Heart Failure In the Post acute and Long-Term Care Setting

Publication Date: October 1, 2015

Key Points

Key Points

  • HF is one of the top causes of 30-day hospital readmissions. Factors such as inadequate staff training and education, provider unavailability and failure to adhere to standard guidelines for care all contribute to increased rate. Randomized control trials of Skilled Nursing Facilities with a designated program focused on, and applied interventions for, HF readmission prevention and reduction have proven to reduce 30-day readmissions rates by 20% to 40%.
  • HF is a complex clinical syndrome that results from any structural or functional disorder that impairs the ability of the ventricles to fill with or eject blood at a rate commensurate with the body’s needs.
    • Differentiation of patients with HF based on left ventricular ejection fraction (LVEF) is important due to different underlying etiologies, demographics, co-morbidities and response to therapies. Consequently HF has been newly classified into 3 subdvisions – HF with preserved ejection fraction (HFpEF) ≥50%, HF with mid-range ejection fraction (HFmrEF) 40–49% and HF with reduced ejection fraction (HFrEF) ≤40%.
  • The AHA prevalence statistics show:
    • For the 60–79 year-old age group, the following have heart failure: 7.8% of men; 4.5% of women.
    • For the 80 years and older age group, the following have heart failure: 8.6% of men; 11.5% of women.
    • Characteristically, patients with HF typically also have hypertension as well as other medical comorbidities, including chronic obstructive pulmonary disease, chronic kidney disease, hyponatremia, and hematologic abnormalities.
  • Clinically, patients with preserved systolic function HFpEF are older and are more likely to be female, to have significant hypertension, and to have less coronary artery disease.

Table 1. Heart Failure in the Post-Acute and Long-Term Care Setting

General

Clinicians should avoid prescribing non-steroidal anti-inflammatory drugs (NSAIDs) to patients with heart failure (HF) since they may increase blood pressure and promote sodium and water retention. ( Strong , Moderate )
704
Use of the calcium channel blockers verapamil and diltiazem should be avoided in patients with HF with reduced ejection fraction. (These agents' negative inotropic effects may exacerbate HF). ( Strong , Moderate )
704
Treatment of anemia in congestive heart failure (CHF)
Use conservative blood-transfusion strategy (threshold transfusion of hemoglobin (Hgb) 7–8 g/dL in stable HF). ( Weak , Low )
704
Do NOT use erythropoiesis-stimulating agents in patients with mild to moderate anemia and HF. ( Strong , Moderate )
704
Intravenous iron carboxymaltose may be used in patients with stable HF. ( Weak , Moderate )
704
All patients with HF should receive counseling/education regarding self-care. ( Strong , Moderate )
704
Clinicians should discuss goals of care with patients with HF and their families. ( Strong , Low )
704
Patients with HF or advanced HF should receive palliative and supportive care as part of a comprehensive care plan designed to improve quality of life. Patients with Stage D HF should be offered palliative care and hospice enrollment. (Strong, Low)
704
All patients with HF who smoke should be counseled about smoking cessation. ( Strong , High )
704
Clinicians should individualize decisions about fluid and sodium restriction, balancing patient preferences, quality of life, and the objective benefit of relief of congestive symptoms. ( Weak , Moderate )
704
Cardiac rehabilitation may improve functional capacity and quality of life in patients with HF. ( Strong , Moderate )
704
Nutritional supplements should NOT be used as adjunctive therapy in patients with chronic HF. ( Strong , Moderate )
704
Effective systems of care coordination, with special attention to care transitions, should be deployed for every patient with chronic HF. ( Strong , Moderate )
704
When reviewing a patient's goals of care, clinicians should discuss deactivating pacemakers and implanted cardioverter defibrillators (ICDs). ( Strong , Low )
704
Clinicians should identify depression and treat it to remission to improve quality of life in patients with HF. ( Strong , Low )
704

Recognition

Unexplained weight gain in a patient may indicate new or worsening CHF. ( Strong , Moderate )
704
Unexplained tachycardia or hypoxemia in a patient may indicate new or worsening CHF. ( Strong , Moderate )
704

Assessment

Measurement of brain natriuretic peptides (BNP or NT-proBNP) may be useful to support a clinical diagnosis of HF in the setting of clinical uncertainty. ( Strong , High )
704
Measurement of BNP or NT-proBNP levels may be useful to assess disease severity or establish prognosis in chronic HF. ( Strong , High )
704

Treatment/Intervention

Loop diuretics should be used to improve symptoms in patients with HF and evidence of fluid retention. ( Strong , Low )
704
Angiotensin-converting enzyme (ACE) inhibitors are recommended to reduce mortality in patients with HF with reduced left ventricular ejection fraction (HFrEF). ( Weak , High )
704
Angiotensin-receptor blockers (ARB) should be prescribed to patients with HFrEF who are intolerant of ACE inhibitors. ( Strong , High )
704
Unless contraindicated, beta blockers are recommended to reduce morbidity and mortality in patients with HFrEF. ( Weak , High )
704
Unless contraindicated, aldosterone antagonists are recommended to reduce morbidity and mortality in patients with HF and ejection fraction of ≤35%. ( Weak , High )
704
The combination of hydralazine and isosorbide nitrates may decrease mortality or morbidity in African American patients with HFrEF. ( Weak , High )
704
Unless contraindicated, digoxin may decrease hospitalization for HF in patients with HFrEF. ( Weak , High )
704

Monitoring

For consistency, patients with HF should be weighed at the same time of day. ( Weak , Low )
704
Serum electrolytes and kidney function should be monitored regularly in patients with HF who are receiving diuretics. ( Strong , Low )
704
Nurses and aides should be educated about possible symptoms and signs of HF in order to better recognize and monitor patients with HF. ( Strong , Low )
704

Recognition

...ecognitio...

...entify Individuals With a History of HF...


...Identify Individuals Who Currently Have Sym...

...mptoms That May Suggest HF Having troubl...

...hat May Suggest HFHaving trouble viewing table? E...

...A Screening Tool for Caregivers (A NEW LEAF)Hav...


...Identify and Assess for Risk Factors...

...on Risk Factors for HF Exacerbatio...


Assessment

...essment...

...able 6. Clinical Events That Can Help to Identify...


...7. Indicators of Poor Cardiac Prognosis Ha...


...ecide if a Workup is Appropriate...


...erform Appropriate Imaging Studies to Help to El...

...Imaging for HF Having trouble viewi...


...if Interventions for Modifiable Risk Facto...

...New York Heart Association Heart F...


Treatment

...reatment

...op an Individualized Care Plan and Define Tr...


...ize Treatment for Comorbid and Contributi...

...ble Cardioverter-Defibrillators (ICD) and...

...e 10. Adjunctive TreatmentsHaving t...


...ure 1. Stages in the Developmen...


...eat Fluid Volume Overload if Present...


...ble 11. Diuretic Indications and Dos...


...t HF With HFrEF...

...HFrEF Stage C: Evidence-Based GDMT...

...Commonly Used for HFrEFHaving tro...

...ble 13. Medications for Treating HFrEF...

...Points about ACE inhibitors:...

...traindications to the Use of ACE Inhib...

...ble 15. Adverse Effects of ACE Inhibito...

...le 16. Risk Factors for Hypotension in Patie...

...ut Beta Blockers:...

...ntraindications to the Use of Beta-BlockersH...

.... Potential Adverse Effects of Beta-Blockers Hav...

...goxin ...

...rone Antagonists...

...nitrate/Hydralazine ...

...or Combinations of Treatments) That May Cause H...


...11: Treat HF with HFpEF...


...e 19. Medication Options for Treating H...


...: Initiate Cardiac Rehabilitation...

.... Phases of Cardiac RehabilitationH...


...Determine When The Patient Has End-Stage...

...1. Clinical Events That Can Help to Ide...


Monitoring

...itoring...

...14: Monitor the Patient’s Condition...

...mponents of Monitoring for HF PatientsHaving troub...


...or the Facility’s Management of HF...

Table 23. Sample Performance Measure...


...ze that people who reside in PA/LTC...