Nyha.pdf

Planning Determine Patient’s 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 acuity •care setting •clinical status (e.g., co-morbidities and prognosis) •patient preferences •etiology of heart failure •psychosocial 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)

NYHA Classification Class I

Ordinary physical activity does not cause undue fatigue, palpitations, dyspnea and/or angina

Class II

Ordinary physical activity does cause undue fatigue, palpitations, dyspnea and/or angina

Class III

Less than ordinary physical activity causes undue fatigue, palpitations, dyspnea and/or angina

Class IV

Fatigue, palpitations, dyspnea and/or angina occur at rest Criteria Committee of the New York Heart Association, 1964.

Heart Failure Population by NYHA Class Class III 1.20 M (25%)

Class IV 240 K (5%)

Class I 1.68 M (35%)

Class II 1.68 M (35%) AHA Heart and Stroke Statistical Update 2001

ACC/AHA Heart Failure Staging System Stage

A B C D

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)

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

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.

ACC/AHA Heart Failure Staging Therapy Stage

A A B B C C D D

High risk for developing heart failure (HF)

Patient Therapy • •  • •

Hypertension Optimal drug therapy Coronary artery disease Aspirin, ACE inhibitors, statins, -blockers, -Diabetes(carvedilol) mellitus diabetic therapy blockers Family history of cardiomyopathy

• Previous myocardial infarction

Asymptomatic HF

 Optimize drug therapy Leftifventricular systolic dysfunction • ICD LV dysfunction (systolic) present

• Asymptomatic valvular disease Symptomatic HF

Known structural heart disease • Optimize drug therapy • ICD if LV dysfunction present Shortness of breath(systolic) and fatigue  CRT (if QRS wide, LVEF<35%) • Reduced exercise tolerance

Refractory end-stage HF

   

Intermittent IV inotropes ICD as a bridge to transplantation CRT Other devices (LVAD, LV restraint)

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

Case Study:

Integrating Assessment and HF Staging into the Plan of Care

HF Case Study  46 year old male  Diagnosis: idiopathic dilated cardiomyopathy, diagnosed 2006,

A

 First admitted 9/10/10 for shortness of breath on exertion for 1 month and found to have decreased ejection fraction (LV 30%, RV 50%) NYHA Class IV  PMH:  Acute Renal Failure  Hypertension  Hyperlipidemia  Diabetes mellitus II (recently diagnosed)  Childhood asthma  FH: Positive family history of coronary heart disease and diabetes

B

HF Case Study  SH:  Married  Smoking ½ 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

HF Case Study Symptoms improved from NYHA Class IV to II with diuresis and 10 pound weight loss ACC/AHA Stage B/C Discharged 9/13 Diabetic education Switch to more affordable medications Heart Failure education Return to clinic

Hospitalization Admission Dates • • •

10/26: 11/18: 12/4:

• 12/21:

• 1/26:

ED for SOB and Chest pain ICD placed ED for SOB which awoke him from sleeping Fatigue, several days of dyspnea, orthopnea and exercise intolerance NYHA Class IV SOB and generally not well, 25 pound weight gain since last admission LVAD and Transplant Team Consults

C

D

Case Study: Assessment  Exam on 1/26 admission:  Overweight, male  Skin warm and dry  Respirations unlabored, lungs clear all fields  JVP 13cm, 2+ LEE  Regular rate and rhythm, Positive S3  Functional: able to converse, dyspnea with ambulation, sleeps on 4 pillows  Quit smoking October (3 months ago)

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

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 to hypokalemia, KCL IV given

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

HF Case Study: Day 9 to 15 Transfer from ICU to Floor on Day 13 Functionally improved NYHA class II-III BP 113/70, HR 103, Sat 94% Plan – Milrinone continued at 0.4mg/kg/min – Transplant/LVAD team consult

Current Medications and Disposition Discharge Medications: DiaBeta 2.5mg QD Metformin 850 mg BID Aspirin 81mg QD Coreg 12.5mg BID Hydralazine 10mg TID Isosorbide 10 mg TID Hydrochlorothiazide 25 mg QD Spironolactone 25mg QD Torsemide 100mg BID Digoxin 0.25mg QD Lisinopril 20 mg BID Pravstatin 10 mg QD Folic Acid 1mg QD Multi-vitamin QD Plan 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