1st August 2007
Institute for Clinical Systems Improvement
Summary,

Source: National Guidelines Clearinghouse

GUIDELINE OBJECTIVE(S)

• To decrease the re-admission rate within 30 days of discharge following hospitalization for heart failure
• To optimize the pharmacologic treatment of adult patients with heart failure
• To improve the use of diagnostic testing in order to identify and then appropriately treat adult patients with heart failure
• To improve care of adult heart failure patients by assuring comprehensive patient education and follow-up care

TARGET POPULATION

Adult patients age 18 and older with suspected heart failure and heart failure requiring hospitalization

INTERVENTIONS AND PRACTICES CONSIDERED

Diagnosis/Evaluation

1. Initial evaluation, including history, cardiac risk factors, symptoms, lifestyle issues, and physical examination
2. Laboratory evaluation, including
   • Initial evaluation: complete blood count (CBC), prothrombin time/international normalized ratio (PT/INR), electrolytes, renal function (blood urea nitrogen [BUN], creatinine [Cr]), liver function (aspartate transaminase [AST], alanine transaminase [ALT], alkaline phosphatase, bilirubin, total protein (T Prot), albumin), urinalysis, sensitive thyroid-stimulating hormone (sTSH)
   • Inpatient/emergency department evaluation: arterial blood gases, tests for myocardial injury (troponin, creatine kinase (CK)/CK muscle brain (CKMB), brain natriuretic peptide (BNP)
   • Evaluation for other causes: ferritin/iron/total iron-binding capacity (TIBC)/macrocytic anemias; lipid profile; blood culture if endocarditis suspected; lyme serology (if suspect bradycardia/heart block); connective tissue disease work up; human immunodeficiency virus (HIV)
3. Assessment of left ventricular functioning by echocardiography or radionuclide ventriculography
4. Electrocardiogram
5. Chest radiograph
6. Ischemia evaluation (stress test, angiography) in selected patients
7. Assessment for causative and precipitating factors of heart failure
8. Assessment for signs and symptoms requiring emergent management or hospitalization

Treatment/Management

1. Hospitalization if indicated
2. Pharmacologic management including
   • Beta blockers
   • Angiotensin-converting enzyme (ACE) inhibitors
   • Angiotensin II receptor blockers (ARBs)
   • Diuretics
   • Aldosterone blocking agents
   • Inotropes such as dobutamine, dopamine, and milrinone (Note: these agents should be restricted to patients needing symptomatic relief who are no longer responding to other therapies.)
   • Digoxin
   • Other vasodilators, such as intravenous nitroglycerin, intravenous nitroprusside, nesiritide
   • Hydralazine/isosorbide dinitrate
   • Calcium channel blockers
   • Anti-arrhythmics
   • Anticoagulants (warfarin)
3. Non-pharmacologic management including diet (including sodium restriction), daily weights, exercise, smoking cessation, coping with chronic disease, advanced directives, and end-of-life considerations
4. Ongoing assessment of treatment and evaluation for symptom exacerbation
5. Emergent management including adjusting O2, continuous or bilevel positive airway pressure
6. Management of acute pulmonary edema including loop diuretics, nitroglycerin or nesiritide

MAJOR OUTCOMES CONSIDERED

Diagnosis

Sensitivity, specificity, accuracy, and reproducibility of diagnostic tests

Treatment

• Hospitalization rates
• Morbidity and mortality
• Change in function and quality of life
• Change in symptoms
• Exercise capacity/tolerance
• Disease progression
• Safety of pharmacologic agents