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HOSPITAL ADMISSION AND DISCHARGE TOOLS

Hospital Admission Orders

Chest Pain/Acute Coronary Syndrome Admission Orders: Provide an overview of diagnostic and therapeutic recommendations.

Heart Failure Admission Orders: Provide an overview of diagnostic and therapeutic recommendations.

Hospital Discharge Tools

Heart Failure Admission to Discharge Checklist: List all recommended therapies and diagnostic tests during hospitalization.

Discharge Summary Checklist: List all recommended therapies and follow-up.

Patient Discharge Contract, Heart Failure: Facilitate patient adherence to healthcare provider recommendations.

Patient Discharge Contract, Acute MI: Facilitate patient adherence to healthcare provider recommendations.

Physician Letter Template: Communicate patient risk for 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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Chest Pain/Acute Coronary Syndrome

Admission Orders

1. Include Date and Time on orders

2. Check all appropriate orders

Intern: Resident: Attending:

Pager: Pager: Pager:

|General |

|Date | |

|Time |Admit to: ( CCU ( Telemetry ( Other __________ SERVICE: |

|Diagnosis |( STEMI ( Non-STEMI ( Unstable Angina ( Chest Pain ( Other __________ |

|Condition |( Good ( Fair ( Guarded |

|Allergies |( NKDA ( Allergy: |

|Nursing |

|Vital Signs |( Per unit routine ( Q _____ |

| |( Call House Officer if: SBP > _____ mmHg or SBP < _____ mmHg; HR >_____ or HR < _____; |

| |  RR > _____ or RR < _____; T > _____ |

|Activity |( Bed rest ( Bed rest with commode privileges |

| |( Out of bed to chair with assistance (BID, TID) ( Ambulate in hall with assistance (BID, TID) |

| |( Physical therapy consultation ( Cardiac rehabilitation consultation |

|Diet |( NPO (except for meds) |

| |( _____ calorie-restricted diet, no caffeine |

| |( CAD/ACS Diet (4 gram Na, low cholesterol), no caffeine |

| |( Heart Failure Diet (2 gram Na), no caffeine |

| |( Other ______________________________________________ |

|IV Fluids |( HEPLOCK with 3 mL normal saline flush Q12 hours (document on flow sheet 0800H and 2000H) |

| |( _____ NS with _____ mEq KCL/L @ _____ mL/hour x _____ hours |

|I/O and Weight |( Strict recording of Ins and Outs with running totals of urine output to be recorded |

| |( Daily AM weights; record in chart |

|Foley |( If patient is unable to void, place Foley catheter |

|Monitoring |( Pulse oximetry: ( continuous ( Q _____ |

| |( Accucheck Q _____ |

|Oxygen |( O2 _____ L/min nasal cannula for chest pain, shortness of breath, SaO2 < 93% |

|Laboratory |

|On Admission |(DO NOT DUPLICATE LABS DONE FOR POST CATH/PCI ORDERS) |

| |( CBC with differential and platelets |

| |( Electrolytes ( BUN ( Creatinine ( Glucose ( Mg ( Ca ( PO4 ( Uric Acid |

| |( HbA1c |

| |( CPK total and MB NOW and 6 hours |

| |( Cardiac troponin I NOW and 6 hours |

| |( PT/INR (if patient receiving warfarin) ( PTT (if patient treated with heparin/LMWH) |

| |( BNP (if indicated) |

| |( Liver function tests: ( AST ( ALT ( Alk Phos ( Total Bili ( Cong Bili ( __________ |

| |( Cardiovascular lipid panel (nonfasting) |

| |( hs-CRP (if indicated) (Cardio-CRP) |

| |( Others:__________________________________________________________________ |

| |( Others:__________________________________________________________________ |

|In AM |( Electrolytes ( BUN ( Creatinine ( Glucose ( Mg ( Ca ( PO4 ( Uric Acid |

| |( CBC with differential and platelets |

| |( PT/INR (if patient receiving warfarin) |

| |( PTT (if patient treated with clopidogrel or heparin) |

| |( Others: __________________________________________________________________ |

| |( Others:___________________________________________________________________ |

|Medication |

|(ACC/ AHA Guideline |Aspirin |

|Class I Recommendations|( Aspirin 325 mg PO NOW chewed (unless given in Emergency Dept.) |

|Indicated in Bold) |( Enteric coated Aspirin 81 mg PO QAM |

| |( Other: ______________________________ |

| |Clopidogrel |

| |( Clopidogrel 600 mg PO NOW (unless given in Emergency Dept.) |

| |( Clopidogrel 75 mg PO daily |

| |Beta-Blocker |

| |( Metoprolol Tartrate 5 mg IVP over 2 min, repeat Q 5 min X2 (hold for SBP < 90 mmHg, |

| |symptomatic bradycardia, severe reactive airway disease, decompensated HF) |

| |( Metoprolol Tartrate 25 mg PO Q 6H x 48 hours, then 50 mg PO BID (hold for SBP < 90 mmHg, |

| |HR < 50) |

| |( Carvedilol 6.25 mg PO BID x 48 hours, then 12.5 mg PO BID (hold for SBP < 90 mmHg, HR < 50) |

| |preferred if EF 100 mmHg |

| |( ____________________________________________ |

| |( ____________________________________________ |

| |( ____________________________________________ |

| |( ____________________________________________ |

| | |

|PRN Medications |( Acetaminophen (Tylenol®) 650 mg PO Q 4H PRN pain, HA or fever T > 38.5 |

| |( Morphine Sulfate __________ mg IVP Q 2H PRN severe pain |

| |( Mylanta II 15 mL PO Q 6H PRN dyspepsia or GI upset |

| |( Docusate Sodium (Colace®) 100 mg PO BID |

| |( Famotidine (Pepcid®) 20 mg PO BID |

| |( Pantoprazole (Protonix®) 40 mg PO QD |

| |( Metoclopramide (Reglan®) 10 mg PO or IV Q 6H PRN nausea (give IV if unable to tolerate PO) |

| |( Regular Insulin Sliding Scale: Standard |

| |( _________________________________________ |

| |( _________________________________________ |

|Tests |

| |( EKG on admission and 6 hours later and with CP |

| |( Chest X-ray (PA and lateral) |

| |( Echocardiogram (if indicated) |

| |( Stress Testing ___________________ (if indicated) |

| |( Confirm physician has reviewed second ECG and second set of cardiac enzymes prior to sending |

| |patient to stress test |

| |( EP device interrogation (ICD, CRT, pacemaker) Brand:____________________ |

| |( Other: ____________________________________________________ |

| |( Other: ____________________________________________________ |

|Vaccinations |

|Pneumococcal Vaccine |INDICATED FOR ALL ACS PATIENTS (Adult) |

| |CONTRAINDICATIONS: Previous SEVERE reaction to vaccine |

| |( INDICATED: Administer 0.5 mL IM x 1 dose on day of admission |

| |( NOT INDICATED: ( previously vaccinated, Date _______ ( Other reason: _______________ |

| |( Patient refusal |

|Influenza Vaccine |INDICATED FOR ALL ACS PATIENTS (October thru February) |

| |CONTRAINDICATIONS: Allergy to eggs; previous SEVERE reaction to vaccine; history of |

| |Guillain-Barre Syndrome |

| |( INDICATED: Administer 0.5 mL IM x 1 dose on day of admission |

| |( NOT INDICATED: ( previously vaccinated, Date _______ ( Other reason: _______________ |

| |( Patient refusal |

|Protocols |

| |( Cardiac Risk Factor Modification Teaching and Documentation |

| |( ACS Education and Documentation |

| |( Smoking Status: ( current ( former ( nonsmoker ( unknown |

| |( Smoking Cessation Counseling and Patient Education Materials |

| |( Outpatient Cardiac Rehabilitation Assessment and Referral |

| |( Nutrition Consultation and Counseling |

MD Signature: Pager:

Date/Time:

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 judgement 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

UC200705410 EN

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Heart Failure Admission Orders

1. Include Date and Time on orders

2. Check all appropriate orders

Intern: Resident: Attending:

Pager: Pager: Pager:

|General |

|Date | |

|Time |Admit to: ( CCU ( Telemetry ________ ( General Med ________ SERVICE: |

| |Diagnosis: HF Etiology: |

|Reason(s) for Admission|( New-onset HF ( HF exacerbation ( Refractory HF ( Arrhythmia |

| |( Noncompliance–meds ( Noncompliance–diet ( Volume overload ( Overdiuresis |

| |( Other__________________ |

|LVEF |_________% Date obtained: ____________ |

|Stage and Class |ACC/AHA Stage: ( C ( D NYHA class (Prior to admission): ( I ( II ( III ( IV |

|Condition |( Good ( Fair ( Guarded |

|Allergies |( NKDA ( Allergy: |

|Nursing |

|Vital Signs |( Per unit routine ( Q _____ |

| |( Call House Officer if: SBP > _____ mmHg or SBP < _____ mmHg; HR >_____ or HR < _____; |

| |  RR > _____ or RR < _____; T > _____ |

|Activity |( Bed rest ( Bed rest with commode privileges |

| |( Out of bed to chair with assistance (BID, TID) ( Ambulate in hall with assistance (BID, TID) |

| |( Physical therapy consultation ( Cardiac rehabilitation consultation |

|Diet |( 2 gram Na diet with 2000 mL (2 quarts) PO fluid restriction |

| |( 2 gram Na diet with 1500 mL PO fluid restriction |

| |( 2 gram Na, carbohydrate-controlled, low-cholesterol diet with _____ mL PO fluid restriction |

| |( Other: ______________________________________________________ |

|IV Fluids |( HEPLOCK with 3 mL normal saline flush Q12 hours (document on flow sheet 0800H and 2000H) |

| |( Other: ______________________________________________________ |

|I/O and Weight |( Strict recording of Ins and Outs ( Daily AM weights; record in chart |

|Foley |( If patient is unable to void, place Foley catheter |

|Monitoring |( Electrocardiographic monitor ( Pulse oximetry: ( continuous ( Q _____ |

|Oxygen |( O2 _____ L/min nasal cannula for chest pain, shortness of breath, SaO2 < 93% |

|Laboratory |

|On Admission |( CBC with differential and platelets |

|(ACC/AHA Class I |( Electrolytes ( BUN ( Creatinine ( Glucose ( Mg ( Ca ( PO4 ( Uric Acid |

|Recommendations |( HbA1c |

|Indicated in Bold, if |( CPK total and MB NOW and Q8 hours x 3 |

|new HF diagnosis) |( Cardiac troponin I NOW and 6 hours |

| |( PT/INR (if patient receiving warfarin) ( PTT (if patient treated with heparin/LMWH) |

| |( BNP (if indicated) |

| |( Liver function tests: ( AST ( ALT ( Alk Phos ( Total Bili ( __________ |

| |( Cardiovascular lipid panel (fasting) |

| |( Digoxin level (if patient receiving digoxin) |

| |( Thyroid function test: ( TSH (___________________________________________ |

| |( Urinalysis |

| |( Others:__________________________________________________________________ |

|In AM |( Electrolytes ( BUN ( Creatinine ( Glucose ( Mg ( Ca ( PO4 ( Uric Acid |

| |( CBC with differential and platelets |

| |( PT/INR (if patient receiving warfarin) |

| |( PTT (if patient treated with heparin/LMWH) |

| |( BNP (if indicated) |

| |( Others: __________________________________________________________________ |

|Medication |

|Intravenous |IV Diuretics: |

| |( Furosemide _______ mg IVP x 1 and/or by ( continuous IV infusion at _______ mg/hour |

| |( Other ___________________________________________ |

| |IV Vasoactive Medications: |

| |( ________________________________________________ |

| |( ________________________________________________ |

| |IV Electrolyte Replacement: |

| |( Potassium chloride _____ mEq IVPB over _____ hours x 1 _____ via central line or |

| |____ via peripheral line |

| |( Magnesium sulfate _____ g over _____ hours x 1 |

|Oral |( ACE Inhibitor: _______________ _____ mg PO ___ (hold for SBP < 80 mmHg or ____, |

|(ACC/AHA Class I |notify MD) |

|Recommendations in |Contraindication/reason not used:___________________________ |

|Bold) |( ARB: _______________ _____ mg PO ___ (hold for SBP 5.5 mmol/L), pregnancy, symptomatic hypotension, systolic blood pressure (SBP) < 80 mmHg, bilateral renal artery stenosis. Consider hold parameter of SBP < 80 mmHg.

• ARBs should be utilized as an alternative treatment in patients with ACEI intolerance

Beta-Blocker

• Beta-blockers are recommended in all patients with HF and LVEF ≤ 40%, unless a contraindication or intolerance to Beta-blockers is documented in the medical record. Use only evidence-based Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol). Patients should be compensated and not on IV inotropes.

• Contraindications: symptomatic bradycardia, significant reactive airway disease, shock, 2nd or 3rd degree heart block without a pacemaker

• Start at low HF dosing. Consider hold parameter of SBP < 80 mmHg and HR < 40. (see beta blocker algorithm)

Aldosterone antagonist

• Aldosterone antagonists are recommended in patients with HF or post-MI left ventricular dysfunction and LVEF ≤ 40% and moderate to severe symptoms, unless a contraindication to aldosterone antagonists is documented in the medical record

• Start at very low HF dosing. It is essential to very closely monitor serum potassium and renal function.

LVEF

• Evaluation of LVEF with echocardiography should occur in all patients with newly diagnosed HF during admission. In patients with established HF, evidence must be present in the medical record that LVEF was evaluated prior to admission, ideally within the past 1-2 years.

Device therapy for HF

• Select patients with LVEF ≤ 35% may benefit from ICD and/or cardiac resynchronization therapy. Patients should be on chronic optimal medical and not have other medical conditions that limit 1-year survival. Appropriate assessment and follow-up should be arranged for potential candidates for device therapy.

Adapted, with permission, by the SCA Prevention Medical Advisory Team, from the OPTIMIZE-HF registry toolkit.

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

This clinical tool is not intended to replace individual 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

UC200705411 EN

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Discharge Summary Checklist

Heart Failure/Post MI with or without Left Ventricular Dysfunction

Patient Name: Discharge Date:

Designated follow-up physicians/follow-up dates:

Brief medical history/discharge diagnosis:

Ejection fraction at discharge: Method: □ Echocardiogram □ Cardiac catheterization □ MUGA scan

|Were the following discharge medications |Y |N |Not Indicated |Agent Prescribed |Contrain-dication |Comments/ |

|prescribed? | | | | | |Reasons |

| | | | | | |for Not |

| | | | | | |Prescribing |

|Cardiac rehabilitation |□ |□ |□ | |Start Date: | |

|Stress test follow-up |□ |□ |□ | | | |

|Echocardiogram follow-up, |□ |□ |□ | | | |

|EF determination (assess need | | | | | | |

|for ICD or CRT) | | | | | | |

|Electrophysiology referral or follow-up |□ |□ |□ | | | |

|(assess need for ICD or CRT) | | | | | | |

|Lipid profile follow-up |□ |□ |□ | | | |

|Anticoagulation service follow-up |□ |□ |□ | | | |

|Electrolyte profile/serum lab work follow-up |□ |□ |□ | | | |

|Clinical summary and patient education record|□ |□ |□ | | | |

|faxed to appropriate physicians | | | | | | |

see algorithms for details

*bisoprolol, carvedilol, and sustained release metoprolol succinate as recommended per ACC/AHA HF Guidelines

Adapted, with permission, by the SCA Prevention Medical Advisory Team, from the OPTIMIZE-HF registry toolkit.

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

UC200705412 EN

Heart Failure

Date:

I understand that I have heart failure, which means that my heart is not pumping blood as well

as it should. I understand that I have been treated in the hospital for heart failure.

Important Test Results

Ejection fraction = _____%

This is a measure of how well my heart is pumping. The normal range for ejection fraction is

55-65%. I understand that I can have a form of heart failure even if my ejection fraction is normal.

I understand that there are several steps I can take to help keep myself healthy and prevent problems that could lead me to need to be hospitalized. I can also take active steps to care for myself and to help slow or reverse the worsening of my heart failure. These steps include knowing my important test results, taking my medications, not smoking, following a low-sodium (salt) diet, and watching for water weight gain. I will keep the visits planned by my doctor or nurse. A heart failure device may be an option for me.

Implantable Devices for Heart Failure

I understand that if my ejection fraction remains 35% or below after treatment, I may benefit from having an implantable cardioverter defibrillator (ICD) and/or a special heart device like a pacemaker to manage my heart failure symptoms.

Taking My Medications

I understand that heart medications, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), beta blockers, and aldosterone antagonists, may help slow or reverse the worsening of my heart failure and may help me live a longer and healthier life. After I leave the hospital, I will take all my medications as directed. I understand that I should not stop any prescribed medications without talking about this with my doctor or nurse. I understand that because my heart failure is a lifelong condition, I will need to remain on many or all of these treatments for the rest of my life.

I will also follow the instructions given to me about:

Smoking Cessation

I understand that smoking increases my chances of having a heart attack, affects my heart and lungs, and can shorten my life.

( I smoke and have been counseled to stop ( I do not smoke

To help me stop smoking, my doctor has suggested/prescribed:

Diet and Weight Reduction

My doctor recommends a low-sodium (salt) diet (< 2000 mg of sodium [salt] per day) to prevent or reduce shortness of breath and swelling in my feet and ankles. Since most sodium (salt) is in non-fresh foods, I can keep a low-sodium (salt) diet by staying away from foods that are canned, frozen, boxed, or packaged in a bag, and by reading food labels for sodium amount and serving size. Also, I should not add salt to my foods. It is also important that I stay at a healthy weight.

( I received counseling about a low-sodium (low-salt) diet

( I received counseling about weight reduction

Physical Activity

My doctor wants me to exercise ______ a day ______ times a week, for now.

A good exercise for me is

Daily Weight

To watch for water weight gain, I should weigh myself daily and tell my doctor or nurse if I gain

3 pounds overnight or 5 pounds in 1 week.

A good weight for me is _______

When to Call My Doctor/Nurse

I will call my doctor/nurse if:

• My breathing gets worse with the same or less activity

• I have to prop myself up on more pillows or raise the head of my bed to sleep at night

• I wake up in the middle of the night feeling like I can’t breathe

• I feel chest pain like pain I have had before

• My appetite has decreased or I feel bloated, full, or nauseated

• I feel lightheaded or dizzy, like I might pass out

• I have palpitations or feel my heart racing

When to Call an Ambulance or 911

I should call 911 if I feel a new kind of chest pain, pain that nitroglycerin does not help, or pain that lasts more than 15 minutes, or if I feel suddenly short of breath or lose consciousness.

Follow-Up Appointments and Testing

Doctor’s/Nurse’s name:

Phone number:

My first visit should be scheduled for:

I should keep this and future appointments even if I am feeling fine, because at these visits

we will:

( Change doses of my medications

( Check lab work

( Check my symptoms

( Re-measure my ejection fraction

( See if an ICD or a special heart device for heart failure is needed

I know that following my doctor’s advice can help me to live a longer, healthier life.

Patient Signature:

Date:

Discharge Doctor or Nurse Signature:

Date:

Adapted by the SCA Prevention Medical Advisory Team from the OPTIMIZE-HF Registry Toolkit.

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

Sponsored by Medtronic, Inc.

April 2007

UC200705803 EN

Acute Myocardial Infarction

with or without Left Ventricular Dysfunction

Date:

I know that I have had a heart attack (myocardial infarction). As a result, my heart may not pump blood as well as it did before.

Important Test Results

Ejection fraction = _____%

This is a measure of how well my heart is pumping. The normal range for ejection fraction is

55-65%.

Cholesterol values

Total cholesterol (TC) = _________ mg/dL (goal: less than 160 mg/dL)

Low density cholesterol (LDL or “bad” cholesterol) = _________ mg/dL

(goal: less than 100 mg/dL or less than 70 mg/dL)

High density cholesterol (HDL or “good” cholesterol) = __________ mg/dL

(goal: greater than 40 mg/dL)

Triglycerides (TG or “fat”) = ___________ mg/dL (goal: less than 150 mg/dL)

I understand that changes to my diet, exercise, and cholesterol-lowering medications will be needed to reach and keep the cholesterol goals above. Getting my cholesterol levels to this goal may help me prevent future heart attacks and strokes and will help me live a longer and

healthier life.

Blood pressure: __________ mmHg (goal: less than 140/90 mmHg; if I have diabetes or renal disease, the goal is less than 130/80 mmHg)

I understand that having a healthy blood pressure is also key to protecting my heart, brain, and kidneys from damage.

Body mass index: ________ kg/m2 (goal 18.5-24.9 kg/m2)

I understand that getting to a healthy weight can reduce my risk of diabetes, heart attacks, and possibly cancer. Body mass index is a good way to measure body fat using both height and weight. A body mass index of 25.0-29.9 kg/m2 is overweight and 30.0 kg/m2 or higher is considered obese. I understand that there are several steps I can take to help keep myself healthy and prevent another emergency like the one that brought me to the hospital. Taking active steps to care for myself can help slow or reverse the progress of my cardiac disease. Things I can do to help myself include knowing my important test results, taking my medications, not smoking, and following a low-fat, low-cholesterol diet. I will keep all of my follow-up appointments.

Implantable Cardiac Devices

I understand that if my ejection fraction remains 35% or below after medical therapy, I may benefit from having an implantable cardioverter defibrillator (ICD).

Taking My Medications

I understand that heart medications, including aspirin, clopidogrel, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta blockers, aldosterone antagonists, and cholesterol-lowering drugs, may help me to prevent a future heart attack and help me live a longer and healthier life. After I leave the hospital, I will keep taking my heart medications. I understand that I should not stop taking any heart medications unless I discuss it with my doctor or nurse. I understand that I will always be at risk for another heart attack and that I may need to remain on many or all of these medications for the rest of my life.

I will also follow the instructions given to me about:

Smoking Cessation

I understand that smoking increases my chances of having another heart attack, can affect the quality of my life, and can shorten my life.

( I smoke and have been counseled to stop ( I do not smoke

To help me stop smoking, my doctor has suggested/prescribed:

Diet and Weight Reduction

I understand that a low-fat, low-cholesterol diet may help to reduce the chances of a future heart attack, as will maintaining a healthy weight.

( I received counseling about a low-fat and low-cholesterol diet

( I received counseling about weight reduction

Physical Activity

My doctor recommends that I exercise ______ a day ______ times a week, for now.

A good exercise for me is

( I was advised to participate in a formal cardiac rehabilitation program:

_____________________________________________________________________________

When to Call My Doctor/Nurse

I will call my doctor/nurse if:

• I feel chest pain like pain I have had before

• I feel pain in my heart area that I’ve never felt before

• I feel lightheaded or dizzy, like I might pass out

• I have palpitations or feel my heart racing

When to Call an Ambulance or 911

I should call 911 if I feel a new kind of chest pain, pain that nitroglycerin does not help, or pain that lasts more than 15 minutes, or I feel suddenly short of breath or lose consciousness.

Follow-Up Appointments and Testing

Doctor’s/Nurse’s name: ___________________________________

Phone number: _________________________

My first visit should be scheduled for:_________________________________________________

I should keep this and future appointments even if I am feeling fine, because at these visits

we will:

( Adjust doses of my medications

( Check lab work

( Check my lipid panel

( Evaluate my symptoms

( Re-measure my ejection fraction

( Evaluate if an ICD may help me live longer

I will contact cardiac rehabilitation to schedule an appointment:

Phone: ____________________

I know that following my doctor’s advice can help me to live a longer, healthier life.

Patient Signature: _______________________________________

Date: _________________________________________________

Discharge Healthcare Provider Signature: ____________________

Date: _________________________________________________

Adapted by the SCA Prevention Medical Advisory Team from the ACC GAP AMI Program.

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

Sponsored by Medtronic, Inc.

April 2007

UC200705804 EN

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Dear Dr. _______________________:

Your patient, , initially hospitalized for , has been discharged on [date], following treatment for _______ days for a diagnosis of:

( Heart failure [with or without left ventricular systolic dysfunction] or ( Acute myocardial infarction [with or without left ventricular systolic dysfunction].

This patient’s admission was caused or contributed to by:

( Volume overload ( Acute coronary syndrome (ACS) ( Nonadherence, medications

( Nonadherence, diet ( Arrhythmias ( Volume depletion ( Respiratory problem/pneumonia

( Other

( None of the above

Patient’s ejection fraction (EF): __________ Date assessed: __________

Method: ( Echocardiogram ( Cardiac catheterization ( MUGA scan

EF ≤ 35% increases patient risk for sudden cardiac arrest.

Patient’s heart rhythm: ________________ QRS duration: __________ Date assessed: _________

Patient’s most recent serum Cr: _______ mg/dL; serum K+: _________ mEq/L; serum Na+: _________ mEq/L; serum BNP: _______ pg/mL

Patient’s lipid panel: Total cholesterol: _______ mg/dL, LDL: _______ mg/dL, HDL: _______ mg/dl,

TG: _______ mg/dL

Patient’s weight at admission: _______________ Patient’s weight at discharge: _______________

The patient underwent the following procedures:

( Cardiac catheterization ( Percutaneous coronary intervention, with stent ( Percutaneous coronary intervention, without stent ( CABG ( ICD placement ( CRT placement ( CRT/ICD placement

( Ultrafiltration ( Other _______________

The following medications were initiated or continued during the hospitalization and are recommended to be continued indefinitely post-discharge, unless otherwise indicated:

|Continued |Initiated |(refer to individual algorithms for details) |

| | |ACE inhibitor __________________ at a dose of ____ mg/(once, twice) daily |

| | |ARB _________________________ at a dose of ____ mg/(once, twice) daily |

| | |Beta-blocker __________________ at a dose of ____ mg/(once, twice) daily |

| | |Aldosterone antagonist __________ at a dose of ____ mg/once daily |

| | |Diuretic ______________________ at a dose of ____ mg/(once, twice) daily |

| | |Digoxin _______________________ mg/once daily |

| | |Aspirin _______________________ mg/once daily |

| | |Clopidogrel ____________________ mg/once daily, continued for 3 months/ |

| | |6 months/12 months/indefinite |

| | |Warfarin ______________________ at a dose of ____ mg/once daily; |

| | |Target INR: _____ |

| | |Nitrate ________________________ at a dose of ____ mg/ (once/twice/three times) daily |

| | |Hydralazine ____________________ at a dose of ___mg/(two/three/four |

| | |times) daily |

| | |Statin _________________________ at a dose of ____ mg/once daily |

| | |Other ________________________________________ |

| | |Other ________________________________________ |

It is important that you titrate or up-titrate the following medications for the patient on an outpatient basis:

The following education was provided:

( Beta-blocker uptitration process ( ACE inhibitor/ARB uptitration process

( Heart failure device (ICD and/or CRT) monitoring ( Low-sodium diet

( Therapeutic Lifestyle Changes diet ( Warning signs of worsened heart failure

( What to do if heart failure symptoms worsen ( Symptoms of myocardial infarction

( What to do if chest pain occurs/worsens ( What to do for syncope

( Medication adherence ( Diuretic use ( Smoking cessation ( Daily weights

( Alcohol reduction ( Activity level ( Other

Follow-up education is strongly recommended in these areas:

( Beta-blocker uptitration process ( ACE inhibitor/ARB uptitration process

( Possible need for heart failure device (ICD and/or CRT) ( Low-sodium diet

( Therapeutic Lifestyle Changes diet ( Cardiac rehabilitation ( Stress test ( Medication adherence

( Diuretic use ( Smoking cessation ( Daily weight monitoring ( Etiology of heart failure

( Alcohol reduction ( Activity level ( End of life ( Other

Follow-up testing and evaluation recommended:

( Cardiac rehabilitation ( Electrophysiology referral to assess need for ICD and/or CRT

( Heart failure device (ICD and/or CRT) clinic follow-up ( Stress testing

( Echocardiogram in _____ weeks

( Fasting lipid panel and liver function testing in ____ weeks

Other recommended follow-up for your patient:

Please see your patient in the next 1 to 2 weeks to review the medical regimen and to reassess NYHA functional class, volume status, and routine lab work. It is important to monitor EF closely; if EF remains

≤ 35% despite optimal medical therapy, this patient will be at risk for sudden cardiac death and should be evaluated for HF device placement. If an aldosterone antagonist was initiated, serum potassium and creatinine should be checked at 3 days, 1 week, and 1 month (x 3 months) and then as needed.

In addition, the medications that were prescribed for your patient’s heart failure at discharge should be reviewed and adjusted as appropriate. In particular, the need for titration of ACE inhibitors, Beta-blockers, and diuretics should be routinely assessed to obtain target doses and maximize benefits.

If you have questions, please contact me at:

Telephone:

Fax:

Voice mail:

Email:

Sincerely,

Adapted, with permission, by the SCA Prevention Medical Advisory Team, from the OPTIMIZE-HF registry toolkit.

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

UC200705402 EN

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