SOAP. – Heart Failure – SỔ TAY LÂM SÀNG

Debbie A. Gunter

Definition

Heart failure (HF) is failure of the heart to pump sufficient blood to meet the metabolic demands of the tissues. The 2017 focused update of the 2013 guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) address management of heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF).

The 2017 focused update of the 2013 ACC/AHA guidelines for HF are available at www.onlinejacc.org/content/70/6/776. These guidelines include the following:

A.HFrEF:

1.Ejection fraction (EF) less than 40%, due to weak, inefficient systolic contractions. The left ventricular ejection fraction (LVEF) is a measurement of systolic failure.

2.S3 ventricular gallop rhythm commonly occurs.

3.Systolic failure is often the result of coronary heart disease (CHD) and/or myocardial infarction (MI).

4.It can result from right- or left-sided failure, or both.

B.HFpEF:

1.EF greater than 50%, but with poor compliance of the ventricle, which impedes ventricular diastolic filling (the ventricle is unable to relax).

2.There are two subgroups:

a.HFpEF borderline (or intermediate): Patients with an EF of 41% to 49%.

b.HFpEF with EF greater than 40% who previously had HFrEF (EF <40%), but improvement or recovery was noted in EF.

3.The patient may be asymptomatic for years.

4.HF presents with the same symptoms of systolic failure, pulmonary congestion, and peripheral edema.

5.S4 atrial gallop rhythm commonly occurs.

Incidence

A.HFrEF incidence is higher in older women, chronic hypertension (HTN), obesity, left ventricular (LV) hypertrophy, cardiomyopathy, excessive alcohol use, end-stage chronic obstructive pulmonary disease (COPD), valvular disorders, anemia, renal failure, atrial fibrillation (AF), coronary artery disease (CAD), or diabetes.

B.Approximately 5.7 million people in the United States have HF. By the year 2030, the AHA estimates that there will be a 46% increase in HF in patients with chronic diseases.

C.Americans over 40 have a 20% lifetime risk of developing HF.

D.There are 650,000 new patients diagnosed yearly.

E.The 5-year mortality rate is 50% from the time of diagnosis and the 1-year mortality increases to 50% if the patient has multiple admissions for HF in the same year.

F.There are one million hospitalizations per year and according to the Centers for Medicare and Medicaid Services (CMS), the rate of readmissions within 1 month nationally is 23% to 25%.

G.The current cost to treat HF exceeds $30 billion yearly and it is also estimated that the costs of direct patient care (healthcare services, hospitalizations, medications, etc.) for these patients with chronic disease will increase to approximately $53 billion by the year 2030.

Pathogenesis

A.Injuries to the myocardium may cause loss of functioning muscle. Compensatory mechanisms, including cardiac hypertrophy and neurohumoral processes, lead to adverse long-term effects. An inotropic insult results in incomplete emptying (systolic failure), and a compliance abnormality results in incomplete filling (diastolic failure). Most HF has some degree of both abnormalities.

Predisposing Factors

A.Atherosclerotic heart disease.

B.MI.

C.Rheumatic heart disease involving mitral and aortic valves.

D.Cardiomyopathies.

E.Hypertensive heart disease.

F.Aortic stenosis or regurgitation.

G.Thyrotoxicosis.

H.Pregnancy-related disorders, such as multiple births with preexisting heart disease.

I.Volume overload.

J.Beta-blockers or other cardiac depressants.

K.Pulmonary embolism (PE).

L.Systemic infection.

M.Arrhythmias.

N.Renal disease.

Common Complaints

Patients are assigned the New York Heart Association classifications by their tolerance of physical activity and shortness of breath (SOB). This classification may change according to their progression or regression of their cardiovascular disease (CVD) (see Table 13.4).

A.Dyspnea on exertion.

B.Hemoptysis.

C.Fatigue.

D.Cough.

E.Orthopnea.

F.Edema/weight gain.

G.Paroxysmal nocturnal dyspnea.

H.Nausea.

I.Right upper abdominal pain or fullness.

J.Chest pain.

K.Palpitations.

Other Signs and Symptoms

A.Hemoptysis.

B.Bibasilar crackles.

C.S3 gallop.

D.Murmurs.

E.Exercise intolerance.

F.Weakness.

G.Cough.

H.Orthopnea.

I.Nocturnal dyspnea.

J.Tachycardia.

K.Pallor.

L.Cyanosis.

M.Anorexia.

N.Constipation.

O.Jugular venous distention (JVD).

P.Hepatomegaly.

Q.Hepatojugular reflux (HJR).

TABLE 13.4 Functional Classification for Heart Failure

Functional Capacity Class I Objective Assessment A	No limitation. Ordinary activity does not cause undue fatigue, palpitation, dyspnea, or angina.	No objective evidence of CV disease
Functional Capacity Class II Objective Assessment B	Slight limitations. Fatigue, palpitation, SOB, angina with ordinary physical activity.	Objective evidence—minimal CV disease
Functional Capacity Class III Objective Assessment C	Marked limitations. No discomfort at rest. Fatigue, palpitation, SOB, and angina with less than usual activities.	Objective evidence—moderately severe CV disease
Functional Capacity Class IV Objective Assessment D	Inability to do physical activity without discomfort. Symptoms are present at rest and become worse with activity.	Objective evidence—moderately severe CV disease

CV, cardiovascular; SOB, shortness of breath.

R.Murmurs.

S.Exercise intolerance.

Subjective Data

A.Ask the patient if he or she has difficulty breathing.

B.Ask how many pillows he or she sleeps on. Does the patient need to sit up in a recliner to sleep?

C.Inquire about how often he or she wakes up at night with SOB.

D.Inquire about how far the patient can walk without getting SOB. Have the patient describe his or her routine activities of daily living and how well he or she tolerates each activity.

E.Discuss the patient’s history of heart disease, heart attack, HTN, or hyperlipidemia.

F.Ask the patient about current medications, as well as prescription, over-the-counter (OTC), and herbal products.

G.Question the patient regarding all symptoms found in the Common Complaints section.

H.Discuss drug and alcohol history.

I.Has the patient ever been treated for cancer/chemotherapy, and how long ago?

J.What is the patient’s usual weight? Has he or she experienced more symptoms if the patient has pedal edema?

K.Does the patient have a cough? (Consider angiotensinconverting enzyme inhibitors (ACEIs) as the cause.)

Physical Examination

A.Check pulse respirations, blood pressure (BP), pulse oximetry, height, and weight:

1.Check BP sitting, standing, and lying down.

2.Be alert for abnormal vital signs: Hypotension, narrow or wide pulse pressure, tachycardia, bradycardia, and tachypnea.

3.Calculate body mass index (BMI).

4.On all subsequent visits, note weight gain of more than 1 pound per day over 3 consecutive days or 3 pounds in 1 day.

B.Inspect:

1.Inspect overall physical appearance. Is the patient in distress?

2.Inspect skin: Note pallor, cyanosis, and temperature.

3.Inspect neck: Check jugular veins for distension.

4.Inspect extremities: Note edema, cyanosis, pallor, and ulcers.

C.Palpate:

1.Palpate abdomen for hepatomegaly and HJR.

2.Palpate extremities for peripheral pulses.

3.Palpate chest wall for displaced point of maximal impulse (PMI), lifts, heaves, and thrills.

D.Auscultate:

1.Auscultate heart for murmurs; tachycardia; S1, S3, or S4 gallops; and other abnormalities.

2.Auscultate lungs: Note moderate-to-severe crackles/rales and other abnormal sounds.

3.Auscultate neck and carotid arteries.

E.Mental status: Check mental status because confusion may occur, especially in the elderly.

Diagnostic Tests

A.Two-dimensional echocardiography with Doppler to evaluate LVEF.

B.Radionuclide ventriculography may be used to measure LVEF and LV volumes.

C.Coronary angiography.

D.Anterior/posterior chest x-ray.

E.ECG for patients with suspected arrhythmia, ischemia, or cardiac disease. Identify acute and old ECG changes to rule out pathologic Q wave, ST segment elevation, and LV hypertrophy.

F.Natriuretic peptides (BNP or NT-proBNP).

Differential Diagnoses

A.HF:

1.HFrEF.

2.HFpEF:

a.HFpEF borderline patients with an EF of 41% to 49%.

b.HFpEF patients with an EF greater than 40% who previously had HFrEF (EF, 40%) with improvement noted in EF.

B.Renal disease or nephrotic syndrome.

C.Liver disease.

D.Asthma.

E.Chronic obstructive pulmonary disease (COPD): To distinguish between progressing HF and a COPD exacerbation when both conditions are present, the presence of weight gain and an S3 gallop indicates HF, not COPD.

Plan

A.General interventions according to the 2017 Focused Update of the ACC/AHA guidelines for HF:

1.Determine the etiology of the failure state and treat appropriately.

2.Treat HF stages:

a.Stage A: Treat/manage the patient’s underlying conditions (HTN, AF, hyperlipidemia, diabetes, tobacco cessation, obesity, substance abuse [alcohol, cocaine, etc.]).

b.Stage B: Begin ACEIs or angiotensin receptor blockers (ARBs), if intolerant to ACEIs, along with beta-blockers for patients with HFrEF. Add statin therapy if patient has a history of MI. If patient has signs of water retention or has a history of water retention, diuretics should be started.

c.Stage C: HFrEF: Implantable cardioverter defibrillators and cardiac resynchronization therapy:

i.Digoxin may be added if the patient is still symptomatic and has been optimized on guideline-directed therapy to help manage symptoms.

ii.Hydralazine and isosorbide dinitrate are indicated for African American patients with HFrEF, patients with kidney dysfunction, or patients who cannot take ACE inhibitors or ARB therapy.

iii.Aldosterone receptor antagonist may be considered in the following scenarios: HFrEF less than 30% or 30% to 35% with QRS greater than 130 ms. Post-MI with EF less than 40% + (HF symptoms or diabetes) New York Heart Association (NYHA) II symptoms, and Scr less than 2.5mg/dL (glomerular filtration rate [GFR] >30 mL/min), serum potassium less than 5.

iv.Angiotensin receptor-neprilysin inhibitors (ARNIs) help prevent degradation of natriuretic peptides, bradykinin, and other vasoactive peptides. Research shows a reduction in composite endpoints of cardiovascular death or hospital admissions by 20%. Prior to starting, a washout of the previous ACEI is needed. Do not start within 36 hours of last dose of an ACEI.

d.Stage D: Advanced treatments such as cardiac transplant, mechanical support, home-based inotropic therapy, and/or hospice care.

3.The goals of therapy are to improve the patient’s quality of life by reducing symptoms, decreasing morbidity, and prolonging survival.

B.Patient teaching:

1.Teach the patient to weigh daily at the same time, on the same scale, and in the same clothing. The patient is to call if there are gains of more than 2 to 3 pounds in 1 day or more than 5 pounds in 1 week:

a.Develop a plan of care for the patient to increase the diuretic dosing for edema/weight gain to decrease dyspnea and prevent hospitalization. The directions could be to take an extra dose of the diuretic each day for several days until the weight gain, swelling, or symptoms improve.

2.Encourage weight loss if overweight.

3.Recommend regular, moderate exercise as long as dyspnea is not induced. Encourage exercise even though the patient may only tolerate a few minutes of walking to increase endurance and strengthen muscles.

4.Encourage smoking cessation.

5.Encourage medication adherence. Instruct the patient about all medications and possible side effects. Do not use OTC medicines without consulting the provider. nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in HF.

6.Utilize continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) for nighttime sleep and naps for treatment of obstructive sleep apnea (OSA).

C.Dietary management:

1.Read food labels for sodium content.

2.Teach dietary modifications, especially salt restriction of 2,000 to 3,000 mg/d for HFrEF and HFpEF. Less than 2,000 mg sodium per day is recommended in patients with moderate to severe HF symptoms.

3.Fluid restriction is not recommended unless the patient is classified as Stage D or is diagnosed with hyponatremia with sodium levels less than 130 mEq/L. Restrict fluid intake to 2,000 mL/d or less for patients with chronic fluid retention despite use of diuretics and sodium restrictions.

4.Alcohol consumption should be limited to one glass of beer or wine per day. This amount should be counted in the daily fluid restriction.

5.See Appendix B for the dietary approaches to stop hypertension (DASH) diet (Tables B.1–B.5).

6.Other diet changes include low fat/low cholesterol and the use of the following:

a.Monounsaturated fats, which decrease cholesterol:

i.Canola oil.

ii.Olive oil.

b.Polyunsaturated fats, which decrease cholesterol but not as well as monounsaturated:

i.Vegetable and fish oils.

ii.Corn, safflower, peanut, and soybean oils.

c.Avoid saturated fats:

i.Animal fats and some plant fats.

ii.Butter and lard.

iii.Coconut oil and palm oil.

D.Pharmaceutical therapy:

1.Therapy is based on extent of cardiac impairment and severity of symptoms. Medication regimens include a combination of the following classes: diuretics, ACEIs (ARBs if unable to tolerate ACEIs), cardioselective beta-blockers, inotropic agents such as Digoxin, vasodilators, nitrates, and anticoagulants if there is an increased risk of thrombus formation. In general, calcium channel blockers (CCBs) are not used in HF management.

2.Drug classifications for antihypertensive and cardiac medication are noted in Table 13.5.

E.Drugs that should be avoided and/or used with caution in HF because they cause exacerbations or are at high risk for adverse reactions include the following:

1.NSAIDs: Increased renal dysfunction, edema, impaired response to ACEI.

2.Cyclooxygenase (COX-2) inhibitors: Increased rate of HF and increased mortality.

3.Aspirin: Interaction between aspirin (ASA) and ACEI and interference with benefits of beta-blockers on LVEF.

4.Metformin: Increased risk of lethal lactic acidosis.

5.Thiazolidinediones: Fluid retention that may precipitate HF.

6.CCBs: Some data on possible effect on systolic dysfunction.

7.Antidepressants tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs): Major adverse cardiovascular events including HF, MI, stroke, and cardiovascular death.

8.Phosphodiesterase inhibitors (PDE-3, PDE-4, and PDE-5): Increased mortality.

9.Antiarrhythmic: Negative inotropic activity and further reduction in LV function can impair the elimination and result in toxicity of the antiarrhythmic.

10.Chemotherapy: Many are cardiotoxic.

11.Androgens-testosterone patch: Edema that may accelerate the rate of HF.

12.Theophylline serum levels may increase and cause toxicity due to acute decompensation of HF.

13.Sodium bicarbonate and Fleet Phospho soda contain significant quantities of sodium.

14.Herbal/supplements may also affect HF.

F.Biventricular pacing or an implantable defibrillator may be necessary for advanced HF.

G.Advanced HF therapies can include the following:

1.Inotropic therapy in hospital and in home.

2.Implanted mechanical-assist devices as a bridge to transplantation or as a destination therapy.

3.Heart transplantation.

H.Discuss the patient’s desire for an evaluation as a heart transplant candidate.

I.The pneumonia vaccination as well as yearly influenza immunization should be encouraged.

J.Discuss the need for compassionate care/hospice when HF does not respond despite maximal therapy.

Follow-Up

A.HF patients should be comanaged with a physician.

B.Close follow-up is essential if the patient is to be maintained as an outpatient.

C.Appointments every 1 to 2 weeks may be necessary, with additional appointments depending on the patient’s symptoms, such as increasing SOB, inability to lie flat to sleep, nocturnal moist cough, and increase in daily weight.

D.Lab monitoring is required for electrolytes, blood urea nitrogen (BUN), creatinine, proteinuria, and digoxin level.

Consultation/Referral

A.Consult a physician when the patient requires the next level up in pharmacologic management.

B.Consult a cardiologist for staging and hospital management.

Individual Considerations

A.Pregnancy:

1.HF is uncommon in healthy women without coexisting heart disease.

2.Pregnancy in a patient with heart disease is considered high risk.

3.Refer to a high-risk obstetrician.

B.Adults:

1.The 5-year survival rate is about 50% for both men and women.

2.Predictors of poor outcome include an EF of less than 25%, ischemic etiology, ventricular arrhythmias, serum sodium greater than 130 mEq/L, poor functional class, low cardiac index, and high filling pressures.

C.Geriatrics:

1.Common signs and symptoms of HF are less specific in older adults, and atypical symptoms may predominate.

2.Age-associated changes in pharmacokinetics must be taken into account when prescribing drugs for HF.

TABLE 13.5 Antihypertensive and Cardiac Medications (Sorted Alphabetically)

Brand Name	Generic Name	Drug Class
Accupril	Quinapril	ACE inhibitor
Aceon	Perindopril erbumine	ACE inhibitor
Adalat CC	Dihydropyridine/Nifedipine	Calcium channel blocker (CCB)
Aldactazide	Spironolactone + HCTZ	Combination—K + sparing + thiazide
Aldactone	Spironolactone	Diuretic-K + sparing
Altace	Ramipril	ACE inhibitor
Amiloride/HCTZ	Amiloride/HCTZ	Combination + diuretic
Atacand	Candesartan cilexetil	ARB
Atacand HCT	Candesartan + HCTZ	Combination—ARB + diuretic
Avalide	Irbesartan + HCTZ	Combination—ARB + diuretic
Avalide Avapro	Irbesartan + HCTZ Irbesartan	Combination ARB + diuretic ARB
Azor	Amlodipine + olmesartan	CCB + ARB
Benicar	Olmesartan medoxomil	ARB
Benicar HCT	Olmesartan + HCTZ	Combination—ARB + diuretic
Betapace	Sotalol	Beta-blocker/class II and III antiarrhythmic
Betapace AF	Sotalol	Class II and III antiarrhythmics
Betaxolol Bidil	Betaxolol HCL isosorbide dinitrate + hydralazine	Beta-blocker—cardioselective nitrate + diuretic
Bumex	Bumetanide	Loop diuretic
Bystolic	Nebivolol	Beta-blocker—cardioselective
Caduet	Amlodipine + atorvastatin	CCB/amlodipine/atorvastatin
Calan	Verapamil	CCB/antianginal
Calan SR	Verapamil	CCB
Capoten	Captopril	ACE inhibitor/CHF
Capozide	Captopril + HCTZ	Combination—ACE + diuretic
Cardizem LA	Diltiazem	CCB
Cardura	Doxazosin	Alpha-1 receptor antagonist (alpha blocker)
Catapres	Clonidine	Central alpha agonist
Chlorothiazide	Various	Thiazide diuretic
Chlorthalidone	Various	Monosulfamyl diuretic
Cleviprex	Dihydropyridine	CCB
Cordarone	Amiodarone	Class II and III antiarrhythmics
Coreg CR	Carvedilol	Beta-blocker—noncardioselective/CHF
Corgard Corlanor	Nadolol Ivabrandine	Beta-blocker—noncardioselective/antianginal HR reduction in SA node/antianginal
Corzide	Nadolol + HCTZ	Combination—beta-blocker (noncardioselective) + diuretic
Covera HS	Verapamil	CCB/antianginal
Cozaar	Losartan	ARB
Demadex	Torsemide	Loop diuretic
Digoxin	Digoxin	Cardiac glycoside/antiarrhythmic
Dilacor XR	Diltiazem	CCB/antianginal
Dilatrate SR	Isosorbide dinitrate	Nitrate
Diovan	Valsartan	ARB/CHF Class II–IV
Diovan HCT	Valsartan + HCTZ	Combination—ARB + diuretic
Diuril	Chlorothiazide	Thiazide diuretic
Dutoprol Dyazide	Metoprolol ext. release + HCTZ triamterene + HCTZ	Beta-blocker (cardioselective) + thiazide combination-K + sparing + thiazide
Dynacirc CR	Isradipine controlled release	CCBr
Edarbi	Azilsartan	ARB
Edarbyclor	Azilsartan + chlorthalidone	ARB + diuretic
Edecrin	Ethacrynic acid	Loop diuretic
Entresto	Sacubitril + valsartan	Neprilysin inhibitor + ARB
Exforge	Dihydropyridine + amlodipine	CCB + ARB
Fosinopril HCTZ	Various hydrochlorothiazide	ACE inhibitor thiazide diuretic
Hytrin	Terazosin	Alpha-1 blocker
Hyzaar	Losartan potassium + HCTZ	Combination—ARB + diuretic
Imdur	Isosorbide dinitrate	Nitrate
Inderal	Propranolol	Beta-blocker—noncardioselective/antianginal/antiarrhythmic
Inderide	Propranolol + HCTZ	Combination—beta-blocker (noncardioselective) + diuretic
Innopran XL	Propranolol HCL ext release	Beta-blocker—noncardioselective
Inspra	Eplerenone	Aldosterone receptor blocker—mineralocorticoid selective/CHF
Ismo	Isosorbide dinitrate	Nitrate
Isoptin SR	Verapamil	CCB
Isosorbide dinitrate	Various	Nitrate
Isosorbide mononitrate	Various	Nitrate
Kerlone	Betaxolol	Beta-blocker—cardioselective
Lanoxin	Digoxin	Cardiac glycoside/antiarrhythmic
Lasix	Furosemide	Loop diuretic
Levatol	Penbutolol sulfate	Beta-blocker—noncardioselective
Lopressor	Metoprolol tartrate	Beta-blocker—cardioselective/antianginal
Lopressor HCT	Metoprolol + HCTZ	Combination—beta-blocker (cardioselective) + diuretic
Lotensin	Benazepril	ACE inhibitor
Lotensin HCT	Benazepril + HCTZ	Combination—ACE + diuretic
Lotrel	Amlodipine + Benazepril	Combination—CCB + ACE inhibitor
Mavik	Trandolapril	ACE inhibitor/CHF
Maxzide	Triamterene + HCTZ	Combination—K + sparing + thiazide
Mexiletine	Various	Class IB antiarrhythmic
Micardis	Telmisartan	ARB
Micardis HCT	Telmisartan + HCTZ	Combination—ARB + diuretic

Microzide	HCTZ	Diuretic
Minitran	Nitroglycerin	Nitrate
Monoket	Isosorbide dinitrate	Nitrate
Monopril	Fosinopril	ACE inhibitor/CHF
Multaq	Dronedarone	Antiarrhythmic
Nicardipine	Various	CCB
Nitro-BID	Nitroglycerin	Nitrate
Nitro-Dur	Nitroglycerin	Nitrate
Nitrolingual	Nitroglycerin	Nitrate
Nitrostat	Nitroglycerin	Nitrate
Normodyne	Labetalol	Beta-blocker
Norpace	Disopyramide	Antiarrhythmics—class 1-ventricular
Norvasc	Amlodipine	CCB/antianginal
Pindolol	Pindolol	Beta-blocker—noncardioselective
Plendil	Felodipine	CCB
Prinivil	Lisinopril	ACE inhibitor/CHF
Prinzide	Lisinopril + HCTZ	Combination—ACE inhibitor + thiazide diuretic
Procanbid	Procainamide	Antiarrhythmics—class la-ventricular
Procardia XL	Nifedipine	CCB/antianginal
Quinidine gluconate	Various	Antiarrhythmics—class 1 atrial and ventricular
Quinidine sulfate	Various	Antiarrhythmics—class 1 atrial and ventricular
Ranexa	Ranolazine	Antianginal
Rythmol	Propafenone	Antiarrhythmics—class Ic-ventricular
Sectral	Acebutolol	Beta-blocker—cardioselective
Sular	Nisoldipine	CCBr
Tambocor	Flecainide	Antiarrhythmics—class Ic-ventricular
Tarka	Trandolapril + verapamil	Combination—ACE + CCB
Tekamlo	Aliskiren + amlodipine	Direct renin inhibitor + DHP CCBr
Tekturna	Aliskiren	Direct renin inhibitor
Tekturna HCT	Aliskiren + HCTZ	Direct renin inhibitor + thiazide diuretic
Tenex	Guanfacine	Central alpha agonist
Tenoretic	Atenolol + chlorthalidone	Combination—beta-blocker (cardioselective) + diuretic
Tenormin	Atenolol	Beta-blocker—cardioselective/antianginal
Teveten	Eprosartan	ARB
Teveten HCT	Eprosartan + HCTZ	Combination—ARB + diuretic
Thalitone	Chlorthalidone	Antihypertensive/diuretic
Tiazac	Diltiazem	CCB/antianginal
Tikosyn	Dofetilide	Class III antiarrhythmic
Timolide	Timolol maleate + HCTZ	Combination—beta-blocker (noncardioselective) + diuretic
Toprol XL	Metoprolol	Beta-blocker—cardioselective/antianginal/CHF class II or III
Trandate	Labetalol	Beta-blocker—noncardioselective
Tribenzor	Olmesartan + amlodipine + HCTZ	ARB + CCB + thiazide diuretic
Twynsta	Telmisartan + amlodipine	ARB + CCB
Uniretic	Moexipril + HCTZ	Combination—ACE + diuretic
Univasc	Meoxipril	ACE inhibitor
Valturna	Aliskiren + valsartan	Direct renin inhibitor + ARB
Vaseretic	Enalapril + HCTZ	Combination—ACE + diuretic
Vasotec	Enalapril	ACE inhibitor/CHF with digitalis and diuretics
Verelan PM	Verapamil	CCB
Zaroxolyn	Metolazone	Diuretic—quinazoline
Zebeta	Bisoprolol	Beta-blocker—cardioselective
Zestoretic	Lisinopril + HCTZ	Combination—ace + diuretic
Zestril	Lisinopril	ACE inhibitor/CHF with digitalis and diuretics
Ziac	Bisoprolol + HCTZ	Combination—beta-blocker (cardioselective) + diuretic

ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; CCB, calcium channel blocker; CHF, congestive heart failure; DHP, dihydropyridine; HCL, hydrochloride; HCTZ, hydrochlorothiazide, HR, heart rate, SA node, sinoatrial node.

3.Effective communication among health professionals, patients, and families is necessary.

4.Given the life-limiting nature of HF in frail older adults, it is critical for clinicians to discuss end-of-life issues with patients and their families as soon as possible. The Medicare hospice benefit is granted to patients who have been certified by two physicians to have a life expectancy of 6 months or less if their terminal illness runs its natural course. The criteria for determining that HF is terminal are:

a.NYHA Class III (symptomatic with less than ordinary activities) or IV (symptomatic at rest).

b.LVEF less than or equal to 20%.

c.Persistent symptoms despite optimal medical management.

d.Inability to tolerate optional management because of hypotension with or without renal failure.

5.Geriatric red flag:

a.For the older adult with existing cognitive, functional, or mobility impairments, the nurse practitioner (NP) should practice special consideration of the following geriatric syndromes if adding or increasing a diuretic:

i.Incontinence.

ii.Falls.

Avoid diuretics after 4 p.m. to reduce the risk of falls from attempting to get to the bathroom during the night. Discuss ways the patient can adjust fluid intake and toileting habits. Alert the patient that avoidance of incontinent episodes by reducing oral intake could result in dehydration and/or urinary tract infection.