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Class IV
Class III 240 K Class I
1.20 M (5%) 1.68 M
(25%) (35%)
Class II
1.68 M
(35%)
AHA Heart and Stroke Statistical Update 2001
ACC/AHA Heart Failure Staging System
Stage Patient Description
A High risk for developing heart failure
•
•
Hypertension
Coronary artery disease
(HF) • Diabetes mellitus
• Family history of cardiomyopathy
B
• 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
interventions)
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 Patient Therapy
• Hypertension
A
A High risk for developing heart
failure (HF)
•
Optimal
Coronary drug therapy
artery disease
Aspirin, ACE inhibitors, statins, -blockers, --
• Diabetes(carvedilol)
blockers mellitus diabetic therapy
• Family history of cardiomyopathy
B
B
• Previous myocardial infarction
Optimize drug therapy
Asymptomatic HF • ICD
Leftifventricular systolic
LV dysfunction dysfunction
(systolic) present
• Asymptomatic valvular disease
C
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%)
D
• Reduced exercise tolerance
Intermittent IV inotropes
D Refractory end-stage HF
ICD as a bridge to transplantation
CRT
Other devices (LVAD, LV restraint)
PMH:
Acute Renal Failure
Hypertension
Hyperlipidemia
Diabetes mellitus II (recently diagnosed)
Childhood asthma
B
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
use
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
sleeping
• 12/21: Fatigue, several days of dyspnea,
orthopnea and exercise intolerance
NYHA Class IV
• 1/26: SOB and generally not well, 25 pound D
weight gain since last admission
LVAD and Transplant Team Consults
Case Study: Assessment
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