Preface

Heart failure (HF) has been a growing clinical problem in Canada and throughout the world resulting in reduced quality of life, recurrent hospitalizations and premature death.

Mission Statement

The mission of the Canadian Heart Failure Network (CHFN) is to provide appropriate, comprehensive, high-quality care to limit disability and improve the quality of life of patients with HF through exemplary outpatient management in outpatient HF clinics. Each clinic will be a centre of excellence for the clinical management of HF and will also serve as a resource centre dedicated to improve the quality and quantity of life for HF patients and their families.

About this Manual

This resource manual has been developed to assist health care professionals in the successful operation of a HF outpatient clinic. It provides an overview of a management structure for the clinic, identifies the clinic team, and describes the roles and responsibilities of each team member. A multidisciplinary approach is recommended where Physicians, Nurses, Dieticians, Pharmacists and other health care professionals provide collaborative advice and direction.

Because patient compliance is a key factor in the management of HF, an extensive patient education program is also included in this manual.

Medical management, care protocols and patient monitoring are key elements of the HF clinic and are included as guidelines to assist in the optimization of HF care across Canada.

Data collection using a flexible data-gathering tool is used to guide current and future practice, measure outcomes, determine quality of life (QOL) issues and track patient satisfaction. Periodic analyses of data collected allows practitioners to review and change practice patterns to enhance patient care and QOL. Ongoing data collection will also allow practitioners to demonstrate the cost-benefits derived from treating HF in the clinic setting.

This resource manual will be updated periodically as warranted by new research findings, changes in clinical practice guidelines, and continuing clinical experience.

Disclosure

This website was developed by the Canadian Heart Failure Network (CHFN) as an aid for health care professionals, heart failure patients, and lay persons to better understand heart failure and how it may be prevented and treated. The information and opinions provided are not a substitute for normal medical care provided by Physicians or other health care professionals, and are for general interest only. The advice and information do not constitute recommendation for changes in treatment for any particular individual, and the information may not apply to all patients or clinical situations. Mention of specific products, processes or services does not constitute or imply a recommendation or endorsement by the CHFN.

The CHFN assumes no liability arising from any error or omission in the information available on the website and recommends that you confirm with your Physician if a change in your management is required. Links to other websites are for your information and convenience only and CHFN accepts no responsibility or liability for the content or any advice in those external websites. When you link to an external website, you have left the CHFN website and the CHFN is not responsible for the privacy policies or content located within these external sites.

Sponsorship

This program is an independent national network with the support of our corporate sponsors.

The impetus for the program came from Cardiology Physicians and Nurses from across Canada who envisioned the need for a common and comprehensive approach to the current management of patients with HF.

Comments/Suggestions

We welcome any comments and suggestions you may have regarding this important educational program. Kindly send them to:

Malcolm Arnold, MD, FRCPC, FACC
Chair, Working Group
Canadian Heart Failure Network (CHFN)
University Hospital - London Health Sciences Centre
C6-124D
339 Windermere Road
London, Ontario
N6A 5A5
www.chfn.ca

T: 519-663-3496
F: 519-663-3497

Rationale for HF Clinics

The Problem: Heart Failure

Heart failure (HF) is a major health problem in Canada and throughout the world. Presently, HF affects 5 million to 7 million North Americans and another 20 million individuals in Third World countries.¹

In Canada, HF affects more than 1% of the population and is responsible for 9% of all deaths. HF is the most common cause of hospitalization of people over 65 years of age.²

The incidence and prevalence of HF will continue to rise as the population ages. As shown in Figure 1.1, it is estimated that HF prevalence will nearly double due to the aging population by the year 2030.³ In some regions of Canada, the rate of HF is increasing by as much as 4% annually.

Despite medical management, recent data suggest that the HF mortality rate may be as high as 40% to 50% two years following treatment.⁴ In addition, the continual cycles of acute crises associated with HF result in high hospital readmission rates and increased health care costs.

This steady increase in the number of deaths, hospitalizations, and medical costs associated with HF continues to occur at a time when morbidity and mortality rates from other common cardiovascular diseases (such as myocardial infarction) are on the decline.

There is an urgent need for aggressive measures to reduce the mortality and morbidity associated with HF, reduce hospital admissions and readmissions, and improve patient management.

One Solution: HF Clinics

In recent years, a number of HF clinics have been established in Canada and the United States in an effort to improve the quality of life of patients with HF and reduce the economic burden associated with the inpatient management of this patient population.

Preliminary findings from the Cardiology Preeminence Roundtable publication suggest that progress in the management of patients with HF depends on avoiding hospitalization in the first place.³

Figure 1.2 shows several approaches that are being successfully used to manage HF patients in the outpatient setting. ³

“As much as 50% of inpatient care for HF ideally should have occurred elsewhere or been avoided altogether.”

Cardiology Preeminence Roundtable³

As shown in Figure 1.3, heart failure clinics have the potential to reduce length of stay
and hospital admissions.³

“Outpatient intervention not only reduces HF admissions, but when hospitalization is unavoidable, it reduces the average length of stay.”

Cardiology Preeminence Roundtable³

Heart Failure

Heart failure (HF) is a state in which the heart is unable to pump blood at a rate to meet the requirements of metabolizing tissues or can only do so from an elevated filling pressure. Many forms of heart disease may lead to heart failure. Other diseases and treatments can precipitate exacerbations of HF.

Etiology of Heart Failure

• Ischemia/myocardial infarction 65%
• Non-ischemic dilated cardiomyopathy 20%
• Other 15%

Ischemia and/or myocardial infarction contribute to the development of heart failure in up to 65% of cases.⁵ Myocardial infarction can lead to ventricular remodelling with compensatory dilation and hypertrophy and subsequent systolic and diastolic dysfunction progressing to the clinical syndrome called HF. In patients with ischemia, the major cause of heart failure is systolic dysfunction with some degree of diastolic dysfunction.

In a subgroup of patients, the cause of heart failure is diastolic dysfunction. These individuals have signs and symptoms of heart failure but a normal left ventricular ejection fraction. Appropriate management of these patients is to address the underlying etiology. Unfortunately, there are few clinical trials to direct decisions about the best choice of drug therapy.

Some patients have signs of HF such as cardiomegaly on chest x-ray or left ventricular dysfunction, but no symptoms.

Goals of Heart Failure Treatment

The clinical goals of heart failure treatment are to:

• Improve heart function
• Reduce symptoms
• Prevent hospital readmissions
• Improve survival
• Improve quality of life

Disease Progression in Heart Failure

Most patients with heart failure have only mild symptoms and often respond well to medical therapy. Unfortunately, because of the progressive nature of HF, these patients remain at risk for worsening disease despite the optimal use of current firstline medications. This is because myocardial damage triggers a series of compensatory mechanisms that progressively compromise cardiac function.

In the early stages of myocardial damage, activation of neurohormonal systems, including the renin-angiotensin-aldosterone (RAA) and sympathetic nervous systems, provides initial support for the failing heart. However, the continued neurohormonal activation becomes deleterious with excessive vasoconstriction, volume expansion, and ventricular remodelling leading to continued deterioration in cardiac function.

Ventricular remodelling can be favourably altered by angiotensin-converting enzyme (ACE) inhibitors, agents that have been shown to reduce morbidity and mortality in patients with HF and asymptomatic left ventricular dysfunction.⁶

Recent clinical findings suggest that beta-blockers can reduce symptoms, improve left ventricular function, and inhibit disease progression in patients with mild to moderate HF on standard therapy consisting of an ACE inhibitor and diuretics, with or without digoxin.^7-10

Emerging data on the beneficial effects on outcome in heart failure patients with beta1-selective blockers further support the importance of this therapy.^11,12 However, in a meta-analysis of the clinical effects of beta-adrenergic blockade in heart failure, Lechat and colleagues reported that the reduction in mortality risk was greater for nonselective beta-blockers than for beta₁–selective agents.¹⁰

Diuretics are very successful in reducing symptoms of HF and they probably reduce readmissions for heart failure. However, their influence on survival has not been adequately tested. Digoxin can improve symptoms and will reduce hospital readmissions for heart failure, but has a neutral effect on survival. Some positive inotropic agents will reduce symptoms and hospital readmissions for heart failure, but may worsen the underlying disease process.

References

1. Ackman ML, Harjee KS, Mansell G, et al. Cause-specific noncardiac mortality in patients with chronic heart failure — a contemporary Canadian audit. Can J Cardiol 1996;12:809-813.
2. Brophy JM. Epidemiology of chronic heart failure. Canadian data from 1970-1989. Can J Cardiol 1992;8:495-498.
3. Cardiology Preeminence Roundtable. Beyond Four Walls: Cost-Effective Management of Chronic Congestive Heart Failure. Washington, D.C.: Advisory Board Company, 1994.
4. Johnstone DE, Abdulla A, Arnold JMO, Bernstein V, et al. Diagnosis and management of heart failure. Can J Cardiol 1994;10:613-631.
5. Canadian Cardiovascular Society. Report on the 1993 Consensus Conference on the Diagnosis and Treatment of Heart Failure. Toronto: Queen’s Printer for Ontario, 1996.
6. The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992;327:685-691.
7. Doughty RN, Whalley GA, Gamble G, MacMahon S, Sharpe N. Left ventricular remodeling with carvedilol in patients with chronic heart disease due to ischemic heart disease. J Am Coll Cardiol 1997;29:1060-1066.
8. Packer M, Bristow MR, Cohn JN, et al, for the U.S. Carvedilol Heart Failure Study Group. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996;334:1349-1355.
9. Heidenreich PA, Lee TT, Massie BM. Effect of beta-blockade on mortality in patients with heart failure: a meta-analysis of randomized clinical trials. J Am Coll Cardiol 1997;30:27-34
10. Lechat P, Packer M, Chalon S, Cucherat M, Arab T, Boissel J-P. Clinical effects of ß-adrenergic blockade in chronic heart failure. Circulation 1998;98:1184-1191.
11. CIBIS Investigators and Committees. A randomized trial of ß-blockade in heart failure: the Cardiac Insufficiency Bisoprolol Study (CIBIS). Circulation 1994;90:1765-1773.
12. The International Steering Committee on Behalf of the MERIT-HF Study Group. Metoprolol CR/XL. Randomized Intervention Trial in Heart Failure (MERIT-HF): rationale, design, and organization. Am J Cardiol 1997;80(Suppl 9B):54J-58J.

*Draft changes pending adoption by CHFN

The HF Clinic

Establishing a Heart Failure Clinic

Informing the Community

HF clinics offer an effective alternative to the current cycle of acute care management. They offer complete patient evaluations, education, regular monitoring, and immediate response to patients’ clinical needs.

In addition, HF clinics offer long-term benefits to patients, families, and the communities they serve. It is expected that each local HF clinic will be a centre of excellence for the clinical management of HF and a resource centre dedicated to improving the lifestyle of HF patients and their families.

Objectives of Heart Failure Clinics

• Improve patient care
• Provide medical care in a timely fashion
• Optimize the use of proven medical therapies
• Educate HF patients about all aspects of their condition
• Improve cardiac function
• Improve quality of life
• Empower patients with the knowledge/capacity to manage heart failure
• Reduce hospital admissions and readmissions
• Reduce morbidity and mortality
• Disseminate the latest information on HF
• Serve the community
• Quality of care assessment

Facility Profile

Clinic Accommodations

• Examination rooms, waiting area, meeting room, offices, exercise room, telemonitoring, telephone follow-up

Equipment

• Office equipment, computers, tables, chairs, blood pressure machines, scales, echocardiograph, treadmill, bikes

Operating Costs

• Part-time cardiologist(s)
• Full-time clinic staff: nurse manager/coordinator, clerical staff
• Telephone costs, Internet access
• Clinic supplies, office supplies

Access/Referral to

• Electrophysiology, CRT, ICD
• Cardiac Surgery
• Transplantation team

HF Clinic Team

The clinics will be Physician-directed and Nurse-managed. The on-staff Cardiologist will perform all initial assessments and examinations, and then develop a treatment plan that will be implemented and managed by the Clinic Nurses.

The Nurse Manager/Clinic Nurse is experienced in cardiology and may have some experience in the outpatient setting. In many settings, Nurses with advanced training are responsible for patient management and the implementation of delegated medical tasks.

Along with the Nurse(s) and the Cardiologist, the clerical staff are considered primary members of the clinic team. They will perform daily administrative duties and assist in data collection and data entry.

Secondary team members who may be affiliated with the clinic on either a part-time, full-time, or referral-only basis include: Pharmacists, Dietitians, Psychologists, Social Workers, and Exercise Physiologists or Physical Therapists as well as EEP Cardiologists and Cardiac Surgeons.

Pharmacists are important members of the clinic’s multidisciplinary team. They provide both patients and staff with information concerning drug interactions, pharmacokinetics of drug action, side-effects of medications, and dosing adjustments required for comorbid conditions. Counselling by a Clinical Pharmacist has been shown to increase patient compliance with medication regimens, resulting in improvements in peripheral edema and physical capacity.^1,6

Referrals to a Registered Dietitian are particularly important for HF patients suffering from comorbid conditions such as diabetes or renal failure. The Dietitian will educate patients about the need for sodium and fluid restriction, assess protein and caloric requirements, and incorporate dietary changes needed to manage comorbid conditions.

Depression, anger, and frustration related to decreased quality of life are common among HF patients, particularly those patients with poor psychosocial adjustment to their situation.² Therefore, referral to a Clinical Psychologist may be necessary. Counselling by a Psychologist can help patients and their family members adjust emotionally to the difficult lifestyle changes required for HF management.

The primary role of the social worker is to develop an individualized living plan for the HF patient. This plan may include making arrangements for food/meals, transportation, home assistance, and providing access to financial assistance. The Social Worker can also assist patients and their family members in finding support groups that provide open discussions of common issues such as work, sexuality, exercise and leisure activities, and the adjustments that must be made to each.

Although HF patients have traditionally been encouraged to modify physical activity, exercise rehabilitation programs have been used successfully to improve the functional capacity of HF patients.^3,4 Therefore, an Exercise Physiologist or Physical Therapist may be affiliated with the clinic to establish an appropriate exercise regimen for the HF patient, provide instruction on exercise limitations, and monitor the exercise program.

In addition to the secondary team members, heart failure clinics may be affiliated with Occupational Therapists, Home-care Providers, Palliative-care Physicians, patient-support groups, transplant teams, members of the clergy, and volunteers. Although not core members of the clinic team, these individuals are highly valued members of a successful clinic program. For example, Home-care Providers are particularly important for the management of older HF patients who may have difficulty performing daily activities such as bathing and sitting in a chair. Also, palliative-care counselling may be required for the emotional well-being of both patients and their family members. Many patients find psychological relief in the ability to talk openly about the mortality associated with heart failure, and preparation for death.^5,6,7,8,9

Patient Selection

Heart failure clinics are outpatient facilities that offer a comprehensive approach to HF management. All patients with suspected and established heart failure (NYHA Classes I to IV) should be eligible for treatment at these clinics. Referrals to the HF clinic are accepted from any source: community Physicians, hospital-based Physicians, and other clinics. Nurse and patient-facilitated referrals for education may also be accepted.

Table 2.1. Physician-directed/Nurse-managed heart failure clinic model.

Clinic director	Responsibilities
Cardiologist	• Receives patient referrals • Performs initial evaluations • Establishes medical regimen • Sees patient regularly • Liaises with Nurse Manager before any major changes in medical intervention
Nurse Manager Registered Nurse with cardiology experience or Registered Nurse with advanced training (experience in outpatient care is beneficial)	• Implements treatment plan • Educates patient • Adjusts medications (using drug management protocols) • Schedules patient appointments • Makes regular follow-up calls

As shown in Figure 2.1, patient education is key to the success of a HF management
program. Education should involve all members of the multidisciplinary clinic team and
should be ongoing.

Data Collection

Data collection can be used by heart failure clinics for the following purposes:

1. To monitor patient care issues and outcomes
2. To track public health data
3. To document the need for the clinic
4. To secure funding
5. To answer research questions

References

1. Uretsky BF, Pina I, Quigg RJ, Brill JV, et al. Beyond drug therapy: nonpharmacologic care of the patient with advanced heart failure. Am Heart J 1998;135(Suppl 2):S264-S284.
2. Dracup K, Walden JA, Stevenson LW, Brecht M-L. Quality of life in patients with advanced heart failure. J Heart Lung Transplant 1992;11:273-279.
3. Coats AJS, Adamopoulos S, Radaelli A, et al. Controlled trial of physical training in chronic heart failure. Circulation 1992;85:2119-2131.
4. Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients with severe left ventricular dysfunction. Circulation 1998;78:506-515.
5. Hauptman PJ, Rich MW, Heidenreich PA et al. The Heart Failure Clinic: A consensus statement of the Heart Failure Society of America. J. Card Failure 2008; 14: 801-815.
6. Gattis WA, Hasselblad V. Whellan DJ, O'Connor CM. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team: Results of the Pharmacist in Heart Failure Assessment Recommendation and Monitoring (PHARM) study. Arch. of Internal Medicine 1999;159(16): 1939-1945.
7. Albert NM, Fonarow GC, Yancy CW et al. Influence of dedicated heart failure clinics on delivery of recommended therapies in outpatient cardiology practices: Findings from the Registry to improve the use of Evidence - Based heart Failure Therapies in the Outpatient Setting (Improve HF). Am Heart J 2010; 159:238-44.
8. McAlister FA, Stewart S, Ferrura S, McMurray JJJV. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: A systematic review of randomized trials. J. Am Coll. Cardiol.2004; 44:810-819.
9. Focused Update Incoporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation / American Heart Association Task Force on Practice Guidelines. Circulation 2009;119:391-479.

*Images provided by Microsoft Clip Art

Medical Management

Running a Heart Failure Clinic

1. Scope

This document provides strategies for the improved diagnosis and management of adults (19 years and older) with heart failure (HF). It is intended for primary care practitioners, allied health professionals and patients with HF. It focuses on approaches needed to provide care to patients with this complex syndrome.

2. Diagnostic Code:

428

3. Clinical Highlights

HF is a complex syndrome associated with a high rate of hospitalization and short-term mortality, especially in elderly patients with comorbidities. Early diagnosis and treatment can prevent complications.

• Successful HF management begins with an accurate diagnosis. All patients should have an objective determination of left ventricular ejection fraction (LVEF) by echocardiogram, or radionuclide ventriculogram (RNV) if echocardiogram is unavailable
• Treat underlying vascular risk factors (see guidelines on Hypertension and Diabetes Care), comorbidities and other chronic diseases
• Patient and caregiver education should be tailored and repeated
• Encourage the patient to accept responsibility for their HF care through an individualized management plan with self-care objectives, including salt restriction, weight monitoring and medication adherence strategies
• Reinforce the importance of healthy lifestyle modifications, including healthy eating, regular exercise, weight management, social support and smoking cessation
• Treatment requires combination drug therapy
• All systolic HF patients should receive an ACE-I and a BB at target dose unless contraindicated. These therapies should be considered in all patients with HF with preserved systolic function (PSF)
• Additional therapy should be guided by clinical situation
• As polypharmacy remains a concern - match drugs to goals of treatment
• Care should be individualized based on symptoms, underlying cause, disease severity and goals of care
• Plan effective systems to ensure follow-up and patient education to improve outcomes
• Engage patients in open discussions on the end of life issues

4. Prevention of Heart Failure

• Assess all patients for known or potential risk factors for HF (hypertension, ischemic heart disease, diabetes mellitus, dyslipidemia and tobacco use)
• Modifiable risk factors should be treated according to current guidelines
• Routine screening for asymptomatic LV dysfunction is currently not recommended
• For selected patients at high risk for HF due to multiple risk factors, the decision to screen (such as by echocardiography) should be individualized
• The prognosis of HF at the earliest appropriate time

5. Patients with Asymptomatic LV Dysfunction

• ACE-I should be used in all asymptomatic patients with LV dysfunction and
  LVEF < 40%
• BB should be considered in all patients with asymptomatic LV dysfunction
  and LVEF < 40% (especially if there is a history of ischemic heart disease)

6. Diagnosis of Heart Failure

HF is under diagnosed in its early stages. Diagnostic accuracy improves when there is a high index of suspicion and a consistent approach to diagnosis.

7. Definition of Heart Failure

HF is a clinical syndrome defined by symptoms suggestive of impaired cardiac output and/or volume overload with concurrent cardiac dysfunction. While a normal LVEF is >60%, the threshold of 40% is used for the purposes of diagnostic classification. As such, HF can be classified into systolic heart failure, as defined by the presence of signs and symptoms of HF with an LVEF <40%, and heart failure with preserved systolic function (HF with PSF – previously called diastolic dysfunction) is defined by the presence of signs and symptoms of HF in the absence of systolic dysfunction (LVEF ≥ 40%). Prognosis for systolic HF is significantly worse than HF with PSF. Research evidence for treatment is best established for systolic HF but, in general, the pharmacologic and nonpharmacologic strategies are similar for both.

8. Evaluation of HF should include:

• A thorough history and physical exam focusing on:
• Current and past symptoms of HF (i.e. fatigue, shortness of breath, diminished exercise capacity and fluid retention/weight gain)
• Functional limitation by New York Heart Association (NYHA)
• Cardiovascular risk factors, cardiovascular disease, and other comorbid conditions
• Assessment of a patient’s endurance, cognition, and ability to perform activities of self-management and daily living
• Assessment of volume status (e.g. peripheral edema, rales, hepatomegaly, ascites, weight, jugular venous pressure, and postural hypotension)
• Initial investigations in all patients (where available):

• Complete blood count
• Serum electrolytes
• Creatinine (Cr), eGFR
• Urinalysis
• Microalbuminuria
• Fasting blood glucose
• Fasting lipid profile, AST
• Albumin
• Thyroid-stimulating hormone (TSH)
• 12-lead electrocardiogram and chest radiograph
• All patients should have an objective determination of LVEF by transthoracic echocardiogram (preferred as it also provides information on cardiac dimensions, valvular function and may suggest the underlying etiology of HF) or RNV if echocardiogram is unavailable
• BNP has high diagnostic value for both types of HF and is recommended where available, when diagnosis is unclear. The use of BNP in non-acute heart failure and community outpatient practice remains to be clarified. (See Table 1)

Table 1. Brain natriuretic peptide (BNP) and prohormone of BNP (NT-proBNP) assay cut-off points for the diagnosis of heart failure.

• In cases where there is doubt, or an objective determination of LVEF is not immediately available, response to a therapeutic trial may increase the diagnostic accuracy (See Figure 1)

• When the etiology of HF is uncertain, consider referral for more specialized cardiac testing as clinically indicated

Figure 1. Diagnosis of heart failure (Adapted from CCS Guidelines, 2006).

9. Non-Pharmacologic Management Strategies

HF care depends on the patient’s understanding of, and participation in, optimal care. Patients can be important partners in individualized goal setting, salt restriction, weight monitoring, and adherence.

9.1. Goals of Care

• Determine the goals of managing their HF with the patient, i.e. aggressiveness from a goal of an advanced cardiac technology and transplantation through to a goal of symptom control and palliation
• Identify an appropriate substitute decision maker (health proxy)
• Advance Directives / Representation Agreements regarding end-of-life care should be addressed at the earliest appropriate time
• Above decisions should be reviewed regularly and specifically when there is a change in the patient’s clinical status

9.2. Self-Monitoring

• Discuss the importance of self-management with the patient and their network of support
• Work with the patient on the specifics of the plan as outlined below (9.3-9.9)

9.3. Weight

• All patients should be encouraged to weigh themselves daily and recognize symptoms of worsening HF
• Initially: Report a weight gain of 2.5 kg/week or a worsening of symptoms
• Goal: Self-assessment and adjustment of fluid/sodium restriction and/or diuretic dosing in response to a weight gain of ≥1 kg (patient-based algorithm)

9.4. Salt Intake

• All HF patients should limit sodium intake, avoid processed foods and avoid adding salt
• Review salt intake when weight gain is experienced

9.5. Fluid Intake

All HF patients with hyponatremia, or severe fluid retention/congestion that is not easily controlled with diuretics, should limit fluid intake to 6-8 cups of liquid/day (1 cup = 8 ounces = 250 mL), including frozen items and fruit (1 serving = 1/2 cup of liquid).

9.6. Alcohol

Not more than one drink per day is recommended. This is equal to a glass of wine (5 oz./150 mL/12% alcohol), beer (12 oz./350 mL/5% alcohol), or one mixed drink (1 1/2 oz./50 mL/40% alcohol). In alcohol related heart failure, alcohol must be totally avoided.

9.7. Exercise Training

• All HF patients with stable symptoms and volume status should undertake regular, moderate intensity physical activity (aerobic and resistance exercises to maintain muscle mass)
• Aerobic physical activity: Start with 5-10 minute sessions every other day, working to a goal of 30-45 minutes per day 4-5 days per week
• Resistance exercises (do 10-15 repetitions at 50-60% of normal effort)

9.8. Immunization

All HF patients should be immunized for influenza (annually) and pneumococcal pneumonia (if not received in the last six years) to reduce the risk of respiratory infections.

9.9. Collaboration with complementary health care providers

• Involve Nurses, Pharmacists, Dieticians and Cardiac Exercise Therapists for individual or group visits when possible
• A Dietician can provide valuable education regarding the practical aspects of implementing a salt and water restriction, how to make healthy food choices and/or a group grocery store tour to help facilitate low-salt food and drink selections
• A Pharmacist may help patients remain on therapy when they are faced with side-effects and provide useful advice to help with medication compliance
• A Cardiac Exercise Therapist may be instrumental in helping HF patients develop and continue a structured exercise program

10. Pharmacotherapy for Heart Failure

• In general, research evidence for treatment is best established for systolic HF, although the underlying principles and pharmacotherapy also apply to HF with PSF. However, when treating HF with PSF, extra caution is required with ACE-I, vasodilators and diuretics to prevent symptomatic hypotension or pre-renal failure as LV filling pressures are volume dependent
• It is important to treat the following underlying cause where possible, especially in the case of HF with PSF:
• Hypertension (goal is blood pressure <140/90 mmHg)
• Ischemic heart disease
• Atrial fibrillation (goal ventricular rate between 60-80 at rest and <110 with exercise)
• Hypertrophic cardiomyopathy (consider referral to specialist)
• All patients with systolic HF should be on an ACE-I and a BB unless contraindicated (these medications should be strongly considered in patients with HF with PSF)
• Historically, an ACE-I was started first and titrated to target dose before starting a BB but current evidence suggests that it does not matter which drug is started first as long as both are titrated to target dose
• See Appendices regarding medication initiation and titration - BB should not be initiated in patients with volume overload
• ARB can be substituted for BB or ACE-I if they are not tolerated
• ARB can be cautiously added to patients with persistent symptoms despite optimal ACE-I and BB dose
• In the elderly, initial doses should be low and titrated slowly
• Concerns may arise as these medications are titrated upwards

Blood Pressure:

• When the systolic BP is below 80 mmHg, limit increase in medication if the patient shows symptoms of low BP (consider measuring postural vitals in the elderly)
• Take blood pressure lowering medication with food
• Separate the dosing of blood pressure lowering medications by at least 2 hours (i.e. give the ACE-I at noon and BB in the morning and at bedtime)
• If hypotension occurs during medication titration consider:
• Adding a higher dose at bedtime first, then increase the morning dose (if BID dosing)
• Decrease or discontinue the diuretic and/or vasodilator
• Consider temporarily reducing the ACE-I dose during BB titration
• Decrease the BB dose by 50% and reinitiate titration once condition stabilizes

Renal Function:

• If Creatinine (Cr) increases by >30% evaluate the patient’s volume status and consider reducing/holding diuretic (if volume deplete) before reducing/holding digoxin, ACE-I, ARB, spironolactone or BB
• Referral to a Nephrologist is encouraged when there is kidney impairment as defined by a Cr increase by >30%, an eGFR <30 mL/min or eGFR <45 mL/min if cause is unknown
• If a drug with proven mortality benefit is not tolerated by the patient (because of hypotension, bradycardia or progressive renal dysfunction) then reduce or discontinue other drugs without proven mortality benefit (namely digoxin, diuretics, calcium channel blockers, amiodarone)
• Diuretics are used to control fluid overload but the goal is to use the minimum effective dose. These drugs can sometimes be discontinued once the patient is asymptomatic
• An effective diuretic dose reduction is more often achieved after ACE-I and BB reach target doses
• By using the minimum effective diuretic dose, it is more likely that symptomatic hypotension and/or unacceptable increases in Cr with ACE-I or BB can be avoided

Aggressive Management of Cardiovascular (CV) Risk Factors (hypertension, diabetes, dyslipidemia, smoking, obesity) and other comorbid conditions is recommended:

• ASA 81 mg daily for patients with CV risk factors or established atherosclerosis
• Treat comorbidities and risk factors as per current guidelines

11. Indications for Referral to a Medical Specialist

• Cause of heart failure unknown
• Suspicion of ischemia or valvular disease as the primary cause
• Severe heart failure that is refractory or difficult to control
• Symptomatic arrhythmias
• LVEF≤ 35% (consideration of cardioverter-defibrillator implantation)
• Consideration for heart transplantation/implantable defibrillator/cardiac resynchronization
• Serum sodium <132 mmol/L (persistent after water restriction)
• Refer to a Nephrologist when renal function is impaired and/or deteriorating and the reason is not apparent (see chronic kidney disease guidelines)
• Refer to the Heart Function Clinic, Cardiac Rehabilitation or Risk Reduction Centre, and to a local Chronic Disease Management Program where available
• Refer to a Geriatric Medicine Specialist or to Long-Term Care Managers when an elderly patient has significant medical comorbidity, medication management issues, and/or significant cognitive, psychological and functional issues
• Advanced Practice Nurses provide integral specialist support of cardiac care in HF clinics where they provide nursing case management for ongoing surveillance and education of patients and family members

12. Heart Failure in the Elderly

• Elderly patients constitute one of the largest groups of patients with HF
• In general, HF medications are under prescribed despite the fact that this group derives a greater absolute benefit from these medications
• Treatment strategies in the elderly patient with HF are the same as other groups. However, care must be taken with respect to medication initiation and uptitration
• A gentle strategy to maximize long-term adherence is preferred because of the propensity for adverse events in this group (especially postural hypotension and digoxin toxicity)
• Assess for relevant comorbid conditions, such as cognitive impairment, that may affect treatment, adherence, follow-up and prognosis
• Identify a capable caregiver
• Consider referral to a specialist in geriatric medicine and/or community support staff

13. Management of Heart Failure with Comorbid Conditions

13.1. Chronic Kidney Disease

• HF patients with stable renal function (Cr < 200 µmol/L and eGFR >30 mL/min) should receive standard therapy with an ACE-I, ARB or spironolactone (use digoxin with extreme caution)
• Monitor serum Potassium (K+) and Cr levels more frequently, especially with combination therapy or in the case of an acute intercurrent illness
• HF patients with persistent volume overload or deteriorating renal function should be assessed for reversible causes - medications (especially NSAIDs), hypovolemia, hypotension, urinary tract obstruction or infection
• Stable oliguric HF patients - daily evaluation of the dose of diuretics, ACE-I, ARB, spironolactone and non-HF drugs that impair renal function is recommended (preferably as an inpatient)
• Stable non-oliguric HF and Cr increase >30% from baseline - consider reducing the dose of diuretics, ACE-I, ARB and spironolactone until renal function stabilizes
• Referral to a Nephrologist is encouraged when there is kidney impairment as defined by a Cr increase of >30%, an eGFR <30 mL/min or eGFR <45 mL/min if cause is unknown

13.2 Anemia (hemoglobin <110 g/L; generally symptomatic if <90 g/L)

• Investigations and treatment should be directed at the underlying cause
• Substrate deficiencies should also be replaced (iron, vitamin B12 or folate)
• There is no evidence to support the use of erythropoietin (or darbepoietin) in HF
• Consider blood transfusion if, after substrate deficiencies have been corrected, anemia and advanced symptoms persist

14. Management during Intercurrent Illness

• During acute intercurrent illness (i.e. pneumonia, COPD exacerbation) BB, ACEI and ARBs should be continued at their usual dose unless they are not tolerated
• If there is a concern about their use, then the dose can be halved during the illness and then uptitrated rapidly as soon as safely possible
• Only with a life-threatening complication should BB, ACEI and ARBs be discontinued abruptly
• HF patients with acute dehydrating illness should have prompt evaluation of their renal function and electrolytes even if they are not overtly volume depleted or overloaded
• If renal function worsens, adjust doses of diuretics, spironolactone, digoxin, ACEI, ARB as necessary
• If surgery is required, then patients with HF should be evaluated by a Physician experienced in HF management perioperatively
• If a patient with HF develops a gout exacerbation, the preferred treatment would include oral colchicine ± prednisone; avoid NSAIDs due to their role in exacerbating HF. Gout can be prevented with the use of allopurinol and/or a reduction in diuretic dose (as tolerated)

15. Ongoing Management

Comprehensive HF management is based on setting treatment goals and monitoring the effectiveness of management:

• Define and monitor cardiovascular goals and the key clinical indicators using a systematic approach (e.g. electronic medical record, flow sheet, file cards)
• Reverse congestion
• Control arrhythmia and ischemia
• Prevent emboli
• Stabilize vital signs (pulse, sit/stand blood pressure, weight)
• Use current drug and non-drug therapy for HF and for cardiovascular and non-cardiovascular comorbidity
• Review medications for intended and unintended effects (inappropriate polypharmacy, potential drug interactions, inadvertent aggravation of comorbid conditions)
• Monitor serum biochemistry (electrolytes, Cr/eGFR) over the short-term (days to two weeks) if the clinical condition or medications have changed . The frequency will depend on whether the current values are normal or abnormal and whether the patient continues to worsen or improve. When stable, remeasurement at six month intervals may be sufficient but will depend on clincal stability and changes in medications
• Monitor serum digoxin only if toxicity is suspected or for checking adherence
• Monitor and treat psychosocial consequences (i.e. non-compliance, anxiety, depression, fear, delirium, dementia, social isolation, home supports and need for respite care)
• Define and re-define the goals of treatment over time with the patient

16. Prognosis of Heart Failure

Outcomes in heart failure are highly variable and it is important to provide accurate information to patients about prognosis to enable them to make informed decisions about medications, devices, transplantation and end of life.

Poor prognostic factors include:

• Recurrent hospitalization for acute HF
• Advanced age (>75 years)
• Female gender
• Ventricular arrhythmias (non-sustained ventricular tachycardia) and atrial fibrillation
• NYHA HF Classes 3 and 4
• LVEF (<35%) or combined systolic and diastolic left ventricular dysfunction
• Marked left ventricular dilatation (LVEDD > 70 mm)
• High BNP levels (See Table 1) - use of BNP for prognostication requires further study
• Low-serum sodium (< 132 mmol/L)
• Hypocholesterolemia

The Seattle Heart Failure model is a valuable resource for prognostication found at http://depts.washington.edu/shfm/

17. Palliative and End-of-Life Care

Predicting time of death in HF is challenging given the cyclical nature of the disease. Helpful clinical prediction tools have been established. Discussions regarding end-of-life care should be initiated with patients who have persistent NYHA Class IV symptomatology or an EF < 25% despite maximal medical therapy (at target doses of study drugs as mentioned above).

Prior to initiating end-of-life care ensure that:

• All precipitating factors have been addressed including:
• Residual angina and hypertension
• Adherence to salt and fluid restrictions
• Adherence to medications
• Contributory conditions (arrhythmias, anemia, infections, thyroid dysfunction)
• All active therapeutic options have been appropriately considered:
• The patient is taking maximal medical therapy (target doses of study drugs)
• Biventricular pacing (possibly indicated with QRS > 120 ms)
• Implantable defibrillator (possibly indicated with LVEF < 30%)
• Revascularization (percutaneous intervention or bypass surgery)
• Transplantation options have been explored

Once the decision to initiate end-of-life care is made, the goal of therapy is to manage all symptoms (including those of comorbid conditions, e.g. chronic pain) and address function and quality of life issues.

Subsequent care should be based on the following principles:

• Support of dying patients and their families
  • Caregivers should be consulted to determine their degree of burden
  • It is important to ensure that advance care planning has been carried out, including financial and health care decisions (e.g. Representation Agreement)

• Control of pain and other symptoms
• Symptoms related to volume overload:
• Adequate diuretic use (sometimes more than one agent) is important
• ACE-I dose may need to be reduced if limited by symptomatic hypotension and renal impairment (Cr > 250 µmol/L or > 30% from baseline)
• Consider choice and dose of narcotic as renal function is likely impaired – i.e. Hydromorphone for narcotic naïve, Duragesic patch. → Consider home oxygen (See COPD Guidelines for indications)
• Decisions on the use of life-sustaining therapies
• Decisions need to be made as to whether and when to pursue hospital admission
• Consider referral to palliative care/hospice teams if available in the community
• Consider narcotic use with uncontrolled angina, or as a first-line for dyspnea

*Images provided by Microsoft Clip Art

Patient Management

Care Protocols

Care protocols, like medical and nursing procedures, allow staff to offer a consistent approach to managing clinic patients. Care protocols will allow caregivers to establish routines and govern tasks that are performed in the HF clinic as well as tasks that involve other hospital departments and outside agencies. Protocols ensure that key steps are taken to fill potential gaps in the system of care as the patient moves from clinic to hospital or from hospital to clinic.

The development of the following protocols may assist in enhancing the overall management of clinic patients:

• A protocol for patient referrals, which would involve two sub-protocols: one for patients who are referred for medical assessment, another for patients who are referred for patient education
• A protocol for discharge from hospital: this protocol would stipulate that a patient is either seen at discharge or at the clinic within 5 working days, or a telephone follow-up 2 days post-discharge will occur. This protocol should also describe clearly the sequence of events that occurs after discharge to ensure patients understand their care path
• A clinic notification protocol to outline when a patient has contacted the clinic about problems, and how those problems were dealt with. Guidelines for dealing with urgent vs. non-urgent calls
• A protocol for discharge from the clinic

Data Collection

Recent data suggest that, despite medical intervention, HF mortality remains high at a time when morbidity and mortality rates from other common cardiovascular diseases (such as myocardial infarction) are on the decline. Many heart failure patients experience frequent acute medical crises resulting in high hospital readmission rates and increased health care costs.

There is an urgent need to reduce mortality and morbidity associated with HF, reduce hospital admissions and readmissions, and improve patient management. HF clinics have been shown to be an effective alternative to inpatient management of this patient population.

Data collection, using a standard data-gathering tool, will allow practitioners to review and change practice patterns to enhance patient care and improve the quality of life for HF patients and their families.

In general, data collection will allow practitioners to monitor patient issues, measure clinical outcomes, track public health data, document the need for a HF clinic, secure clinic funding, and answer research questions.

Care Plan

A patient care plan, which specifies interventions and teaching done by staff and the anticipated patient outcomes, should be initiated and followed on all patients.

Such a care plan will ensure that patients receive optimum care and understand all facets of their diagnosis and long-term care. Care plans should be customized to meet the individual needs of each patient and should be developed with input from patients and family members.

Moreover, a care plan enhances communication and ensures continuity of care.

*Draft changes pending adoption by CHFN

Starting a HF Clinic

Assembling the Team

At a minimum, team members starting a multidisciplinary HF clinic should consist of:

Executive Sponsor
This person should be a member of the hospital executive who give the clinic the “rubber stamp” of approval and who will advocate on the clinic’s behalf.

Administrative Leader
The administrative lead should have the ability to hire staff, ensure the day-to-day operations are in order, provide support where needed and arrange for appropriate space and resources.

Physician Leader with expertise in HF Care
The Physician should provide clinical leadership as well as active involvement in preparing the protocols and pathways required for good patient care. The Physician should be committed to providing this leadership.

Nurse(s) with skills in heart failure and patient teaching
Within the multidisciplinary model, the Nurse should have extensive cardiac experience, specifically in HFcare. The Nurse should have skills in education and understand the concepts of chronic disease management.The level of nursing support decided upon may vary from clinic to clinic. Some clinics prefer the Nurse Practitioner role, others an expert Registered Nurse and others a hybrid of both roles. This is a decision that needs to be made with the team from the outset. Nurse Practitioners can provide a wider scope of care, whereas the registered nurse can practice with Physician orders. The scope of practice varies between provinces and we recommend that this is ascertained before starting.

Some examples of competencies required of the HF Nurse are:

• Able to provide heart failure self-management teaching and support
• Advanced cardiac assessment skills
• Confidence to introduce the concept of end of life planning
• Safely provide telephone support/advice to patients
• Able to use word processing, email, and spreadsheets on computer

Clerical support
The Clerk should be responsible for making appointments, registering the patients, phoning patients before the clinic, filing, preparing charts for the visit, taking calls, collating lab and test results for checking by the Physician/Nurse Practitioner.

Programs with the following resources should also consider support from the following health care providers:

• Pharmacist
• Dietitian
• Physiotherapist
• Social Worker
• Palliative Care
• Geriatrician
• Palliative Care
• Occupational Therapist

Staffing Levels

It is not easy to determine staffing levels. First, it is important to determine how many patients the clinic may expect. To do this, data around local HF demographics should be sought and a clear care pathway be defined to ensure that once the endpoint is reached that the patient is discharged back to their referring source.

A survey to determine patterns of staffing in heart function clinics across Canada was performed in 2004 (presented at Canadian Cardiovascular Congress, 2004 by Kaan A, Clark C and Edmonds M). Fifteen clinics responded and showed that:

• Most clinics (87%) function using the “Nurse-managed, Physician-directed” model of care. Meaning that the day to day function of the clinic is managed by the Nurse, however the care of patients is directed by the Physician. One clinic was directed by a Nurse Practitioner. As this survey is now 6 years old, this model may have changed somewhat
• 40% of clinics see 10-19 patients per week. There was great variation in the number of patients seen as some clinics were just one session per week and some ran 5 days per week
• On average, clinics see 8 patients per session
• Average caseload of RNs was 136 patients (range 60-200). One Nurse saw 10 to 20 patients per week
• One Clerk manages an average caseload of 50 patients per week
• 25% of nursing time involved clerical duties and data entry, the rest was telephone support, clinic visits and patient education

There must be a commitment to meet regularly to assess staffing levels based on the patient load and whether or not the patients are appropriate for the clinic.

Developing a Clinic Philosophy

The philosophy of the HF clinic should be spelled out early on. What is it that the clinic wants to achieve? This focuses the team and allows for planning of services.

Identifying Key Indicators

It is important to identify what indicators the clinic will measure to determine success and monitor progress. The CHFN recommends the following indicators: symptoms, quality of life, heart function, HF hospitalizations, CV hospitalizations, and survival.

Measuring Outcomes

Membership to the CHFN facilitates access to the National Database. For more information on applying for membership please go to http://www.chfn.ca/how-to-become-a-chfn-site.

Each new centre needs to have:

• A Physician leader of the HF clinic
• A commitment to HF management and follow up
• A Nurse (full or part time) with special expertise and training in HF management
• A sufficient number of HF patients and referral community
• A commitment to enter their patient data into the database with regular downloads to national database
• A willingness to sign a contract of agreement.

We make regular updates to our database to enhance implementation and usefulness. It is expected that you will upload data within 6 months of receiving the database. The CHFN pays a yearly licensing cost on your behalf. If data are not uploaded in 6 months then the summarized National data will not be sent to your centre. If data are not uploaded regularly a reminder will be sent and if no data are uploaded in four consecutive quarters then you would be required to pay the yearly licensing cost in order to remain a Network participant.

The database is designed as a local tool like an electronic medical record but also allows download of data without specific patient identifiers to the National Database. The data that is uploaded is secure and password protected, as the upload technology uses the same encryption technology used for online banking. All patients must sign a consent form before their unidentified data can be entered into the database and uploaded to the national database. There is a consent template located in the members section. Once we have approved and received your signed Program Agreement, you will get a username and password for the website.

Support

What we can give to you is the database to help organize and track your patients locally (you ‘own’ this data), opportunity to benchmark your clinic with the National data, opportunity to ask research questions of your data and that of the National data, use of the data to lobby more effectively for local resources, an invitation to come to our annual meeting currently held in conjunction with the Heart Failure Society of America in September, networking with like minded colleagues to improve the management of HF patients and to learn together, and access to all benefits of the website and the Network.

Team Development

The clinic should meet each month at least to review difficult cases, prepare a plan and to review clinic issues. An agenda should be prepared and action items prepared. Once a year, it is valuable for the team to meet in a “retreat” style to review outcomes, revise the goals and plan for the year. The CHFN database is able to provide centre specific reports that allows a program to track outcomes.

Documentation

Some sample documentation is included that may help with preparing local documentation: