Lippincott Williams & Wilkins



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OUTPATIENT TOOLS

Patient Identification Tools

Heart Failure Patient Assessment: Track important patient clinical data.

Physician Alert Letter: Inform physician that a mutual patient has been identified for SCA risk.

Identifying Patients at High Risk for Cardiac Arrest in Your Practice: Screen heart failure patient population via medical records to identify those at high risk for SCA.

SCA Provider Fact Sheet: Provide an overview of etiology, epidemiology, and treatment recommendations for SCA.

Heart Failure Outpatient Clinical Pathway: Detail essential elements of heart failure management and prevention of SCA.

SCA Prevention Medical Advisory Team

Gregg C. Fonarow, MD Nancy M. Albert, PhD, RN David Cannom, MD

UCLA Cleveland Clinic Good Samaritan Hospital

Los Angeles, California Cleveland, Ohio Los Angeles, California

William R. Lewis, MD Julie Shea, MS, RNCS Mary Norine Walsh, MD

MetroHealth Medical Center Brigham and Women’s Hospital The Care group, LLC

Cleveland, Ohio Boston, Massachusetts Indianapolis, Indiana

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Heart Failure Patient Assessment

Name: Age/date of birth:

Initial diagnosis: EF:

Date EF was obtained:

|Date of Visit | / / | / / | / / | / / |

| |/ |/ |/ |/ |

|Clinical and Diagnostic Assessment |

|Recent Hospitalizations|Describe reason(s): |Describe reason(s): |Describe reason(s): |Describe reason(s): |

|Weight | (kg/lbs) | (kg/lbs) | (kg/lbs) | (kg/lbs) |

| |□ Unable to weigh |□ Unable to weigh |□ Unable to weigh |□ Unable to weigh |

|BMI | | | | |

|Heart Rate (resting) | bpm | bpm | bpm | bpm |

|Blood Pressure |Sitting/Supine: mmHg |Sitting/Supine: mmHg |Sitting/Supine: mmHg |Sitting/Supine: mmHg |

| |Standing: mmHg |Standing: mmHg |Standing: mmHg |Standing: mmHg |

|QRS Duration | | | | |

|Atrial Fibrillation |□ Permanent |□ Permanent |□ Permanent |□ Permanent |

|Status |□ Persistent |□ Persistent |□ Persistent |□ Persistent |

| |□ Paroxysmal |□ Paroxysmal |□ Paroxysmal |□ Paroxysmal |

| |□ NSR |□ NSR |□ NSR |□ NSR |

|EF Assessed |□ Echo □ MUGA/RVG |□ Echo □ MUGA/RVG |□ Echo □ MUGA/RVG |□ Echo □ MUGA/RVG |

| |□ m |□ m |□ m |□ m |

| |EF: m |EF: m |EF: m |EF: m |

| |( / / |( / / |( / / |( / / |

| |) |) |) |) |

|Symptoms of |Dyspnea: Y N n|Dyspnea: Y N n|Dyspnea: Y N n|Dyspnea: Y N n|

|Volume Overload |Fatigue: Y N |Fatigue: Y N |Fatigue: Y N |Fatigue: Y N |

| |n |n |n |n |

| |Orthopnea: Y N n |Orthopnea: Y N n |Orthopnea: Y N n |Orthopnea: Y N n |

| |Other: |Other: |Other: |Other: |

| |n |n |n |n |

|Assessment of Clinical |Peripheral |Peripheral |Peripheral |Peripheral |

|Signs of Volume |edema : Y N |edema : Y N |edema : Y N |edema : Y N |

|Overload |n |n |n |n |

| |Rales: Y N |Rales: Y N |Rales: Y N |Rales: Y N |

| |n |n |n |n |

| |Hepatomegaly: Y N n |Hepatomegaly: Y N n |Hepatomegaly: Y N n |Hepatomegaly: Y N n |

| |Ascites: Y N |Ascites: Y N |Ascites: Y N |Ascites: Y N |

| |n |n |n |n |

| |Assessment of |Assessment of |Assessment of |Assessment of |

| |jugular venous |jugular venous |jugular venous |jugular venous |

| |pressure: Y N |pressure: Y N |pressure: Y N |pressure: Y N |

| |n |n |n |n |

| |S3 or S4 |S3 or S4 |S3 or S4 |S3 or S4 |

| |Gallop: Y N |Gallop: Y N |Gallop: Y N |Gallop: Y N |

| |n |n |n |n |

| |Other: |Other: |Other: |Other: |

| |n |n |n |n |

|Lab Tests |Please specify results: |Please specify results: |Please specify results: |Please specify results: |

| |□ Hb/Hct |□ Hb/Hct |□ Hb/Hct |□ Hb/Hct |

| |n |n |n |n |

| |□ BUN |□ BUN |□ BUN |□ BUN |

| |n |n |n |n |

| |□ Glucose |□ Glucose |□ Glucose n|□ Glucose |

| |n |n |□ Sodium n|n |

| |□ Sodium |□ Sodium |□ Potassium n |□ Sodium |

| |n |n |□ Creatinine n|n |

| |□ Potassium n|□ Potassium n |□ TSH |□ Potassium n|

| |□ Creatinine |□ Creatinine |n |□ Creatinine |

| |n |n |□ BNP |n |

| |□ TSH |□ TSH |n |□ TSH |

| |n |n |□ LDL |n |

| |□ BNP |□ BNP |n |□ BNP |

| |n |n |□ INR |n |

| |□ LDL |□ LDL |n |□ LDL |

| |n |n |□ Other |n |

| |□ INR |□ INR |n |□ INR |

| |n |n | |n |

| |□ Other |□ Other | |□ Other |

| |n |n | |n |

|Functional Status |□ NYHA Class I |□ NYHA Class I |□ NYHA Class I |□ NYHA Class I |

| |□ NYHA Class II |□ NYHA Class II |□ NYHA Class II |□ NYHA Class II |

| |□ NYHA Class III |□ NYHA Class III |□ NYHA Class III |□ NYHA Class III |

| |□ NYHA Class IV |□ NYHA Class IV |□ NYHA Class IV |□ NYHA Class IV |

| |□ Other assessment: |□ Other assessment: |□ Other assessment: |□ Other assessment: |

| | | | | |

| |n |n |n |n |

|Recommended Consults |Please specify: |Please specify: |Please specify: |Please specify: |

|Medical Therapy (Dose and Frequency) |

|Drug Intolerance(s)/ |Please specify: |Please specify: |Please specify: |Please specify: |

|Contraindications | | | | |

|Beta-Blocker |□ Carvedilol |□ Carvedilol |□ Carvedilol |□ Carvedilol |

| |n |n |n |n |

| |□ Metoprolol |□ Metoprolol n|□ Metoprolol n|□ Metoprolol |

| |n | | |n |

| |succinate |succinate |succinate |succinate |

| |□ Other |□ Other |□ Other |□ Other |

| |n |n |n |n |

|ACE Inhibitor |Specify medication: |Specify medication: |Specify medication: |Specify medication: |

| |□ |□ |□ |□ |

| |n |n |n |n |

|Angiotensin Receptor |□ Candesartan n |□ Candesartan n |□ Candesartan n |□ Candesartan n |

|Blocker |□ Valsartan |□ Valsartan |□ Valsartan |□ Valsartan |

| |n |n |n |n |

| |□ Other |□ Other |□ Other |□ Other |

| |n |n |n |n |

|Aldosterone Antagonist |□ Spironolactone n |□ Spironolactone n |□ Spironolactone n |□ Spironolactone n |

| |□ Eplerenone n |□ Eplerenone n |□ Eplerenone n |□ Eplerenone n |

|Hydralazine/ Nitrate |□ |□ |□ |□ |

| |n |n |n |n |

|Warfarin |Dose: |Dose: |Dose: |Dose: |

|(specify med) |Target INR: |Target INR: |Target INR: |Target INR: |

|Indication: | | | | |

|Antiarrhythmic |Specify medication: |Specify medication: |Specify medication: |Specify medication: |

| |□ |□ |□ |□ |

| |n |n |n |n |

|Diuretic |□ Furosemide n |□ Furosemide n |□ Furosemide n |□ Furosemide n |

| |□ Torsemide n|□ Torsemide n |□ Torsemide n |□ Torsemide n|

| |□ Metolazone n |□ Metolazone n |□ Metolazone n |□ Metolazone n |

| |□ HCTZ |□ HCTZ |□ HCTZ |□ HCTZ |

| |n |n |n |n |

| |□ Other |□ Other |□ Other |□ Other |

| |n |n |n |n |

|Digoxin |□ |□ |□ |□ |

| |n |n |n |n |

|Other |□ |□ |□ |□ |

| |n |n |n |n |

| |□ |□ |□ |□ |

| |n |n |n |n |

| |□ |□ |□ |□ |

| |n |n |n |n |

| |□ |□ |□ |□ |

| |n |n |n |n |

|Device Therapy |

|Device Therapy |□ CRT □ DDD pacer |□ CRT □ DDD pacer |□ CRT □ DDD pacer |□ CRT □ DDD pacer |

| |□ CRT-D □ VVI pacer |□ CRT-D □ VVI pacer |□ CRT-D □ VVI pacer |□ CRT-D □ VVI pacer |

| |□ ICD □ Other |□ ICD □ Other |□ ICD □ Other |□ ICD □ Other |

| |Brand: |Brand: |Brand: |Brand: |

| |n |n |n |n |

|Date of Implant | / / | / / | / / | / / |

| |/ |/ |/ |/ |

|ICD Therapy Administered |□ ICD Shock |□ ICD Shock |□ ICD Shock |□ ICD Shock |

| |□ ATP |□ ATP |□ ATP |□ ATP |

|ICD Shock(s) Documented |Cause of shock: |Cause of shock: |Cause of shock: |Cause of shock: |

|Notes |BiV pacing (%) |BiV pacing (%) |BiV pacing (%) |BiV pacing (%) |

| |n |n |n |n |

| |AFib burden |AFib burden |AFib burden |AFib burden |

| |n |n |n |n |

| |NSVT episodes (#) |NSVT episodes (#) |NSVT episodes (#) |NSVT episodes (#) |

| |n |n |n |n |

| |SVT episodes (#) |SVT episodes (#) |SVT episodes (#) |SVT episodes (#) |

| |n |n |n |n |

| |Volume alert |Volume alert |Volume alert |Volume alert |

| |n |n |n |n |

|Patient Education |

|Patient Education |A P |A P |A P |A P |

|A = Knowledge Assessed |□ □ Diet: 2000-mg NA |□ □ Diet: 2000-mg NA |□ □ Diet: 2000-mg NA |□ □ Diet: 2000-mg NA |

| |restriction |restriction |restriction |restriction |

|P = Education Provided |□ □ Exercise/activity |□ □ Exercise/activity |□ □ Exercise/activity |□ □ Exercise/activity |

| |promoted |promoted |promoted |promoted |

| |□ □ Daily weight |□ □ Daily weight |□ □ Daily weight |□ □ Daily weight |

| |monitoring |monitoring |monitoring |monitoring |

| |□ □ Disease process |□ □ Disease process |□ □ Disease process |□ □ Disease process |

| |□ □ Fluid intake |□ □ Fluid intake |□ □ Fluid intake |□ □ Fluid intake |

| |restriction |restriction |restriction |restriction |

| |□ □ Smoking cessation |□ □ Smoking cessation |□ □ Smoking cessation |□ □ Smoking cessation |

| |□ □ Medication |□ □ Medication |□ □ Medication |□ □ Medication |

| |compliance |compliance |compliance |compliance |

| |□ □ What to do for |□ □ What to do for |□ □ What to do for |□ □ What to do for |

| |worsened symptoms |worsened symptoms |worsened symptoms |worsened symptoms |

| |□ □ Device therapy |□ □ Device therapy |□ □ Device therapy |□ □ Device therapy |

| |□ □ Other: |□ □ Other: |□ □ Other: |□ □ Other: |

| |n |n |n |n |

Developed by the SCA Prevention Medical Advisory Team.

This is a general algorithm to assist in the management of patients.

This clinical tool is not intended to replace individual medical judgment or individual patient needs.

Please refer to the manufacturers’ prescribing information and/or instructions for use for the indications, contraindications, warnings, and precautions associated with the medications and devices referenced in these materials.

Sponsored by Medtronic, Inc.

April 2007

UC200705406 EN

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Dear Dr. ,

Our mutual patient, _________________________, has been identified as being potentially at high risk for sudden cardiac death, and may benefit from placement of an implantable cardioverter defibrillator (ICD) and/or cardiac resynchronization therapy (CRT) (also known as a biventricular pacer).

Our patient has been diagnosed with:

( Ischemic cardiomyopathy

( Nonischemic cardiomyopathy

Left ventricular ejection fraction (LVEF): ___________________________

Date: ______________ Method: __________________________

NYHA Functional Class: ______________

Heart Rhythm: _____________________ Date: ______________

QRS Duration: _____________________ Date: ______________

Date of most recent MI (if ischemic cardiomyopathy): _________

Date of last cardiac surgery: _______________

Anticoagulation status: ___________________

And is currently maintained on chronic optimal medical therapy.

Since our patient is potentially at high risk for sudden cardiac death, placement of an ICD and/or CRT is recommended to substantially reduce the risk of death.

At this point there are currently no contraindications to device implantation, however, it is recommended that this patient be formally evaluated for HF device placement with referral to

________________________________________.

If you have any questions, please contact me at:

Telephone:

Fax:

Voice mail:

E-mail:

Sincerely,

Developed by the SCA Prevention Medical Advisory Team.

Please refer to the manufacturers’ prescribing information and/or instructions for use for the indications, contraindications, warnings, and precautions associated with the medications and devices referenced in these materials.

Sponsored by Medtronic, Inc.

April 2007

UC200705403 EN

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Identifying Patients at High Risk for Sudden Cardiac Arrest

in Your Practice

Checklist

Patients with ischemic cardiomyopathy

Patient is:

❑ At least 40 days post-MI and

❑ LVEF ≤ 30% and

❑ NYHA Functional Class I, II, or III and

❑ On chronic optimal medical therapy

Patient does not have any of the following contraindications*:

❑ NYHA Class IV (unless eligible for CRT) or

❑ Cardiogenic shock or hypotension or

❑ CABG or PTCA within past 3 months or

❑ Candidate for coronary revascularization or

❑ Irreversible brain damage from preexisting cerebral disease or

❑ Other disease with survival < 1 year

If all checked, refer for consideration of ICD placement

 

Patients with ischemic or nonischemic cardiomyopathy

Patient is:

❑ At least 40 days post-MI (if ischemic)

❑ At least 3 to 9 months (if nonischemic)

❑ LVEF ≤ 35% and

❑ NYHA Functional Class II or III and

❑ On chronic optimal medical therapy

Patient does not have any of the following contraindications*:

❑ NYHA Class IV (unless eligible for CRT) or

❑ Cardiogenic shock or hypotension or

❑ CABG or PTCA within past 3 months or

❑ Candidate for coronary revascularization or

❑ Irreversible brain damage from preexisting cerebral disease or

❑ Other disease with survival < 1 year

If all checked, refer for consideration of ICD placement

CRT potential patient eligibility

Patient has:

❑ LVEF ≤ 35%

❑ Sinus rhythm

❑ NYHA Functional Class III or Ambulatory Class IV

❑ On recommended optimal medical therapy

❑ QRS duration ≥ 120 ms

Patient does not have any of the following contraindications*:

❑ Cardiogenic shock or hypotension or

❑ CABG or PTCA within past 3 months or

❑ Candidate for coronary revascularization or

❑ Irreversible brain damage from preexisting cerebral disease or

❑ Other disease with survival < 1 year

If all checked, refer for consideration of CRT placement

CRT-D – inclusion of CRT device with defibrillator should be based on ICD indications and physician discretion.

* These contraindications are included in the expanded CMS Coverage Guidelines for ICDs, effective January 27, 2005.

Reference

1 European Heart Rhythm Association; Heart Rhythm Society; Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for

management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American

College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for

Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients with Ventricular Arrhythmias

and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol. September 5, 2006;48(5):e247-346.

Developed by the SCA Prevention Medical Advisory Team.

This is a general algorithm to assist in the management of patients.

This clinical tool is not intended to replace individual medical judgment or individual patient needs.

Please refer to the manufacturers’ prescribing information and/or instructions for use for the indications, contraindications,

warnings, and precautions associated with the medications and devices referenced in these materials.

Sponsored by Medtronic, Inc.

April 2007

UC200705404 EN

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Sudden Cardiac Arrest Provider Fact Sheet

Sudden Cardiac Arrest (SCA) Is Responsible for a Significant Number of Deaths

that Are Preventable

• SCA claims more lives in the United States every year than lung cancer, breast cancer, and AIDS combined1

• Defibrillation within 6 minutes is critical to survive SCA; every additional minute reduces the chance of success by 7-10%. The overall survival from SCA is 5-10% without defibrillation2

• Ventricular fibrillation and tachycardia account for upwards of 70% of all SCA deaths3

• Randomized clinical trials have not shown that antiarrhythmic drug therapy can effectively reduce mortality in heart failure patients3

Primary Prevention of SCA

• MADIT-II (Multicenter Automatic Defibrillator Implantation Trial): 1,232 patients with prior myocardial infarction (MI) and left ventricular ejection fraction (LVEF) ≤ 30% randomized to optimal medical therapy alone or optimal medical therapy plus implantable cardioverter defibrillator (ICD), with follow-up for 20 months

– Significant reduction in all-cause mortality seen with ICD versus optimal medical therapy alone4

• SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial): 2,521 patients with New York Heart Association (NYHA) Class II or III heart failure with ischemic or nonischemic etiology and LVEF

≤ 35% receiving optimal medical therapy, randomized to optimal medical therapy and placebo, optimal medical therapy and amiodarone, or optimal therapy and ICD, followed for 45.5 months

– Decreased mortality with ICD therapy versus placebo or amiodarone5

• Risk of SCA increases exponentially when LVEF < 30%6

• Patients with mild heart failure should not be considered at lower risk for SCA; among patients with NYHA Functional Class II heart failure symptoms, SCA accounts for 64% of all deaths7

How to Explain the Difference between SCA

and Heart Attack to Your Patients

• SCA is an electrical and rhythm problem

that causes the heart muscle to quiver and not pump blood to the rest of the body

and brain

• Heart attack is caused by a blood flow problem in the heart when one or more of

the arteries delivering blood to the heart muscle become clogged or blocked.

Oxygen cannot get to the heart and the

heart muscle is damaged

ICDs are Recommended for the Following Patients 8-9

• With a life expectancy of greater than 1 year

• Class I (Level of Evidence A) Recommendations:

Current or prior symptoms of heart failure, reduced LVEF, and

– History of cardiac arrest

– Ventricular fibrillation

– Hemodynamically destabilizing tachycardia

Patients with ischemic heart disease†

– At least 40 days post-MI

– LVEF ≤ 30%, NYHA Class I symptoms; LVEF < 35%, NYHA Class II/III symptoms

Patients with cardiomyopathy of any origin†

– LVEF ≤ 30%

– NYHA Class II or III symptoms

• Class I (Level of Evidence B) Recommendations:

Patients with nonischemic cardiomyopathy†

– LVEF < 35%

– NYHA Class II or III symptoms

†On chronic optimal medical therapy.

See algorithms for details.

What Implanting Physician Needs to Know When Referring Patients for Further Evaluation

• LVEF and date – how assessed

• Length of time diagnosed with heart failure

• NYHA classification

• QRS duration

• History of syncope or VT

• Current or past atrial fibrillation

• Previous MI, CABG, and/or PCI and dates

• Most recent EKG, anticoagulation status, INR, serum Cr, and medication list

References

1 Heart Disease and Stroke Statistics – 2006 Update. American Heart Association; Dallas, TX; 2006.

2 Cummins RO. From concept to standard-of-care? Review of the clinical experience with automated external

defibrillators. Ann Emerg Med. December 1989;18(12):1269-1275.

3 Bayés de Luna A, Coumel P, Leclercq JF. Ambulatory sudden cardiac death mechanisms of production of fatal

arrhythmia on the basis of data from 157 cases. Am Heart J. January 1989;117(1):151-159.

4 Moss AJ, Zareba W, Hall WJ, et al; Multicenter Automatic Defibrillator Implantation Trial II Investigators. Prophylactic

implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med.

March 21, 2002;346(12):877-883.

5 Bardy GH, Lee KL, Mark DB, et al; Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone

or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. January 20, 2005;352(3):225-237.

6 Huikuri HV, Castellanos A, Myerburg RJ. Sudden death due to cardiac arrhythmias. N Engl J Med. November 15, 2001;

345(20):1473-1482.

7 Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart

Failure (MERIT-HF). Lancet. June 12, 1999;353(9169):2001-2007.

8 Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic

Heart Failure in the Adult – summary article: a report of the American College of Cardiology/American Heart Association

Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and

Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the

International Society for Heart and Lung Transplantation: endorsed by the heart Rhythm Society. Circulation.

September 20, 2005;112(12):e154-235.

9 Epstein AE, Dimarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. Heart Rhythm. June 2008;5(6):934-955.

Developed by the SCA Prevention Medical Advisory Team.

Please refer to the manufacturers’ prescribing information and/or instructions for use for the indications, contraindications,

warnings, and precautions associated with the medications and devices referenced in these materials.

Sponsored by Medtronic, Inc.

April 2007

Revised September 2008

UC200705819a EN

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Heart Failure Outpatient Clinical Pathway

| |PHASE 1: |PHASE 2: |PHASE 3: |PHASE 4: |

| |Initial Consult and Treatment |Optimization of Therapy |Reassessment and Further Optimization |Maintenance |

|I. |Complete history and physical including: |Perform interim history |Perform interim history |Perform interim history |

|Provider |Document weight, vital signs, orthostatic BP, HR, |and physical |and physical |and physical |

| |signs and symptoms indicative of volume status, |Document vital signs, |Document vital signs, |Document vital signs, |

| |waist circumference, BMI, functional status and |orthostatic BP, HR, and weight |orthostatic BP, HR, and weight |orthostatic BP, HR, and weight |

| |activity assessment, and assessment of |Assess signs and symptoms |Assess signs and symptoms |Assess signs and symptoms |

| |cardiovascular and noncardiovascular comorbidities |indicative of volume status |indicative of volume status |indicative of volume status |

| |or behaviors that might cause or accelerate the |Assess functional status |Assess functional status |Assess functional status |

| |development or progression of HF |and activity level |and activity level |and activity level |

| |Evaluate medications, including over-the-counter | | | |

| |medications, current or past alcohol use, | | | |

| |chemotherapy, diet, activity, fluid management, and | | | |

| |self-care/other factors that might influence HF status | | | |

| |(self-care practices: weight monitoring, sodium | | | |

| |restriction, alcohol restriction, fluid restriction, | | | |

| |physical activity, smoking cessation, medication | | | |

| |instruction, minimizing or avoiding NSAIDs, symptom | | | |

| |management, coping mechanisms) | | | |

| |Assess patient knowledge and self-care practices; | | | |

| |initiate patient education | | | |

| |Discuss advanced directives | | | |

|II. |If indicated: |Consultation p.r.n. |Consultation p.r.n. |Consultation p.r.n. |

|Consults |Subspecialty consultation (see algorithms) | | | |

| |Cardiac rehabilitation | | | |

| |Home healthcare | | | |

| |Nutritionist | | | |

| |Pharmacist | | | |

| |Social work | | | |

| |Hospice | | | |

| |Other services as indicated | | | |

|III. Diagnostic |1. Lab work: |1. Lab work as necessary: |1. Lab work as necessary: |1. Lab work as necessary: |

|Studies |CBC |Basic metabolic profile |Basic metabolic profile |Basic metabolic profile |

| |Comprehensive metabolic profile, calcium, |If taking aldosterone |If taking aldosterone |If taking aldosterone |

| |and magnesium |antagonist, check serum |antagonist, check serum |antagonist, check serum |

| |Lipid profile |potassium and creatinine at |potassium and creatinine at |potassium and creatinine at |

| |PT/INR (if on anticoagulation) |3 days, 1 week, 1 month |3 days, 1 week, 1 month |3 days, 1 week, 1 month |

| |HbA1c |(x 3 months), and then |(x 3 months), and then |(x 3 months), and then |

| |Thyroid-stimulating hormone |as needed |as needed |as needed |

| |Liver function test |Lipid profile (if indicated) |Lipid profile (if indicated) |Lipid profile (if indicated) |

| |UA |CBC (if indicated) |CBC (if indicated) |CBC (if indicated) |

| |BNP (if indicated) |Digoxin level if signs or |Digoxin level if signs or |Digoxin level if signs or |

| |Digoxin level if signs or symptoms of toxicity or |symptoms of toxicity or recent |symptoms of toxicity or recent |symptoms of toxicity or recent |

| |recent addition of interacting drug |addition of interacting drug |addition of interacting drug |addition of interacting drug |

| |2. Other procedures as appropriate: |PT/INR every month and p.r.n. |PT/INR every month and p.r.n. |PT/INR every month and p.r.n. |

| |Disease-specific screening labs as indicated |(if on anticoagulation) |(if on anticoagulation) |(if on anticoagulation) |

| |12-lead EKG; document QRS duration |HbA1c (if diabetic) |HbA1c (if diabetic) |HbA1c (if diabetic) |

| |Echo with Doppler flow studies; document EF |BNP (if indicated) |BNP (if indicated) |BNP (if indicated) |

| |Posterior-to-anterior (PA) and lateral chest x-ray | |2. Other procedures: |2. Other procedures: |

| |Consider noninvasive imaging to detect | |12-lead EKG |Echo/MUGA if there is a |

| |ischemia/viability | |Echo/MUGA |change in clinical status |

| |Consider left-heart catheterization, if indicated | | | |

|IV. |1. ACEI/ARB: initiate if not receiving prior therapy; |Assess if all indicated |Adjust medications as needed |Adjust medications as needed |

|Medical Therapy |if receiving therapy, titrate to target dose; |therapies have been titrated to |Assess use of over-the- |Assess use of over-the- |

|(See individual |document contraindications or intolerance; see |target dose |counter or nonprescription |counter or nonprescription |

|treatment |algorithm for details |Assess use of over-the- |therapies |therapies |

|algorithms |2. Beta blocker: initiate if not receiving prior therapy; |counter or nonprescription |Assess need for vaccination |Assess need for vaccination |

|for details) |if receiving therapy, titrate to target dose; document |therapies | | |

| |contraindications or intolerance; see algorithm |Assess need for vaccination | | |

| |for details | | | |

| |3. Aldosterone antagonist: initiate if not receiving prior | | | |

| | | | | |

| |therapy and post-MI with HF or diabetes or | | | |

| |moderately severe to severe HF symptoms; if receiving | | | |

| |therapy, dose per algorithm; document contraindications or | | | |

| |intolerance; see algorithm | | | |

| |for details | | | |

| |4. Hydralazine/isosorbide dinitrate: in black patients on | | | |

| |standard medical therapy including ACEI and BB; others may | | | |

| |benefit similarly but this has not yet been tested; see | | | |

| |algorithm for details | | | |

| |5. Diuretic: initiate or titrate as indicated by volume | | | |

| |status; see algorithm for details | | | |

| |6. Digitalis: for atrial fibrillation requiring rate | | | |

| |control or residual symptoms; see algorithm for details | | | |

| |7. Anticoagulation: for atrial fibrillation; document | | | |

| |contraindications; see algorithm for details | | | |

| |8. Antiplatelet therapy: if CAD, prior MI, diabetes, prior | | | |

| |CVA/TIA, or peripheral vascular disease | | | |

| |9. Lipid-lowering therapy: if hyperlipidemia, CAD, | | | |

| |prior MI, diabetes, prior CVA/TIA, or peripheral vascular | | | |

| |disease | | | |

| |10. Pneumococcal vaccination and annual influenza | | | |

| |vaccination are recommended in all patients with HF in the | | | |

| |absence of known contraindications | | | |

|V. |1. Indicated for secondary prevention if: |If existing device, device |Reassess LVEF and functional |Periodically reassess LVEF and |

|Device Therapy |Cardiac arrest due to VT/VF |interrogation and HF data |status (PMI: 40 days, |functional status; review |

|(See individual |Sustained VT/VF, spontaneous or induced by EPS |monitoring |nonischemic: 3-9 months); |indications for ICD/CRT per |

|treatment |Hemodynamically disabling VT | |review indications for ICD/CRT |algorithms |

|algorithms |Syncope | |per algorithms |If existing device, device |

|for details |2. Consider primary ICD and/or CRT for eligible | |Recommend ICD and/or CRT |interrogation and HF data |

|and ACC/AHA 2005 |patients receiving optimal medical therapy; see | |for eligible patients receiving |monitoring |

|HF Guideline |algorithms for details | |optimal medical therapy; see | |

|Update for |3. If existing device, device interrogation and HF | |algorithms for details | |

|references) |data monitoring | |If existing device, device | |

| | | |interrogation and HF data | |

| | | |monitoring | |

|VI. |Assess knowledge base, identify potential barriers to |Ongoing assessment of |Ongoing assessment of |Ongoing assessment of |

|Patient Education |adherence, and provide patient and family education: |knowledge base and |knowledge base and |knowledge base and |

| |Causes of HF |educational needs of patient |educational needs of patient |educational needs of patient |

| |What is ejection fraction? |and family |and family |and family |

| |Medication instruction |Review recommendations |Review recommendations |Review recommendations |

| |Minimizing/avoiding use of NSAIDs |Reassess adherence |Reassess adherence |Reassess adherence |

| |Risk of sudden death | | | |

| |Potential need for device therapy | | | |

| |ICD/CRT education | | | |

| |Diet | | | |

| |Activity | | | |

| |Smoking-cessation counseling | | | |

| |Limiting alcohol intake | | | |

| |Daily weight monitoring | | | |

| |Importance of adherence | | | |

| |Fluid management | | | |

| |Signs or symptoms of worsening condition | | | |

| |When to call provider | | | |

| |Social isolation/depression | | | |

| |Prognosis/end-of-life issues | | | |

|VII. |1. 2- to 3-gram sodium diet; < 2-gram sodium |Assess dietary adherence and |Emphasize importance of |Emphasize importance of dietary/fluid |

|Diet/ |restriction if moderate-to-severe symptoms |need for further dietary |dietary/fluid management |management adherence |

|Fluids |(NYHA Class III-IV) |education/counseling and/or |adherence | |

| |2. Low-saturated-fat, low-cholesterol diet (if indicated) |compliance monitoring | | |

| |3. Diabetic dietary teaching (if indicated) |Emphasize importance of | | |

| |4. Fluid restriction < 2 L/day is recommended in |dietary/fluid management | | |

| |patients with moderate hyponatremia (serum sodium |adherence | | |

| |< 130 mEq/L) and should be considered to assist in | | | |

| |treatment of fluid overload in other patients | | | |

|VIII. |1. Advise patient of the potential benefits of aerobic |Continue to assess and |Continue to assess and |Continue to assess and |

|Activity |activity and discuss initiation of a walking program |promote potential benefits of |promote potential benefits of |promote potential benefits of |

| |increasing to 30-60 min daily, as tolerated. |a physical activity program |a physical activity program |a physical activity program |

| |2. Discourage lifting, pushing, or pulling weights over | | | |

| |25 pounds | | | |

| |3. If homebound, evaluate for physical therapy | | | |

| |4. Consider referral to specialized cardiac | | | |

| |rehabilitation | | | |

|IX. |Provider follow-up: |Provider follow-up: |Provider follow-up: |Provider follow-up: |

|Monitoring |Medication adjustments |Medication adjustments |Medication adjustments |Medication adjustments |

|(See individual |Symptoms |Symptoms |Symptoms |Symptoms |

|treatment |Problems |Problems |Problems |Problems |

|algorithms |Lab results and follow-up labs |Lab results and follow-up labs |Lab results and follow-up labs |Lab results and follow-up labs |

|for details) |Phone-in prescriptions as needed |Phone-in prescriptions |Phone-in prescriptions |Phone-in prescriptions |

| |Consider referral to comprehensive HF disease |as needed |as needed |as needed |

| |management program for patients recently |Consider referral to |Consider referral to |Consider referral to |

| |hospitalized for HF or other patients at high risk |comprehensive HF disease |comprehensive HF disease |comprehensive HF disease |

| |Device monitoring (device function, rhythm, |management program for |management program for |management program for |

| |antiarrhythmic therapy, pacing, heart rate variability, |patients recently hospitalized for |patients recently hospitalized for |patients recently hospitalized for |

| |patient activity, volume status) |HF or other patients at high risk |HF or other patients at high risk |HF or other patients at high risk |

| |Overall plan adherence |Device monitoring (device |Device monitoring (device |Device monitoring (device |

| | |function, rhythm, |function, rhythm, antiarrhythmic |function, rhythm, antiarrhythmic |

| | |antiarrhythmic therapy, |therapy, pacing, heart rate |therapy, pacing, heart rate |

| | |pacing, heart rate variability, |variability, patient activity, |variability, patient activity, |

| | |patient activity, volume status) |volume status) |volume status) |

| | |Overall plan adherence |Overall plan adherence |Overall plan adherence |

Developed by the SCA Prevention Medical Advisory Team based on the ACC/AHA and HFSA Guidelines.

This is a general algorithm to assist in the management of patients.

This clinical tool is not intended to replace individual medical judgment or individual patient needs.

Please refer to the manufacturers’ prescribing information and/or instructions for use for the indications, contraindications,

warnings, and precautions associated with the medications and devices referenced in these materials.

Sponsored by Medtronic, Inc.

April 2007

UC200705405 EN

-----------------------

Patients at high risk for sudden cardiac arrest include those with EF ≤ 40%, particularly those with EF ≤ 35%, regardless of etiology, with or without heart failure symptoms.1

Alternative Primary Screen

Screen all ventricular function studies for LVEF ≤ 35%

Primary Screen

Screen Medical Records Using ICD-9 Codes:

402 – Hypertensive heart disease with heart failure

404 – Hy数瑲湥楳敶栠慥瑲愠摮爠湥污搠獩慥敳眠瑩⁨敨牡⁴慦汩牵൥ㄴ‰ₖ捁瑵⁥祭捯牡楤污椠普牡瑣潩൮ㄴ‱ₖ捁瑵⁥潣潲慮祲猠湹牤浯൥ㄴ′ₖ汏⁤祭捯牡楤污椠普牡瑣潩൮ㄴ‴ₖ瑏敨⁲潦浲⁳景挠牨湯捩椠捳敨業⁣敨牡⁴楤敳獡൥㈴‵ₖ慃摲潩祭灯瑡票㐍㠲阠䠠慥瑲䘠楡畬敲഍匍捥湯慤祲匠牣敥楮杮䤠pertensive heart and renal disease with heart failure

410 – Acute myocardial infarction

411 – Acute coronary syndrome

412 – Old myocardial infarction

414 – Other forms of chronic ischemic heart disease

425 – Cardiomyopathy

428 – Heart Failure

Secondary Screening Information

Screen Medical Records:

Date of last office visit: ____________ _______

• Assess recent LV function: Document LVEF ______ ___ Date:__________________

• Assess ventricular dyssynchrony: document QRS duration from recent

EKG QRS (ms) _____ __ Date: _________ _______ and/or measure of mechanical dyssynchrony

Study: ____ ____ Measure: ______ ___ Date: _________________

• Assess medication regimen: Has optimal heart failure therapy with ACEI/ARB, evidence-based

beta blocker, aldosterone antagonist been achieved?

• Assess functional status and symptoms: NYHA Functional Class ____ __ Date: __________________

• Duration of HF symptoms: _______________

• Date of last MI: _______ ____

• Date of last cardiac surgery: _______ ____

Treatment Decision Point:

( Schedule patient follow-up to optimize/uptitrate medical therapy

( Schedule patient follow-up to assess LV function, QRS duration, NYHA Functional Class

( Assess for indications and contraindications to device therapy; see individual algorithms for details

( If patient eligible, initiate discussion with patient regarding risk for Sudden Cardiac Arrest and device options to

reduce risk

( Refer to Sudden Cardiac Arrest fact sheets and Patient FAQ sheets to aid in patient discussion

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