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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,
NYHA Classification
Class Ordinary physical activity does not cause undue
I fatigue, palpitations, dyspnea and/or angina

Class Ordinary physical activity does cause undue

II fatigue, palpitations, dyspnea and/or angina

Class Less than ordinary physical activity causes undue

III fatigue, palpitations, dyspnea and/or angina

Class Fatigue, palpitations, dyspnea and/or angina occur

IV at rest
Criteria Committee of the New York Heart Association, 1964.
Heart Failure Population by NYHA Class

Class IV
Class III 240 K Class I
1.20 M (5%) 1.68 M
(25%) (35%)

Class II
1.68 M
AHA Heart and Stroke Statistical Update 2001
ACC/AHA Heart Failure Staging System
Stage Patient Description
A High risk for developing heart failure

Coronary artery disease
(HF) • Diabetes mellitus
• Family history of cardiomyopathy

• Previous myocardial infarction
Asymptomatic HF • Left ventricular systolic dysfunction
• Asymptomatic valvular disease

C Symptomatic HF
• Known structural heart disease
• Shortness of breath and fatigue
• Reduced exercise tolerance

D 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

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.
ACC/AHA Heart Failure Staging Therapy
Stage Patient Therapy
• Hypertension
A High risk for developing heart
failure (HF)

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

• Previous myocardial infarction
 Optimize drug therapy
Asymptomatic HF • ICD
Leftifventricular systolic
LV dysfunction dysfunction
(systolic) present
• Asymptomatic valvular disease

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

• Reduced exercise tolerance
 Intermittent IV inotropes
D Refractory end-stage HF

ICD as a bridge to transplantation
 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%)

 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 ½ pack day for 20 years
 No alcohol use
 Occasional marijuana use and history of prior cocaine

 Medication non-compliance due to inability to afford his

 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: ED for SOB and Chest pain
• 11/18: ICD placed C
• 12/4: ED for SOB which awoke him from
• 12/21: Fatigue, several days of dyspnea,
orthopnea and exercise intolerance
• 1/26: SOB and generally not well, 25 pound D
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%
– 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