Managing Heart Failure in Primary Care: A Case Study Approach

Description

This guide provides a clear and concise overview of heart failure for primary care clinicians. Written by two nurse practitioners for nurses, nurse practitioners, physician assistants, medical students, and pharmacists, it is uniquely designed to bridge the gap between cardiology and primary care. It delivers the most current recommendations outlined by the American Heart Association and the Heart Failure Society of America guidelines for the management and treatment of heart failure. This book includes a comprehensive overview of heart failure with reduced ejection fraction and heart failure with preserved ejection fraction. Special chapters are dedicated to physical exam, interpretation and application of diagnostic testing, and the management of chronic illness in the setting of acute and chronic heart failure. Additionally, the book provides clinicians with guidance on common medications to avoid, patient education, successful transitions of care, and conversations regarding goals of care. Each chapter includes an overview and learning objectives. The “Practice Pearls” and case studies found throughout the text highlight key takeaway points. Foreword Preface Acknowledgments Contents Editors and Contributors About the Editors Contributors Part I: What Is Heart Failure? 1: Pathophysiology of Heart Failure 1.1 Introduction 1.2 Definition of Heart Failure 1.3 Factors that Govern Systolic Function 1.4 Neurohormonal Mechanisms 1.5 Correlation of Pathophysiology and Symptomology References 2: Heart Failure Across the Population 2.1 Epidemiology 2.2 Etiology 2.3 Classification and Stages of Heart Failure References Part II: Clinical Assessment of Heart Failure 3: Comprehensive Heart Failure History 3.1 Introduction 3.2 History: Etiology and Precipitating Factors of Heart Failure 3.2.1 Risk Factors 3.2.2 Coronary Artery Disease (CAD) 3.2.3 Valvular Heart Disease 3.2.4 Hypertension 3.2.5 Endocrine 3.2.6 Pregnancy 3.2.7 Family History/Genetics 3.2.8 Illicit Substances and Toxic Agents (Chemotherapy, Drugs, Alcohol) 3.2.9 Myocarditis 3.2.10 Connective Tissue and Systemic Disorders 3.2.11 Anemia 3.2.12 Nutritional Deficiencies 3.2.13 Arrhythmias 3.2.14 Idiopathic 3.3 History: Symptoms of Heart Failure 3.4 History Taking: Assessment of Symptom Severity 3.5 Sample History Taking: Etiology, Risk Factor Assessment, and Symptoms 3.6 Conclusions References 4: Physical Exam for Presence and Severity of Heart Failure 4.1 Introduction 4.2 General Inspection 4.3 Heart Rate and Rhythm, Blood Pressure, and Arterial Pulse 4.3.1 Heart Rate and Rhythm 4.3.2 Blood Pressure 4.4 Venous Congestion: Jugular Venous Pulse, Hepatojugular Reflux, Peripheral Edema, Hepatic Congestion, and Ascites 4.4.1 Jugular Venous Pressure and Hepatojugular Reflex 4.4.2 Peripheral Edema 4.4.3 Hepatic Congestion and Ascites 4.5 Pulmonary Congestion: Lung Examination 4.5.1 Respiratory Rate, Pattern, and Quality 4.5.2 Lung Sounds 4.6 Cardiac Examination: Examination of the Precordium, Heart Sounds, Heart Murmurs, Extra Sounds, and Rubs 4.6.1 Inspection and Palpation of the Precordium 4.6.2 Heart Sounds [39–41] 4.6.3 Heart Murmurs [39–41] 4.6.4 Pericardial Friction Rub and Other Extra Sounds 4.7 Putting It All Together: Assessment of Congestion and Perfusion References 5: The Cardiology Referral for Heart Failure: Work-up and Expectations 5.1 Initial Clinic Evaluation 5.1.1 General Approach 5.1.2 Physical Exam 5.1.3 Diagnostic Testing 5.2 Case Scenario: Diagnostic Testing 5.2.1 Assessment for the Etiology of Heart Failure 5.2.2 Assessment for Coronary Artery Disease 5.3 Case Scenario: Invasive Testing 5.3.1 Work-up for Nonischemic Cardiomyopathy 5.4 Case Scenario: Diagnosis 5.4.1 Putting It All Together References Part III: Heart Failure Management 6: Heart Failure with Reduced Ejection Fraction 6.1 Introduction 6.2 Epidemiology 6.3 Etiology 6.4 Prevention 6.5 Outpatient Management 6.5.1 Diagnosis and Evaluation 6.5.2 Patient History 6.5.3 Physical Exam 6.5.4 Diagnostic Evaluation 6.5.5 Clinical Presentation 6.5.6 Guideline-Directed Medical Therapy 6.5.7 Initiation, Titration, and Optimization 6.5.8 Adjunctive Therapies 6.5.9 Nonpharmacological Interventions 6.5.10 Device Therapy 6.6 Putting It All Together 6.6.1 Case Study 6.6.1.1 Subjective HPI 6.6.1.2 Past Medical History 6.6.1.3 Current Medical Regimen 6.6.1.4 Review of Systems 6.6.2 Objective 6.6.3 Assessment 6.6.4 Plan 6.6.5 Heart Failure with Reduced Ejection Fraction: Clinical Considerations 6.7 Conclusion References 7: Heart Failure with Preserved Ejection Fraction 7.1 Introduction 7.2 Definition 7.3 Epidemiology 7.4 Etiology 7.5 Prevention 7.6 Diagnosis of HFpEF 7.6.1 Natriuretic Peptides 7.6.2 Echocardiography 7.6.3 Invasive Diagnostics 7.6.4 Cardiac Magnetic Resonance 7.6.5 Diagnostic Algorithms 7.7 Clinical Mimics of HFpEF 7.7.1 Cardiac Amyloidosis 7.7.2 Hypertrophic Cardiomyopathy 7.7.3 Other Cardiomyopathies 7.7.4 Pericardial Disorders 7.7.5 Stiff Left Atrial Syndrome 7.8 Medical Management 7.8.1 Diuretics 7.8.2 Aldosterone Antagonists 7.8.3 Angiotensin Receptor-Neprilysin Inhibitor 7.8.4 Sodium-Glucose Co-transporter (SGLT) Inhibition 7.8.5 Pulmonary Artery Pressure Monitoring 7.8.6 Cardiac Rehabilitation 7.8.7 Coronary Revascularization 7.8.8 Hypertension Management 7.8.9 Atrial Fibrillation Management 7.8.10 Referral for Clinical Trials 7.9 Case Study 7.10 Conclusion References 8: Transitions of Care and Self-Care Strategies for the Heart Failure Patient 8.1 Introduction 8.2 Transition from Hospital to Home 8.3 Community Resources 8.4 Initial Post-discharge Clinic Visit 8.4.1 History 8.4.2 Physical Examination 8.4.3 Assessment of Weights 8.4.4 Medication reconciliation 8.4.5 Diagnostics and Laboratory Testing 8.4.6 Optimization of Guideline-Directed Medical Therapy 8.5 Self-Care Strategies for the Heart Failure Patient 8.5.1 Definition of Self-Care and the Importance of Symptom Monitoring 8.5.2 Role of Family Caregiver with Promoting Self-Care 8.5.3 Cultural Influences of Self-Care 8.5.4 Health Literacy, Self-Care Education, and Self-Efficacy 8.5.5 Overall Self-Care Strategies for Managing a Patient with Heart Failure 8.6 Putting It All Together References 9: Goals of Care for the Heart Failure Patient 9.1 Case Study: Setting the Stage 9.2 Palliative Care in Heart Failure 9.2.1 What Is Palliative Care? 9.2.2 Why Is Palliative Care in Heart Failure Important? 9.3 Current State of Palliative Care in Heart Failure 9.3.1 How and When to Refer to Palliative Care for the Primary Care Provider 9.4 Goals of Care Discussions in Heart Failure 9.4.1 Components of Goals of Care Conversations 9.4.2 Current State of Goals of Care Conversations 9.4.3 How to Initiate Goals of Care Conversations 9.5 Special Considerations for Goals of Care Conversations in Heart Failure 9.5.1 Difficulties in Discussing Goals of Care 9.5.2 Code Status Discussions 9.5.3 Defibrillator Device Deactivation 9.6 Hospice and End of Life Best Practices 9.6.1 Hospice Care 9.6.2 Barriers to Hospice Care Referral 9.7 Case Study: Putting It All Together References Part IV: Heart Failure and the Management of Co-morbidities in Primary Care 10: Atrial Fibrillation and Heart Failure 10.1 Introduction 10.2 Atrial Fibrillation-Induced Heart Failure 10.3 Heart Failure Induced Atrial Fibrillation 10.4 Other Causes of Atrial Fibrillation 10.5 Special Considerations 10.6 Treatment of Atrial Fibrillation and Heart Failure 10.7 Heart Failure and Rhythm Control 10.7.1 Antiarrhythmic Medications 10.7.2 Catheter Ablation 10.8 Heart Failure and Rate Control 10.9 Putting It All Together 10.9.1 Case Study 10.9.2 Objective 10.9.3 Assessment 10.9.4 Plan 10.9.5 Clinical Pearls References 11: Cardiorenal Syndrome, Chronic Kidney Disease, Anemia, and Heart Failure 11.1 Cardiorenal Syndrome 11.1.1 Definition 11.1.2 Pathophysiology 11.1.3 Differential Diagnosis 11.2 Diagnostic Tools 11.2.1 Biomarkers 11.2.2 Imaging 11.3 Treatment 11.3.1 Diuretics 11.3.2 Diuretic Resistance 11.4 Chronic Kidney Disease and Heart Failure 11.4.1 Definitions and Staging of CKD 11.4.2 Prevalence with Heart Failure 11.4.3 Prevention of Heart Failure in a Patient with CKD 11.5 Medication Limitations with CKD and Heart Failure 11.5.1 Beta Blockers 11.5.2 RAAS-Altering Medications 11.5.3 Mineralocorticoid Receptor Antagonists (MRAs) 11.5.4 Sodium-Glucose Cotransporter 2 (SLGT2) Inhibitors 11.6 Ultrafiltration and Dialysis with Heart Failure 11.7 Renal Transplant Considerations for Heart Failure 11.8 Hyperkalemia in CKD and Heart Failure 11.9 Anemia, Heart Failure, and CKD Considerations 11.9.1 Incidence and Associations 11.9.2 Pathophysiology of Anemia in Heart Failure 11.9.3 Diagnosis 11.9.4 Iron Replacement 11.10 Conclusion Case Study 1: Cardiorenal Syndrome Type II and Diuretic Resistance Case Scenario Objective Labs Diagnostics Assessment Plan Clinical Pearls Case Study 2: The Complex Interaction of CKD, HF, and Anemia Case Scenario Objective Clinical Pearls References 12: Diabetes and Heart Failure 12.1 The Bidirectional Link Between Diabetes and Heart Failure 12.2 Management of Type 2 Diabetes Mellitus 12.2.1 Evidence-Based Recommendations 12.2.2 Individualized Therapy 12.2.3 Cardiovascular Safety 12.2.4 T2DM and Kidney Disease 12.2.5 Special Considerations for Treatment of DM in Patients with HF 12.2.5.1 Individualized Glycemic Goals 12.3 Pharmacotherapy for T2DM 12.3.1 General Considerations 12.3.2 Metformin 12.3.3 SGLT-2 Inhibitors 12.3.4 GLP-1 Receptor Agonists 12.3.5 DPP-4 Inhibitors 12.3.6 Sulfonylureas 12.3.7 Thiazolidinediones 12.3.8 Insulin 12.3.9 Combination Therapy 12.4 Conclusion 12.5 Case Study 12.5.1 Subjective 12.5.2 Objective 12.5.3 Assessment 12.5.4 Plan 12.6 Clinical Pearls References 13: Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, and Heart Failure 13.1 Introduction 13.2 Obstructive Sleep Apnea 13.2.1 Obstructive Sleep Apnea Definition and Prevalence 13.2.2 Obstructive Sleep Apnea Risk Factors and Pathophysiology 13.2.3 Obstructive Sleep Apnea Concerns 13.2.4 Obstructive Sleep Apnea Evaluation and Management in the Presence of Heart Failure 13.3 Chronic Obstructive Pulmonary Disease 13.3.1 COPD Definition and Prevalence 13.3.2 COPD Chronic Bronchitis 13.3.3 Pathophysiology of Chronic Bronchitis 13.3.4 COPD Emphysema 13.3.5 Pathophysiology of Emphysema 13.3.6 COPD Clinical Manifestations 13.3.7 Heart Failure and Chronic Obstructive Pulmonary Disease Clinical Manifestations 13.3.8 Approach to the Management of Chronic Obstructive Pulmonary Disease and Heart Failure 13.3.9 Pharmacological Management of Chronic Obstructive Pulmonary Disease and Heart Failure 13.3.10 Medications Used in Comorbid Chronic Obstructive Pulmonary Disease and Heart Failure 13.3.11 Nonpharmacological Management of Comorbid Chronic Obstructive Pulmonary Disease and Heart Failure 13.3.11.1 Smoking Cessation 13.3.11.2 Cardiopulmonary Rehabilitation 13.3.11.3 Dietary Considerations 13.3.11.4 Recommended Vaccinations 13.4 Case Study References 14: Pulmonary Hypertension in Heart Failure 14.1 Introduction 14.2 Pathophysiology 14.3 Assessment of PH-LHD 14.4 Case Study 14.4.1 Interim Assessment and Plan 14.4.2 Follow-Up 14.5 Conclusions/Practice Pearls References 15: Liver Disease and Heart Failure 15.1 Introduction 15.2 Liver Disease Related to Heart Failure 15.2.1 Liver Diseases and Conditions That Exacerbate Heart Failure 15.2.1.1 Cirrhotic Cardiomyopathy 15.2.1.2 Nonalcoholic Fatty Liver Disease 15.2.1.3 Heart Failure Following Liver Transplant 15.3 The Role of Heart Failure in Liver Disease 15.3.1 Congestive Hepatopathy 15.3.2 Cardiogenic Ischemic Hepatitis 15.4 Approach to the Management of Liver Disease and Heart Failure 15.4.1 Pharmacologic Management 15.4.1.1 Nonalcoholic Fatty Liver Disease (NAFLD) 15.4.1.2 Heart Failure ACE Inhibitors ARBs ARNIs Beta Blockers Diuretics SGLT2 Inhibitors Aldosterone Antagonists Lipid-Lowering Agents Anticoagulant/Antiplatelet Therapy 15.4.1.3 Congestive Hepatopathy 15.4.1.4 Cardiogenic Ischemic Hepatitis 15.4.1.5 Post-Liver Transplant 15.4.2 Nonpharmacologic Management 15.4.2.1 Lifestyle Modifications Diet Exercise Weight Loss 15.5 Laboratory Monitoring and Diagnostics for Hepatic Complications in Heart Failure 15.5.1 Liver Function Tests 15.5.2 Synthetic Function Tests 15.5.3 Metabolic Markers 15.5.4 EKG 15.5.5 Echocardiogram 15.5.6 Risk Scores 15.5.7 Fibrosis Score 15.5.8 Model for End-Stage Liver Disease (MELD) 15.5.9 Child-Pugh Score 15.6 Case Study: Putting It All Together 15.6.1 Subjective 15.6.1.1 History of Presenting Illness (HPI) 15.6.1.2 Chronic Conditions Changes Since Last Visit 15.6.1.3 Past Medical History/Problem List 15.6.1.4 Family History 15.6.1.5 Social History 15.6.1.6 Medications/Allergies 15.6.1.7 Review of Systems (ROS) 15.6.2 Objective 15.6.2.1 Physical Examination 15.6.2.2 Labs and Risk Scores 15.6.3 Assessment 15.6.3.1 Plan 15.6.3.2 Nonpharmacology 15.7 Clinical Pearls 15.8 Conclusion References 16: Substance Abuse and Heart Failure 16.1 Alcoholic Cardiomyopathy 16.1.1 Overview of Alcoholic Cardiomyopathy 16.1.2 Prevalence of Alcoholic Cardiomyopathy 16.1.3 Pathophysiology of Alcoholic Cardiomyopathy 16.2 Clinical Presentation and Diagnostic Testing for Alcoholic Cardiomyopathy 16.2.1 History and Physical 16.2.2 Diagnostic Testing 16.3 Management of Alcoholic Cardiomyopathy 16.4 Prognosis of Alcoholic Cardiomyopathy 16.5 Additional Considerations for Alcoholic Cardiomyopathy 16.6 Case Study: Alcoholic Cardiomyopathy 16.7 Cocaine- and Methamphetamine- Induced Cardiomyopathy 16.7.1 Overview of Cocaine and Methamphetamine Use 16.8 Clinical Presentation and Diagnostic Testing in Setting of Cocaine and Methamphetamine Use 16.9 Methamphetamine-Induced Cardiomyopathy 16.9.1 Prevalence 16.9.2 Pathophysiology of Methamphetamine- Induced Cardiomyopathy 16.9.3 Clinical Presentation and Diagnostic Testing 16.10 Additional Considerations for the Primary Care Provider for Methamphetamine-Induced Cardiomyopathy 16.11 Case Study: Methamphetamine-Induced Cardiomyopathy 16.12 Clinical Pearls for Alcohol- and Cocaine-Induced Cardiomyopathy References 17: Human Immunodeficiency Virus and Heart Failure 17.1 Case Study 17.2 Background 17.3 HIV and Heart Failure 17.4 Pathophysiology and Clinical Presentation 17.4.1 Pre-ART Era or Limited ART Access 17.4.2 Contemporary ART Era 17.4.3 Clinical Implications 17.5 Risk Factors 17.5.1 Traditional Risk Factors 17.5.2 Nontraditional Risk Factors 17.6 Antiretroviral Therapy and HF 17.7 Evaluation and Management of HIV and Heart Failure 17.7.1 Diagnostic Testing and Advanced Therapy 17.7.2 Prognosis 17.8 Disparities in Care 17.9 Heart Failure Prevention 17.10 Case Study Discussion 17.11 Conclusion References 18: Medications to Avoid When Treating Heart Failure 18.1 Case Example 18.2 Case Discussion 18.3 Introduction 18.4 Potential for Medication-Induced Worsening HF 18.5 Evaluation of a Medication’s Potential for Harm 18.6 Prescription Medications That May Cause De Novo HF 18.6.1 Anticancer Medications 18.6.2 Alkylating Agents 18.6.3 Antimetabolites 18.6.4 Biologic Agents 18.6.5 TNF-α Inihibitors 18.6.6 Sympathomimetic Stimulants 18.6.7 Anagrelide and Cilostazol 18.6.8 Bromocriptine, Pramipexole, and Ergotamine 18.6.9 Hydroxychloroquine 18.7 Prescription Medications That May Exacerbate Chronic HF 18.7.1 Anti-Arrhythmic Medications 18.7.2 Antidepressants 18.7.3 Antidiabetes Medications 18.7.4 Calcium Channel Blockers 18.7.5 Mineralocorticoids 18.7.6 NSAIDs 18.7.7 Pulmonary Hypertension Medications 18.7.8 Carbamazepine 18.7.9 Itraconazole 18.7.10 Minoxidil 18.7.11 Pregabalin 18.7.12 Alpha-Adrenergic Antagonists 18.8 Conclusion References Part V: Heart Failure Case Studies 19: Heart Failure Case Studies 19.1 Case Study 1 19.1.1 Diuretic Resistance and Asymptomatic Hyperuricemia in HFpEF 19.2 Case Study 2 19.2.1 HFrEF Optimization Considerations in the Setting of Volume Depletion 19.3 Case Study 3 19.3.1 HFrEF Optimization Considerations in the Setting of Volume Overload 19.4 Case Study 4 19.4.1 Valvular Heart Failure 19.5 Case Study 5 19.5.1 Anemia in the Setting of HFrEF 19.6 Case Study 6 19.6.1 Heart Failure and Social Determinants of Health 19.7 Case Study 7 19.7.1 Heart Failure with Improved Ejection Fraction 19.7.1.1 HFimpEF 19.8 Case Study 8 19.8.1 Advanced Decompensated Heart Failure References