OSCE Fall 18 - Heart Failure

SUBJECTIVE

ASSESSMENT and PLAN

ACCF/AHA Stages:
• A​ = at high risk for HF w/o structural HD or Sx of HF
• B​ = structural HD w/o Sx of HF
• C​ = Structural HD w/ prior or current Sx
• D​ = Refractory HF requiring specialized interventions

NYHA Classification:
• I ​- ​no limitation​ of physical activity, ordinary physical activity does not cause Sx of HF
• II ​- ​slight limitation​ of physical activity, comfortable at rest, but ordinary activity causes Sx of HF
• III ​- ​marked limitation​ of physical activity, comfortable at rest, but less than ordinary activity causes Sx of HF
• IV ​- ​unable​ to carry on any physical activity w/o Sx of HF, or Sx of HF at rest

# Heart Failure HFrEF (≤40%)

Dx:
● Echocardiography- recommended for pts with suspected HF with SOB, basal rales, males with ankle
edema, history of MI.
● Troponin 1. Part of initial labs for decompensated HF.
● CBC - evaluate anemia, infections that exacerbate HF.
● Serum electrolytes - Hyponatremia suggests severe HF.
● BUN - HF exacerbation can cause renal impairment.
● Creatinine - HF exacerbation can cause renal impairment. Value should be obtained before starting pt
on ACEi or diuretics.
● LFTS - liver can be affected by hepatic congestion.
● Fasting blood glucose - for evaluation of diabetes.
● Chest x-ray - differentiate dyspnea from HF and pulmonary disease.
● BNP, >400 HF likely - BNP is produced in the ventricles and level goes up with high pressure in
ventricles. Used to differentiate between cardiac and non-cardiac dyspnea.
● Urinalysis
● Fasting lipids
● TSH
Tx:
● Aspirin PO QD
● Metoprolol - BB reduces mortality, syx and hospitalization in pts with HFrEF. Caution if HR <60 and if
NYHA class IV HF.
● ACEi (or ARB if intolerant) - reduces mortality in pts with recent MI. ACEi will also control HTN.
● Spironolactone (aldosterone receptor antagonist)
● Hydralazine/Isosorbide for African Americans
* Treat HTN for optional BP<130/80

Pt Ed:
● Caution if HR<60.
● ACEi can cause hyperkalemia - we will monitor potassium.
● Sodium restriction <1500 mg of sodium a day - for reduction of HTN and prevent fluid retention.
● DASH diet (fruits, vegetables, unprocessed foods, nuts, no sweetened beverages).
 ● Exercise to decrease weight and increase cardiac resilience.
● Avoid NSAID - due to HF exacerbation.
● Daily weight monitoring.
F/U:
● Go to ED if worsening SOB.
● Monitor for SE of hypo and hyperkalemia, dizziness, hypotension, increased urination, hyponatremia,
renal insufficiency, gynecomastia (spironolactone), anemia.
● RTC in 1 week to evaluate BP and adjust medications.

HCM: