Heart Failure In the Post acute and Long-Term Care Setting
Publication Date: October 1, 2015
Key Points
Key Points
- HF is one of the top causes of 30-day hospital readmissions. Factors such as inadequate staff training and education, provider unavailability and failure to adhere to standard guidelines for care all contribute to increased rate. Randomized control trials of Skilled Nursing Facilities with a designated program focused on, and applied interventions for, HF readmission prevention and reduction have proven to reduce 30-day readmissions rates by 20% to 40%.
- HF is a complex clinical syndrome that results from any structural or functional disorder that impairs the ability of the ventricles to fill with or eject blood at a rate commensurate with the body’s needs.
- Differentiation of patients with HF based on left ventricular ejection fraction (LVEF) is important due to different underlying etiologies, demographics, co-morbidities and response to therapies. Consequently HF has been newly classified into 3 subdvisions – HF with preserved ejection fraction (HFpEF) ≥50%, HF with mid-range ejection fraction (HFmrEF) 40–49% and HF with reduced ejection fraction (HFrEF) ≤40%.
- The AHA prevalence statistics show:
- For the 60–79 year-old age group, the following have heart failure: 7.8% of men; 4.5% of women.
- For the 80 years and older age group, the following have heart failure: 8.6% of men; 11.5% of women.
- Characteristically, patients with HF typically also have hypertension as well as other medical comorbidities, including chronic obstructive pulmonary disease, chronic kidney disease, hyponatremia, and hematologic abnormalities.
- Clinically, patients with preserved systolic function HFpEF are older and are more likely to be female, to have significant hypertension, and to have less coronary artery disease.
Table 1. Heart Failure in the Post-Acute and Long-Term Care Setting
General
Clinicians should avoid prescribing non-steroidal anti-inflammatory drugs (NSAIDs) to patients with heart failure (HF) since they may increase blood pressure and promote sodium and water retention. ( Strong , Moderate )
704
Use of the calcium channel blockers verapamil and diltiazem should be avoided in patients with HF with reduced ejection fraction. (These agents' negative inotropic effects may exacerbate HF). ( Strong , Moderate )
704
Treatment of anemia in congestive heart failure (CHF)
Use conservative blood-transfusion strategy (threshold transfusion of hemoglobin (Hgb) 7–8 g/dL in stable HF). ( Weak , Low )
704
Do NOT use erythropoiesis-stimulating agents in patients with mild to moderate anemia and HF. ( Strong , Moderate )
704
Intravenous iron carboxymaltose may be used in patients with stable HF. ( Weak , Moderate )
704
All patients with HF should receive counseling/education regarding self-care. ( Strong , Moderate )
704
Clinicians should discuss goals of care with patients with HF and their families. ( Strong , Low )
704
Patients with HF or advanced HF should receive palliative and supportive care as part of a comprehensive care plan designed to improve quality of life. Patients with Stage D HF should be offered palliative care and hospice enrollment. (Strong, Low)
704
All patients with HF who smoke should be counseled about smoking cessation. ( Strong , High )
704
Clinicians should individualize decisions about fluid and sodium restriction, balancing patient preferences, quality of life, and the objective benefit of relief of congestive symptoms. ( Weak , Moderate )
704
Cardiac rehabilitation may improve functional capacity and quality of life in patients with HF. ( Strong , Moderate )
704
Nutritional supplements should NOT be used as adjunctive therapy in patients with chronic HF. ( Strong , Moderate )
704
Effective systems of care coordination, with special attention to care transitions, should be deployed for every patient with chronic HF. ( Strong , Moderate )
704
When reviewing a patient's goals of care, clinicians should discuss deactivating pacemakers and implanted cardioverter defibrillators (ICDs). ( Strong , Low )
704
Clinicians should identify depression and treat it to remission to improve quality of life in patients with HF. ( Strong , Low )
704
Recognition
Unexplained weight gain in a patient may indicate new or worsening CHF. ( Strong , Moderate )
704
Unexplained tachycardia or hypoxemia in a patient may indicate new or worsening CHF. ( Strong , Moderate )
704
Assessment
Measurement of brain natriuretic peptides (BNP or NT-proBNP) may be useful to support a clinical diagnosis of HF in the setting of clinical uncertainty. ( Strong , High )
704
Measurement of BNP or NT-proBNP levels may be useful to assess disease severity or establish prognosis in chronic HF. ( Strong , High )
704
Treatment/Intervention
Loop diuretics should be used to improve symptoms in patients with HF and evidence of fluid retention. ( Strong , Low )
704
Angiotensin-converting enzyme (ACE) inhibitors are recommended to reduce mortality in patients with HF with reduced left ventricular ejection fraction (HFrEF). ( Weak , High )
704
Angiotensin-receptor blockers (ARB) should be prescribed to patients with HFrEF who are intolerant of ACE inhibitors. ( Strong , High )
704
Unless contraindicated, beta blockers are recommended to reduce morbidity and mortality in patients with HFrEF. ( Weak , High )
704
Unless contraindicated, aldosterone antagonists are recommended to reduce morbidity and mortality in patients with HF and ejection fraction of ≤35%. ( Weak , High )
704
The combination of hydralazine and isosorbide nitrates may decrease mortality or morbidity in African American patients with HFrEF. ( Weak , High )
704
Unless contraindicated, digoxin may decrease hospitalization for HF in patients with HFrEF. ( Weak , High )
704
Monitoring
For consistency, patients with HF should be weighed at the same time of day. ( Weak , Low )
704
Serum electrolytes and kidney function should be monitored regularly in patients with HF who are receiving diuretics. ( Strong , Low )
704
Nurses and aides should be educated about possible symptoms and signs of HF in order to better recognize and monitor patients with HF. ( Strong , Low )
704
Recognition
STEP 1: Identify Individuals With a History...
...entify Individuals Who Currently Have Symptoms...
...Symptoms That May Suggest HF Having tr...
...e 3. Signs That May Suggest HFHaving...
...ble 4. A Screening Tool for Caregivers (A NEW LEAF...
STEP 3: Identify and Assess for Ris...
...mmon Risk Factors for HF Exacerbati...
Assessment
...al Events That Can Help to Identify Patie...
...able 7. Indicators of Poor Cardiac Prognosis Havi...
...Decide if a Workup is Appropriate...
...Perform Appropriate Imaging Studies to...
...ble 8. Imaging for HF Having troubl...
STEP 6: Decide if Interventions fo...
...w York Heart Association Heart FailureHaving tr...
Treatment
...an Individualized Care Plan and Define Treatm...
...TEP 8: Optimize Treatment for Como...
...e Cardioverter-Defibrillators (ICD) and C...
...0. Adjunctive TreatmentsHaving troubl...
...Stages in the Development of HF...
STEP 9: Treat Fluid Volume Overload...
...etic Indications and Dose EquivalentsHaving troub...
...HFrEF Stage C: Evidence-Based GDMT...
...Drugs Commonly Used for HFrEFHaving trou...
...dications for Treating HFrEF Having trou...
...ey Points about ACE inhibitors:...
...raindications to the Use of ACE Inhibit...
...erse Effects of ACE InhibitorsHaving tr...
...able 16. Risk Factors for Hypotension in Pa...
...about Beta Blockers:...
...able 17. Contraindications to the Use of B...
...ial Adverse Effects of Beta-Blockers H...
...initrate/Hydralazine ...
...or Combinations of Treatments) Tha...
...1: Treat HF with HFpEF...
...Medication Options for Treating HFpEFHaving troub...
...Initiate Cardiac Rehabilitation...
.... Phases of Cardiac RehabilitationHaving troub...
STEP 13: Determine When The Patient Has End-Stag...
...ical Events That Can Help to Identify Pat...
Monitoring
...EP 14: Monitor the Patient’s Condition and...
...ents of Monitoring for HF PatientsHaving troub...
...: Monitor the Facility’s Management of HF...
.... Sample Performance Measurement In...
...cognize that people who reside in PA/LTC facilit...
