NW YORK HEART AS

7/25/2019 NW YORK HEART AS

1/17

Planning

Determine Patients Clinical Status

New York Heart Association (NYHA) functional class

ACC/AHA stage

Integrate assessment findings into plan of care

When determining care plan objectives, consider

patient acuitycare setting

clinical status (e.g., co-morbidities and prognosis)

patient preferences

etiology of heart failurepsychosocial and economic factors

Prioritize implementation of the plan of care based on assessment findings

and clinical status (e.g., history, signs and symptoms, test results,pathophysiology)


2/17

NYHA Classification

Class

I

Ordinary physical activity does not cause undue

fatigue, palpitations, dyspnea and/or angina

Class

II

Class

III

Class

IV

Ordinary physical activity does cause undue


Less than ordinary physical activity causes undue


Fatigue, palpitations, dyspnea and/or angina occur

at restCriteria Committee of the New York Heart Association, 1964.


3/17

Heart Failure Population by NYHA Class

Class II

1.68 M

(35%)

Class IV

240 K(5%)

Class III1.20 M

(25%)

Class I1.68 M

(35%)

AHA Heart and Stroke Statistical Update 2001


4/17

ACC/AHA Heart Failure Staging System

Stage Patient Description

High risk for developing heart failure

(HF)

Hypertension

Coronary artery disease

Diabetes mellitus

Family history of cardiomyopathy

Asymptomatic HF

Previous myocardial infarction

Left ventricular systolic dysfunction

Asymptomatic valvular disease

Symptomatic HF

Known structural heart disease

Shortness of breath and fatigue

Reduced exercise tolerance

Refractory end-stage HF

Marked symptoms at rest despite maximal medical therapy

(e.g., those who are recurrently hospitalized or cannot be

safely discharged from the hospital without specialized

interventions)

AA

BB

CC

DD

Hunt SA, et al. Circulation 2001;104:2996-3007.


5/17

Recommended Therapy by Stage of Heart Failure

Hunt SA et al. ACC/AHA 2005 Guideline update for diagnosis and management of chronic heart failure in the adult. Summary Article. Circulation

2005; 112:1825-1852.

Jessup M et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation.

2009;119(14):1977-2016.


6/17

ACC/AHA Heart Failure Staging Therapy

Stage Patient Therapy

High risk for developing heart

failure (HF)

Hypertension

Coronary artery disease Diabetes mellitus

Family history of cardiomyopathy

Asymptomatic HF

Previous myocardial infarction

Left ventricular systolic dysfunction

Asymptomatic valvular disease

Symptomatic HF

Known structural heart disease

Shortness of breath and fatigue

Reduced exercise tolerance

Refractory end-stage HF

AA

BB

CC

DD

AA

BB

CC

DD

Hunt SA, et al. Circulation 2001;104:2996-3007.

Optimal drug therapy

Aspirin, ACE inhibitors, statins, -blockers, --blockers (carvedilol) diabetic therapy

Optimize drug therapy

ICD if LV dysfunction (systolic) present

Optimize drug therapy

ICD if LV dysfunction (systolic) present

CRT (if QRS wide, LVEF


7/17

Case Study:

Integrating Assessment and HFStaging into the Plan of Care


8/17

HF Case Study

46 year old male

Diagnosis: idiopathic dilated cardiomyopathy, diagnosed 2006,

First admitted 9/10/10 for shortness of breath on exertion for 1 month andfound to have decreased ejection fraction (LV 30%, RV 50%)NYHA Class IV

PMH:Acute Renal FailureHypertension

HyperlipidemiaDiabetes melli tus II (recently diagnosed)Childhood asthma

FH: Positive family history of coronary heart disease and diabetes

46 year old male

Diagnosis: idiopathic dilated cardiomyopathy, diagnosed 2006,

First admitted 9/10/10 for shortness of breath on exertion for 1 month andfound to have decreased ejection fraction (LV 30%, RV 50%)NYHA Class IV

PMH:Acute Renal FailureHypertensionHyperlipidemiaDiabetes melli tus II (recently diagnosed)Childhood asthma

FH: Positive family history of coronary heart disease and diabetes

AA

BB


9/17

HF Case Study

SH:

MarriedSmoking pack day for 20 years

No alcohol use

Occasional marijuana use and history of prior cocaine

use

Medication non-compliance due to inability to afford his

medication

Unfamiliar with checking blood sugars, low fat, low

carbohydrate diet

SH:

MarriedSmoking pack day for 20 years

No alcohol use

Occasional marijuana use and history of prior cocaine

use

Medication non-compliance due to inability to afford his

medication

Unfamiliar with checking blood sugars, low fat, low

carbohydrate diet


10/17

HF Case Study

Symptoms improved from NYHA Class IV to IIwith diuresis and 10 pound weight loss

ACC/AHA Stage B/C

Discharged 9/13

Diabetic education

Switch to more affordable medications

Heart Failure educationReturn to clinic

Symptoms improved from NYHA Class IV to IIwith diuresis and 10 pound weight loss

ACC/AHA Stage B/C

Discharged 9/13

Diabetic education

Switch to more affordable medications

Heart Failure educationReturn to clinic


11/17

Hospitalization Admission Dates

10/26: ED for SOB and Chest pain

11/18: ICD placed 12/4: ED for SOB which awoke him from

sleeping

12/21: Fatigue, several days of dyspnea,orthopnea and exercise intolerance

NYHA Class IV 1/26: SOB and generally not well, 25 pound

weight gain since last admission

LVAD and Transplant Team Consults

10/26: ED for SOB and Chest pain

11/18: ICD placed 12/4: ED for SOB which awoke him from

sleeping

12/21: Fatigue, several days of dyspnea,orthopnea and exercise intolerance

NYHA Class IV 1/26: SOB and generally not well, 25 pound

weight gain since last admission

LVAD and Transplant Team Consults

CC

DD


12/17

Case Study: Assessment

Exam on 1/26 admission:

Overweight, maleSkin warm and dry

Respirations unlabored, lungs clear all f ields

JVP 13cm, 2+ LEERegular rate and rhythm, Positive S3

Functional: able to converse, dyspnea with ambulation,

sleeps on 4 pil lows

Quit smoking October (3 months ago)

Exam on 1/26 admission:

Overweight, maleSkin warm and dry

Respirations unlabored, lungs clear all f ields

JVP 13cm, 2+ LEERegular rate and rhythm, Positive S3

Functional: able to converse, dyspnea with ambulation,

sleeps on 4 pil lows

Quit smoking October (3 months ago)


13/17

HF Case Study: Day 1 to 3

Admitted to Intensive Care Unit

Admission Labs: Na 135, K 2.9, Glucose 161, BUN

22, Cr 1.1, BNP 452

Admission Vitals: 90/70, 114, 18, 98.0, 96% O2 Sat

Administered intravenous diuretic

ACE Inhibitor held due to low BP

Echo LV 20% RV 30%

Right Heart Catheterization:

Initial - MRA 27, MPA 37, PCW 28, CI 1.5, CO 3.67

Admitted to Intensive Care Unit

Admission Labs: Na 135, K 2.9, Glucose 161, BUN

22, Cr 1.1, BNP 452

Admission Vitals: 90/70, 114, 18, 98.0, 96% O2 Sat

Administered intravenous diuretic ACE Inhibitor held due to low BP

Echo LV 20% RV 30%

Right Heart Catheterization:

Initial - MRA 27, MPA 37, PCW 28, CI 1.5, CO 3.67


14/17

HF Case Study

Day 6: Initiated Milrinone infusions

PO diuretic

Net loss approximately 3.5L/day

Marked improvement in LEE

BP 110-120 systolic

Day 8: PO diuretic discontinued due tohypokalemia, KCL IV given

Day 6: Initiated Milrinone infusions

PO diuretic

Net loss approximately 3.5L/day

Marked improvement in LEE

BP 110-120 systolic

Day 8: PO diuretic discontinued due tohypokalemia, KCL IV given


15/17

Repeat RHC on Day 8

Day 1 Day 8

MRA 27 18

MPA 37 39

PCW 28 31

CO 1.5 2.2

CI 3.7 5.15


16/17

HF Case Study: Day 9 to 15

Transfer from ICU to Floor on Day 13

Functionally improved NYHA class II-IIIBP 113/70, HR 103, Sat 94%

Plan

Milrinone continued at 0.4mg/kg/min

Transplant/LVAD team consult

Transfer from ICU to Floor on Day 13

Functionally improved NYHA class II-IIIBP 113/70, HR 103, Sat 94%

Plan

Milrinone continued at 0.4mg/kg/min

Transplant/LVAD team consult


17/17

Current Medications and Disposition

Discharge Medications:DiaBeta 2.5mg QDMetformin 850 mg BIDAspirin 81mg QD

Coreg 12.5mg BIDHydralazine 10mg TIDIsosorbide 10 mg TIDHydrochlorothiazide 25 mg QDSpironolactone 25mg QD

Torsemide 100mg BIDDigoxin 0.25mg QDLisinopril 20 mg BIDPravstatin 10 mg QDFolic Acid 1mg QD

Multi-vitamin QDPlan for home Milrinone

Finish Heart Transplant and LVAD Evaluation

Return to Advanced Heart Failure Clinic in 1 week

Patient is NYHA II/III and Stage D

Discharge Medications:

DiaBeta 2.5mg QDMetformin 850 mg BIDAspirin 81mg QD

Coreg 12.5mg BIDHydralazine 10mg TIDIsosorbide 10 mg TIDHydrochlorothiazide 25 mg QDSpironolactone 25mg QD

Torsemide 100mg BIDDigoxin 0.25mg QDLisinopril 20 mg BIDPravstatin 10 mg QDFolic Acid 1mg QD

Multi-vitamin QDPlan for home Milrinone

Finish Heart Transplant and LVAD Evaluation

Return to Advanced Heart Failure Clinic in 1 week Patient is NYHA II/III and Stage D

Documents

NW YORK HEART AS