Planning

Determine Patients 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,

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

HF Case Study
SH:
Married
Smoking 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

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