.0 mg/dL B. Worsening cough C. GI distress D. Azotemia E. Angioedema F. Severe cough G. K+ ≥5.5 mEq/L H. Symptomatic hypotension I. K+ <3.5 mEq/L J. Symptomatic bradycardia K. Serum Na+ ≤130 mg/dL L. Visual disturbances M. Other rhythmic change N. Altered taste sensation O. Forgetfulness/confusion in taking medications P. Fatigue Q. Rash R. Reactive airways disease S. Second- or third-degree heart block (without pacemaker) T. Dizziness or lightheadedness U. Depression V. Impotence W. Volume overload X. Other CRG849RO Adapted by the OPTIMIZE-HF Steering Committee from the UCLA Medical Center. Your hospital logo/address here Dear Dr _______________________: Your patient, __________________, initially hospitalized for _______________, has been discharged on [date] _____________, following treatment for ________________days for a diagnosis of heart failure. His/her heart failure was of new onset He/she had worsening of existing heart failure This patient’s heart failure admission was caused or contributed to by: Noncompliance, medications Noncompliance, diet Acute coronary syndrome (ACS) Arrhythmias Overdiuresis Other __________________________________________ None of the above Patient’s weight at discharge: _____________________________________________________ The patient underwent the following procedures: ______________________________________ ______________________________________________________________________________ The following medications were initiated or continued during the hospitalization and are recommended to be continued postdischarge: ACE inhibitor ( __________________________) at a dose of ____ mg/(once, twice) daily Angiotensin-receptor antagonist (____________) at a dose of ____ mg/(once, twice) daily β-Blocker ( _____________________________) at a dose of ____ mg/(once, twice) daily Diuretic ( _______________________________) at a dose of ____ mg/(once, twice) daily Digoxin ( _______________________________) at a dose of ____ mg/once daily Aldosterone antagonist ( ___________________) at a dose of ____ mg/once daily Aspirin _____________________________ mg/once daily Other: ________________________________________________________________________ Other: ________________________________________________________________________ It is also recommended that you initiate the following medications for the outpatient: ______________________________________________________________________________ (β-blocker, ACE inhibitor, statin, aspirin, other) The following counseling was provided: β-Blocker uptitration process ACE inhibitor uptitration process Low Na diet Medicine compliance Diuretic use Smoking cessation Daily weights Alcohol reduction Activity level Other_____________________________________ Follow-up counseling is strongly recommended in these areas: β-Blocker uptitration process ACE inhibitor uptitration process Low Na diet Medicine compliance Diuretic use Smoking cessation Daily weights Alcohol reduction Activity level End-of-life Other________________________ The following drugs should be avoided in your patient: NSAIDs and sympathomimetics (over- the-counter or prescription decongestants containing pseudoephedrine). Other recommended follow-up for your patient: Please see your patient in the next 1 to 2 weeks and have his/her fluids and electrolytes checked. In addition, the medications that were prescribed for his/her heart failure at discharge should be reviewed and adjusted as appropriate. In particular, the need for titration of ACE inhibitors, β-blockers, and diuretics should be routinely assessed to obtain target doses and maximize benefits. If you have questions, please contact me at: Telephone ( ) Fax_____________________Voice mail__________________E-mail _____________________ Sincerely, CRG847RO Adapted by the OPTIMIZE-HF Steering Committee from the UCLA Medical Center PATIENT INFORMATION What I Need to Know about Heart Failure WHAT IS HEART FAILURE? Heart failure means that the heart muscle is weakened and does not pump blood normally. In heart failure, the heart is too weak to supply the right amount of blood to all parts of the body. When the heart muscle doesn’t squeeze strongly enough, fluid can back up into the heart and lungs and into other places such as the legs or abdominal (belly) area. This buildup of fluid in the tissues is why heart failure is sometimes referred to as congestive heart failure. When you have heart failure, it means that your heart muscle is weaker than normal. It does not mean that your heart has stopped pumping or beating or has completely failed. WHAT ARE THE SIGNS AND SYMPTOMS OF HEART FAILURE? As a heart failure patient, you may experience some or all of the following: • Shortness of breath • Tiredness, loss of energy • Loss of appetite, abdominal (belly) discomfort • Abdominal bloating (stomach swelling) • Swollen ankles or legs • Rapid weight gain (2–3 pounds over 5 days) • Unable to lie down flat and breathe comfortably WHAT SHOULD I DO IF MY SYMPTOMS WORSEN? If you ever have questions regarding your symptoms or medicines, call your doctor/nurse. In an emergency, call the ambulance or 911 and ask to be taken to the nearest emergency room. You can reach your doctor, ___________________ or nurse, ___________________, with urgent questions at ( ) - after hours. Call your doctor or nurse if you experience any of the following: • Chest pain/pressure or tightness that is new, happens when you are not active (e.g., lying down, watching TV), or if it is more uncomfortable than usual or if it starts happening more often. If you have chest pain, sit down and take nitroglycerin sublingual (under your tongue) 1 pill or 1 spray. If the pressure/pain or tightness is there after 5 minutes, use another pill or spray under you tongue. If the pressure/pain or tightness is still there 5 minutes after you have taken the 2nd tablet or spray, take a 3rd tablet or spray and call 911 or go to the nearest emergency room and notify your doctor/nurse. • Difficulty breathing, shortness of breath at rest (when you are not active) • Dizziness, feeling faint, or passing out • Swelling of the feet, ankles, or lower legs • Strong, fast, or irregular heartbeats • Weight gain of greater than 2 pounds overnight or 3–4 pounds over 5 days • Nausea or vomiting • Severe leg cramping (may be due to a low potassium level in the body) • Decrease in ability to exercise If you ever have any questions regarding your medicines, call your doctor/nurse. You should always tell your doctor or nurse about any medicines you are taking. WHAT ELSE CAN I DO? Fluid Restriction. This is done to reduce the amount of fluid that builds up in your body. You should take in only 2 quarts (slightly less then 2 liters) a day, or even less if you have been having more problems with fluid buildup. This is equal to eight 8-ounce glasses a day. It is important to count all liquids taken in over a 24-hour period including soups, ice cream, yogurt, popsicles, and gelatins. Fruits (e.g., melons and citrus fruits) have a high water content and should not be eaten in large quantities. If you eat a lot of fruit, you need to count this as part of your fluid intake and decrease the amount of fluid you drink. Daily Weight Monitoring. You should monitor your daily weights, or how much you weigh each day. Daily weight monitoring is the best way to see if you are holding onto fluid. If your heart isn’t pumping normally, fluid may start to build up in your body and this will cause you to gain weight. If you eat too much sodium or drink too much fluid, it is likely your weight will go up. It is very important that you weigh yourself each day and write your weight on a weight chart or in a notebook. Daily weight monitoring should be done at the same time every day (for example, in the morning after you use the bathroom, or before you eat breakfast), and wear the same amount of clothing. You should always write your weight down in a notebook or weight chart. Gaining 2 pounds overnight or 3 to 4 pounds in a week is not normal and usually means you have fluid buildup. If this occurs, you should follow the instructions to increase your diuretic (water pill) dose, or call your doctor/nurse and they will make changes in the dose of your water pill, and possibly your potassium dose. Cigarette Smoking. You should stop smoking completely. Smoking increases the risk of heart disease 3–6 times and causes lung damage. Smoking lowers the amount of oxygen in your blood, makes your heart beat faster, makes your blood vessels smaller, and makes your blood pressure higher. Smoking can worsen heart failure, so it is very important you not smoke. Also, you must not smoke in order to be considered for heart transplantation. There are programs to help you stop smoking and medicines that can help you quit. If you are interested in more information about quitting, ask your doctor/nurse. (See Patient Information on Smoking Cessation.) HOW DOES MY DIET HAVE TO CHANGE? Salt. It is recommended you follow a 2000 milligram (2 g) sodium diet. Heart failure patients should take in 2000 milligrams (mg) or less of sodium a day. Salt is about 40% sodium and is one of the top sources of sodium in the average diet. One teaspoon of salt has 2300 mg of sodium. Even a little salt added to foods can make it hard not to go over your daily sodium limit. You should find it easy to adjust to a low-sodium diet if you follow these guidelines: • Do not add salt to your food at the table; instead season foods with black pepper, fresh or dried herbs, garlic, onion, or lemon. Avoid condiments and sauces like ketchup, regular soy sauce, and BBQ sauce. You should also avoid seasonings that have the word salt in their names, such as celery salt, onion salt, and garlic salt. Garlic powder and onion powders do not contain salt. • Buy fresh fruits and vegetables. These do not have added salt. • Avoid preserved or processed convenience foods (e.g., canned food, frozen dinners, or deli food). These usually have added salt. Frozen fresh vegetables without sauces are usually OK to eat. • When eating out, ask that foods be prepared without salt or salty seasonings such as teriyaki sauce, soy sauce, salad dressings, BBQ sauce, or monosodium glutamate (MSG). You should also order the sauces on the side so you can control how much you use. • You may use a salt substitute. However, do not use large amounts of this product because salt substitutes have high potassium content and may change your blood potassium level. • Check with your doctor/nurse before taking other medicines that may contain large amounts of sodium (e.g., Alka-Seltzer, antacids, laxatives). • Be cautious about using foods labeled “healthy” or “lean” or “reduced fat.” Often times, extra salt is added to improve the flavor of “low fat,” “healthy” foods. • Check labels for words that indicate added sodium, e.g., salt, sodium, monosodium glutamate (MSG), sodium chloride (NaCl). These should be avoided as they are all forms of sodium. Be cautious of low-salt/low-sodium products because even products labeled “light,” or “1/3 less” may be high in sodium. See “What Do Food Labels Tell Us?” and “Understanding the Nutrition Facts Panel on Food Labels” (next page) for more information on sodium. In addition to low salt, your doctor/nurse may also recommend that you be on a low-fat, low- cholesterol, or anti-diabetic diet. Ask your doctor, nurse, or dietitian for other instructions regarding a low-sodium and low-fat diet. What Do Food Labels Tell Us? LABEL TERM MEANS EXAMPLES of FOODS Sodium free Less than 5 mg sodium per Crackers serving Very low sodium 35 mg or less sodium per Chips serving Low sodium 140 mg or less sodium per Soup, cereal, crackers serving Reduced or less sodium At least 25% less sodium* Soy sauce, soup, bacon, pretzels, crackers Light in sodium 50% less sodium*; restricted Crackers to foods with more than 40 calories per serving or more than 3 g fat per serving Salt free Less than 5 mg sodium per Herb blends serving Low sodium meal 140 mg or less sodium per Frozen dinner 100 g or 3.5 oz Unsalted or no added No salt added during Peanuts, butter, canned processing; does not vegetable, microwave necessarily mean sodium free popcorn, crackers, breakfast cereals *As compared with a standard serving size of the traditional food Reference: Duyff RL. The American Dietetic Association’s Complete Food and Nutrition Guide. New York, NY: John Wiley & Son; 1998. Understanding The Nutrition Facts Panel on Food Labels. Sample Label for Macaroni & Cheese Nutrition Facts ① Start Here Serving Size 1 cup (228g) (Serving Size) Serving Per Container 2 Amount Per Serving Calories 250 Calories from Fat 110 % Daily Value* Total Fat 12g 18% Saturated Fat 3g 15% Cholesterol 30mg 10% ② Sodium Sodium 470mg 20% Total Carbohydrate 31g 10% Dietary Fiber 0g 0% Sugars 5g Protein 5g Vitamin A 4% Vitamin C 2% Calcium 20% Iron 4% *Percent Daily Values are based on a 2,000-calorie diet. Your Daily Values may be higher or lower depending on your calories needs: Calories: 2,000 2,500 Total Fat Less than 65g 80g Sat Fat Less than 20g 25g Cholesterol Less than 300mg 300mg Sodium Less than 2,400mg 2,400mg Total Carbohydrate 300g 375g Dietary Fiber 25g 30g The Serving Size. Serving Size 1 cup (228g) Serving Per Container 2 (#1 on sample label): The first place to start when you look at the Nutrition Facts panel is the serving size and the number of servings in the package. Serving sizes are provided in familiar units, such as cups or pieces, followed by the metric amount, e.g., the number of grams. Serving sizes are based on the amount of food people typically eat, which makes them realistic and easy to compare with similar foods. Pay attention to the serving size, including how many servings there are in the food package, and compare it with how much you actually eat. The size of the serving on the food package affects all of the nutrient amounts listed on the top part of the label. In the sample label, 1 serving of macaroni and cheese equals 1 cup. If you ate the whole package, you would eat 2 cups. That doubles the calories and other nutrient numbers, including the amount of sodium you would eat. Instead of 470 mg, you would have eaten 940 mg of sodium or almost half of your total limit for the day! The Sodium Content. (#2 on sample label): The best way to cut back on sodium is to cut back on salt, salty foods, and seasonings that contain salt. Reading food labels will help you make low-sodium choices. Alcohol. Alcohol and heart failure are a bad combination. Alcohol damages heart cells and can lead to a further deterioration and weakness of the heart muscle. Even as much as a glass of wine or 1 drink a few times a week can be harmful to your heart. As a general rule, you should not drink any alcoholic beverages. WHAT SHOULD MY ACTIVITY LEVEL BE? It is important that you first discuss this issue with your doctor before starting to exercise. It is recommended that you begin a walking exercise program, but avoid lifting more than 20 lb. Some exercise is good for patients with heart failure and it might help heart failure patients live longer. Exercise may make you feel better, allow you to accomplish more, and make daily routine activities easier to do. How do I start an exercise program? • Discuss with your doctor before starting to exercise • Start slowly. It will take time for your heart, muscles, and bones to build strength. • Start by walking for 5 minutes a day, 6 or 7 days a week. Slowly increase your activity level each week. When 5 minutes of exercising becomes easy to do, increase the time to 10 minutes daily. When 10 minutes becomes easy, increase to 15 minutes daily, etc. • When you get to 30 minutes a day of exercise, you should try to increase the pace by covering a greater distance in the 30-minute time period. • Develop a weekly exercise schedule that works with your daily schedule. • If you miss exercising for a couple of days, you may have to exercise at a lower level for a few days and then work back up to your former level. • Once you are walking 30 minutes a day, you can switch to other activities such as biking or swimming. What About Sex? Sexual activity, like most physical activity, means added work for your heart. Sexual intercourse takes about the same amount of energy as climbing 1 to 2 flights of stairs or walking briskly. The guidelines for sexual activity are the same as for any other exercise you do. Sexual activity should occur in a relaxed environment to reduce the stress on your heart. Try to avoid positions where you support your weight with your arms for long periods. If you are having any sexual difficulties and/or performance problems, do not hesitate to discuss this with your doctor or nurse. HOW OFTEN SHOULD I SEE THE DOCTOR OR GO TO THE HEART FAILURE CLINIC? You should have a follow-up appointment with your doctor within 14 days of being discharged from the hospital with heart failure. You should make sure that you have appointments scheduled with your doctor before you leave the hospital. If you miss an appointment, make sure to reschedule. You should keep taking the medicines to treat your heart failure. These medicines can greatly improve how well you do. It is important that you follow up with your doctor/nurse and keep using the medicines that will help you—they may have been started while you were in the hospital. Two of the major reasons patients are readmitted to the hospital are that they did not continue to take their heart medicines or did not follow a low-salt diet. • Follow your doctor/nurse’s advice • Take your medicines the way your doctor or nurse has told you • Eat a low (2000-mg) sodium diet, restrict your fluid intake, keep a healthy body weight • Keep your doctor appointments • Monitor your weight, keep a record of your daily weighings (how much you weigh each day) • If you smoke, stop. Stopping smoking completely is advised • As a general rule, you should not drink any alcoholic beverages HOW CAN I LEARN MORE? Talk to your doctor, nurse, or health care professional. The Heart Failure Society of America has a website, www.hfsa.org/hf_modules.asp, containing a series of programs designed to help patients, their loved ones, and individuals at risk for heart failure to communicate better with their doctor or nurse. Also, call the American Heart Association at (800) 242-8721 to get local chapter information. The American Heart Association also has a web site you can visit: www.americanheart.org/chf. CRG652RO Adapted from the UCLA Medical Center in collaboration with the OPTIMIZE-HF Steering Committee. PATIENT INFORMATION What I Need to Know About Smoking Cessation WHAT IS THE PROBLEM WITH SMOKING? Smoking increases your risk of diseases, including: heart disease, heart attack, heart failure, stroke, lung disease, and cancer. Smoking damages blood vessels making it more likely for the arteries to become blocked. Smoking makes your blood thicker and as a result, makes you more likely to form clots in your arteries. Once you have heart disease or damage to your blood vessels, it is very important that you find a way to quit smoking. If you have had a heart attack and continue to smoke, you are up to 5 times more likely to die than if you had quit smoking. If you have a balloon angioplasty or bypass surgery and continue to smoke, you are more likely to continue to have chest pain, more likely to need another surgery, and more likely to die, than if you had quit smoking. Once you have lung disease, you are at much greater risk of infection, heart failure, and death, if you continue to smoke. WHAT CAN I DO TO PREPARE TO QUIT SMOKING? Be determined to quit smoking Decide positively that you want to quit. Committing yourself right now puts you on a path to success. Make a list of all the reasons why you want to stop. Carry these reasons with you and read them several times a day. Figure out what makes you smoke. Being more aware of your triggers and cues (things that make you want to smoke) for smoking will help you to avoid the triggers while you are trying to quit. Tell your family and friends that you are quitting and get their support. Think of personal rewards for quitting smoking. Begin thinking of what your life will be like as a nonsmoker. Think about how much healthier your heart and lungs will be, how much better you will feel in the long run, and how much longer you’ll be likely to live. Throw away all of your tobacco, lighters, ashtrays, and other smoking-related products as soon as you get home. You also may ask a family member or friend do this before you arrive home. Clean your clothes, car, drapes, and furniture to get rid of the smell of smoke. Stay away from other tobacco users and other tempting situations (for example, drinking alcohol). Do something special that you’ve been putting off. It will help you associate positive feelings with quitting smoking. HOW CAN I PREPARE TO AVOID URGES TO SMOKE? Spend more time with friends who do not smoke. Find activities that make smoking difficult (for example, gardening, exercising, washing the car, and going to the movies or other places where smoking is not allowed). Keep healthy snacks and substitutes handy that you can use when you have the urge to smoke. Try carrots, sunflower seeds, sugarless gum, straws, toothpicks, or apples. Change your daily routine to break your old habits. Distract yourself from thoughts of smoking by talking to someone, reading, or doing a task. Use relaxation techniques such as deep breathing, yoga, or exercising. HOW CAN I HAVE THE GREATEST CHANCE OF SUCCESS? Enrolling in a program that helps people who are trying to stop smoking offers you the best chance of success with quitting. Quitting success rates are the highest when nonsmoking activities are combined. Helpful activities include the following: • Physician advice • Self-help materials • Behavioral counseling • Self-management techniques • Support groups • Nicotine replacement therapy (nicotine patches or gum) • Medicine that reduces the urge to smoke • Follow-up with your health care provider WHAT SHOULD I DO IF I RELAPSE AND BEGIN SMOKING AGAIN? Try to get some help, especially by talking to someone about your situation and why you started smoking again. Get rid of all tobacco products. Don’t be too hard on yourself. Get yourself back on track as soon as possible. Remember that most people try several times before they successfully quit. Identify the triggers and cues that led you to smoking again and learn from your past mistakes. Set a new quit date and begin again. WHERE CAN I GET ADDITIONAL HELP? • SmokEnders offers home-study package for $125: 7-week audiotape, workbook course with counseling line. Call 800-828-4357 or learn more online at www.smokenders.com (site accessed October 7, 2002). • The American Lung Association’s 8-session Freedom From Smoking program costs $75 to $150 (depending on location). Call 800-LUNG USA or 212-889-3370, or learn more online at www.lungusa.org. A new Freedom from Smoking Online program is available for free at www.ffsonline.org (site accessed on October 7, 2002). • The American Cancer Society provides a variety of quit-smoking programs. Call the nationwide office 800-ACS-2345 or write: American Cancer Society, 1599 Clifton Road NE, Atlanta, GA 30026 for information about programs within your local ZIP code area. Information from the American Cancer Society can also be found online at www.cancer.org (site accessed October 3, 2002). • Nicotine Anonymous: 800-642-0666 or 213-476-1161; www.nicotine-anonymous.org (site accessed October 3, 2002); ongoing support group; no dues or fees. • The Mayo Nicotine Dependence Center’s week-long stop-smoking program costs $3,560. Call 800-344-5984 or find information online at www.mayoclinic.org/ndc-rst (site accessed October 7, 2002). • The following websites contain useful information on smoking cessation and smoking- related diseases: Centers for Disease Control and Prevention at www.cdc.gov/tobacco (site accessed October 3, 2002) and the World Health Organization at www5.who.int/tobacco (site accessed October 7, 2002). CRG652RO Adapted by the OPTIMIZE-HF Steering Committee from the UCLA Medical Center. Aldosterone Antagonist: Patient Information Sheet Your doctor has prescribed ____________________, a medicine also known as an aldosterone antagonist. USES These medicines have several uses. Your doctor has prescribed it for you because you have heart failure. They work by blocking the effects of a chemical in your blood called aldosterone. Aldosterone worsens the symptoms of heart failure and may even damage the heart muscle over time. These medicines can also be used to treat high blood pressure, but with a very different dosing schedule. These medicines are different from diuretics like furosemide because they do not cause potassium loss. DIRECTIONS FOR USE Dosing You should ALWAYS take this medicine EXACTLY as your doctor has prescribed. The dose may vary depending on other medications you are taking for heart failure. When to Take Your Medicine You should take your medicine at the same time each day. This will help you to remember to take it. You may take this medication with or without food depending on your preference. What to Do if You Miss a Dose of the Medicine If you miss a dose of the medicine, you may take it as soon as you remember it, as long as it is not too close to the time for the next dose. A good rule of thumb is if it is more than half way through the dosing interval, then wait until the next dose is due. You should NEVER double up or take extra doses of a medicine, unless instructed by your doctor. POSSIBLE SIDE EFFECTS OF ALDOSTERONE ANTAGONISTS Dizziness, breast tenderness, development of breast tissue in men (gynecomastia), and high potassium are some of the common side effects of these medicines. Your doctor may check blood work on a regular basis to monitor the potassium level. PRECAUTIONS These medicines may cause you to feel dizzy when you get up from a sitting or lying position. Remember to stand up slowly; this will make you feel less dizzy and will help you avoid falls. Be sure to tell your doctor if you are taking ACE-inhibitors, angiotensin-receptor–blockers, potassium-sparing diuretics, potassium supplements, or salt substitutes. If you were previously taking potassium supplements, you may no longer need to take them, or you may need a lower dose once you start taking an aldosterone antagonist. It is very important to tell your doctor of all the medicines you are taking. Before you take an over-the-counter medicine (medicines you can buy without a prescription), you should always ask your doctor or pharmacist whether you can take it with your other medicines. Make sure you always inform ALL your doctors and other health care providers of ALL the medicines you are taking, including nonprescription medications and other food or herbal supplements. This information will help your doctor avoid prescribing drugs that interact with each other. Please consult your doctor or pharmacist for more information on this medication. CRG652RO Adapted by the OPTIMIZE-HF Steering Committee from Duke University Medical Center.