Outpatient Management of Heart Failure

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Left to right: Carol L. Pisano, RN, BSN, CCRN; Marc A. Silver, MD; Pamela Cianci, RN, MSN, APN, BC Authors Marc A. Silver, MD, is Chairman of the Department of Medicine, Director of the Heart Failure Institute, and Associate Director of the Cardiovascular Disease Fellowship at Advocate Christ Medical Center in Oak Lawn, Illinois. He is also Clinical Professor of Medicine at the University of Illinois School of Medicine. A leading authority on heart failure, Dr. Silver has served as principal investigator for more than 60 large-scale clinical trials, is co–Editor-in-Chief of Congestive Heart Failure, and serves on the editorial boards of 11 professional journals, including the American Journal of Cardiology, Journal of Cardiac Failure, and Journal of the American College of Cardiology. Dr. Silver is a Fellow of the American College of Physicians, the American College of Cardiology, and the American College of Chest Physicians. He is also the author of “Success with Heart Failure,” a patient- and family-focused educational primer to heart failure. Pamela Cianci, RN, MSN, APN, BC, is a Clinical Nurse Specialist/Certified Advanced Practice Nurse at Advocate Christ Medical Center. Ms. Cianci has authored articles published in the Journal of Cardiovascular Nursing, Critical Care Nurse, and the Journal of the American College of Cardiology. She is a member of the American Heart Association, American Association of Critical Care Nurses (CCRN 1989–1992), Sigma Theta Tau Honor Society of Nursing, and the Heart Failure Society of America. Carol L. Pisano, RN, BSN, CCRN, manager of the Heart Failure Center at Advocate Christ Medical Center, created and developed the Heart Failure continuum of care initiatives including the outpatient clinic in 1995. With more than 25 years of cardiac nursing experience, Ms. Pisano is a member of the American Association of Critical Care Nurses and the Heart Failure Society of America. ♥ 2
TABLE OF CONTENTS Introduction................................................................................................................................................... 4 Overview of Outpatient Heart Failure Disease Management.................................................................. 4 The Experience at Advocate Health Care ............................................................................................ 4 Components of an Outpatient Management Program for Heart Failure............................................... 6 Facilities and Staffing ........................................................................................................................... 6 Knowledge Base of Staff...................................................................................................................... 6 Patient Management ............................................................................................................................. 6 Medications................................................................................................................................. 6 Laboratory Testing ...................................................................................................................... 6 Ancillary Testing...........................................................................................................................7 Weight Maintenance ................................................................................................................... 7 Follow-up .................................................................................................................................... 7 Family Support............................................................................................................................ 7 Patient Support Groups............................................................................................................... 7 Clinic Communications With Other Medical Personnel ............................................................ 7 Transitioning Management From Inpatient to Outpatient ...................................................................... 9 Selection of Appropriate Patient Candidates for Outpatient Management.......................................... 9 Referral for Outpatient Heart Failure Management ............................................................................. 9 Drug Treatment Protocols in Heart Failure...............................................................................................11 Guidelines.............................................................................................................................................11 Diuretic Titration ..................................................................................................................................11 Patient Instructions......................................................................................................................11 Treatment ....................................................................................................................................11 Angiotensin-Converting Enzyme Inhibitor Titration ...........................................................................11 Laboratory Testing ......................................................................................................................11 Metoprolol (Lopressor ® ) and Metoprolol-XL (Toprol-XL ® ) Slow Titration........................................12 Carvedilol (Coreg ® ) ..............................................................................................................................12 Nesiritide (Natrecor ® ) Outpatient Infusion...........................................................................................12 Pharmacology/Mechanism of Action..........................................................................................12 Indications for Nesiritide Use.....................................................................................................13 Contraindications ........................................................................................................................13 Pharmacokinetics ........................................................................................................................13 Dosing and Administration .........................................................................................................14 Follow Up Serial Infusions of Natrecor ® (FUSION I) ...............................................................14 Cardiac Resynchronization Therapy ....................................................................................................15 Indications for Cardiac Resynchronization Therapy ..................................................................15 Prioritization for Cardiac Resynchronization .............................................................................15 Putting It All Together..........................................................................................................................15 Case Studies in Heart Failure Management ..............................................................................................16 Other Issues, Considerations, and Informational Resources...................................................................21 Sample Forms Congestive Heart Failure Orders (Emergency Department) ................................................................22 Congestive Heart Failure Orders (Admission).....................................................................................23 Patient Discharge Instructions..............................................................................................................25 Heart Failure Homecare Guidelines .....................................................................................................26 Physician Referral Letters ....................................................................................................................27 Homecare Referral to Outpatient Heart Failure Clinic ........................................................................28 Posttest.........................................................................................................................................................................29 Evaluation Form ...........................................................................................................................................30 Note to the reader: Medicine remains an inexact science and every patient is unique. The material contained in this publication is for educational purposes only. Although this monograph includes specific medications, dosages, and other relevant clinical information, it is important that this information not be taken as direct prescriptive advice for any individual patient in the absence of consultation with the responsible physician or other healthcare personnel. Full Prescribing Information should be consulted before considering the use of any medication referred to in this publication. ♥ 3
Page 1 and 2: Second Edition Outpatient Managemen
Page 3: Target Audience This activity has b
Page 7 and 8: approach delivered in hospital, hom
Page 9 and 10: FIGURE 1 13 Evaluation and Treatmen
Page 11 and 12: Transitioning Management From Inpat
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Page 15 and 16: Is SBP < 90 mmHg and/or SVR < 800 d
Page 17 and 18: TABLE 13 21 Mortality (High-Risk St
Page 19 and 20: CASE 2 Background A man aged 46 yea
Page 21 and 22: CASE 4 Background This woman aged 6
Page 23 and 24: Other Issues, Considerations, and I
Page 25 and 26: Congestive Heart Failure Orders (Ad
Page 27 and 28: DIET/FLUIDS A balanced diet is impo
Page 29 and 30: Dear Doctor: After having seen your
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Page 33 and 34: Follow-up As part of our ongoing co
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Outpatient Management of Heart Failure

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