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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE

ADULT HEART FAILURE MANAGEMENT Updated May 2011

Key Content Experts:

Dr. George Kondos, Professor of Medicine, Cardiology* Carolyn Dickens, Cardiology Nurse Practitioner* Dr. Thomas Stamos, Assistant Professor of Medicine, Cardiology Dr. Rob DiDomenico, Clinical Associate Professor of Pharmacy *Co-Chairs, Cardiovascular Quality Improvement Committee

These systematically developed statements have been created to assist the practitioner in the formulation of health care decisions in specific clinical circumstances. They are not to be construed as an inflexible set of correct procedures or protocols. In each clinical circumstance the exercise of individual judgment is essential. Guidelines are based upon statistical averages and opinions of practicing clinicians. Variation from these guidelines does not constitute improper care or improper professional judgment. Evaluation of these variations requires detailed analysis of the facts and circumstances surrounding the individual patient’s care.

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE NO: G-1.2 DATE: May 6, 2011 SUBJECT: Adult Heart Failure Management

OBJECTIVE To improve the quality and efficiency of care for our adult heart failure patients, specifically: 1. 2. 3. 4.

Treat to improve cardiac function Reduce mortality Return patient to normal activity levels including exercise. Prevent recurrent exacerbations and minimize the need for emergency room visits or hospitalizations. 5. Maximize optimal pharmacotherapy with minimal adverse effects. 6. Meet patient and family expectations of and satisfaction with heart failure care. These goals will be achieved by: 1. 2. 3. 4.

Accurate diagnosis and assessment of severity. Periodic assessment and monitoring. Pharmacologic therapy. Education. DEFINITIONS

Heart Failure: Inadequate blood supply to meet the metabolic demands of the body.  Systolic heart failure (systolic dysfunction): Inability of the heart to eject/pump sufficient blood supply to meet the metabolic demands of the body.  Diastolic heart failure (diastolic dysfunction): Inability of the heart to fill properly, resulting in an inadequate supply of blood to meet the metabolic demands of the body. Heart Failure can result from:  Narrowed arteries that supply blood to the heart muscle -- coronary artery disease.  Past heart attack, or myocardial infarction, with scar tissue that interferes with the heart muscle's normal performance.  High blood pressure.  Heart valve disease due to rheumatic heart disease or other causes.  Primary disease of the heart muscle itself or cardiomyopathy.  Heart defects present at birth (congenital heart defects).  Infection of the heart valves and/or heart muscle itself (endocarditis and/or myocarditis). Heart failure affects more than 5 million Americans, with more than 500,000 new cases occurring annually and a resultant 1,000,000 hospitalizations, which translates into an annual

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE estimated cost of nearly $23 billion dollars. Mortality with this condition is high, approximately 50% at 5 years. Implementation of the advances in management of heart failure have the potential to improve patients' quality of life, reduce the need for hospitalizations, reduce total medical costs, and prolong survival. Hypotension: Systolic blood pressure less than 90 mmHg, however this can be subdivided into symptomatic and asymptomatic hypotension.  Symptomatic hypotension: systolic blood pressure less than 90 mmHg with evidence of hypoperfusion (altered mental status, cyanosis, cool extremities, decreased urine output).  Asymptomatic hypotension: systolic blood pressure less than 90 mmHg without evidence of hypoperfusion, as above.  Medications should not be held or discontinued for asymptomatic hypotension.

POSITION STATEMENTS Appropriate drug therapy will be administered to all patients with heart failure (unless contraindicated) to improve symptoms and decrease morbidity/mortality. Once on appropriate medical therapy, every effort will be made to optimize medication doses. Patients will be educated on this chronic disease and provided with the knowledge they need to live with heart failure. Attempts will be made at improving quality of life and reducing hospitalizations for these patients. Regular monitoring with serial measurements of ejection fraction (i.e., left ventricular systolic dysfunction) will be done to assess response to therapy. PROCEDURE Ambulatory Care I.

Assessment/Diagnosis A. The assessment of any patient with a diagnosis of heart failure begins with a thorough history and physical. The patient should be questioned about: 1. History of hypertension. 2. History of diabetes. 3. Hypercholesterolemia. 4. Coronary valvular or peripheral vascular disease. 5. Rheumatic fever. 6. Chest irradiation. 7. Exposure to cardiotoxic agents. 8. Illicit drug use. 9. Alcohol use. 10. Sexually transmitted disease(s). 11. Family history.

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE B. The patient should have regulator monitoring with serial measurements of ejection fraction (i.e., left ventricular systolic dysfunction) to assess response to therapy. 1. The study should quantitate/evaluate: a. LV size. b. Hemodynamics. c. Diastolic function. d. Valvular function. e. Infiltrative disease. 2. Repeat imaging should not be done within 1 year of last study unless clinically indicated. C. The following laboratory test should be performed: 1. Electrolytes, BUN, Creatinine - exclude renal disease. 2. CBC - exclude anemia. 3. T4, TSH - exclude thyroid disease. 4. Liver Function Tests - evaluate for right heart failure. 5. Cholesterol panel (LDL) - evaluate risk for CAD and need for statin. 6. Urinalysis - exclude nephrotic syndrome. 7. BNP- when the diagnosis is uncertain, should not be interpreted in isolation D. The following diagnostic tests should be performed: 1. EKG. 2. Chest X-ray. E. The following additional tests can be performed if clinically indicated: 1. ETT/Nuclear Imaging/Stress Echocardiogram: in patients with known CAD but no angina. 2. Coronary Angiogram: patients with angina or suspected CAD. 3. Radionuclide ventriculography (MUGA scan): highly accurate assessments of global and regional functions. a. The following assessments should be specified when ordering: (a) Left ventricular ejection fraction (LVEF). (b) Right ventricular ejection fraction (RVEF). (c) Regurgitant index. 4. Cardiac Magnetic Resonance Imaging (CMR): may be obtained to assess left and right ventricular function and viability when clinically indicated 5. All heart failure patients will be encouraged to obtain an influenza vaccine each fall and to assure that the patient is up to date on their pneumococcal vaccine. II. Care Treatment Plan A. The general approach the pharmacologic therapy in heart failure patients is to start at a low dose and titrate up (every two weeks, if tolerated) to goal doses (see Table 1). 1. Patients with asymptomatic left ventricular dysfunction, the following therapy is recommended (barring any contraindications): a. Angiotensin converting enzyme (ACE) inhibitor

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE (a) See Addendum 5 b. Beta blocker (a) See Addendum 6. Patients with symptomatic left ventricular systolic dysfunction, the following therapy is recommended (barring any contraindications): a. Diuretics in patients who have evidence of fluid retention. b. ACE inhibitors in all patients. c. Beta blockers in all patients who are stable and have no or minimal evidence of fluid retention. d. Digoxin. e. Spironolactone or eplerenone in patients with preserved renal function and normal potassium and have moderate to severe heart failure who are on appropriate background therapy (e.g., ACE inhibitor plus beta-blocker at or near goals doses). f. Angiotensin receptor blockers (ARB) in patients who cannot tolerate an ACE inhibitor due to cough or angioedema. g. Hydralazine and nitrates in patients who cannot tolerate ACE inhibitor or ARB because of renal insufficiency or hyperkalemia. h. The addition of an ARB or Hydralazine/nitrates to therapy with ACE inhibitor and Beta-blocker who remain symptomatic or hypertensive. i. Medications should not be held or discontinued for asymptomatic hypotension (see Table 1). Electrophysiology consult for possible implantable cardioverter-defibrillator a. Patients with non-ischemic dilated cardiomyopathy or ischemic heart disease b. at least 40 days post MI c. LVEF less than or equal to 35%. d. NYHA functional class II or III e. On optimal medical therapy f. History of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia Electrophysiology consult for possible cardiac resynchronization therapy a. Patients with LVEF less than or equal to 35% b. Sinus Rhythm c. NYHA functional class III or ambulatory class IV symptoms d. Widened QRS interval ≥120ms e. Optimal medical therapy Avoid the following medications in patients with heart failure: a. Class I anti-arrhythmic: (a) Disopyramide. (b) Procainamide. (c) Quinidine. (d) Flecainide. (e) Propafenone. b. Calcium channel blockers: (a) Verapamil. (b) Diltiazem.

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE c. NSAIDs and Cox-2 inhibitors. 6. Dronedarone (a) Class IV heart failure (b) Patients who have had an episode of decompensated heart failure in the past 4 weeks 7. Treat concomitant diseases: a. Diabetes. b. Hypercholesterolemia. c. Hypertension. d. Other. III. Patient Education A. Education of patients with heart failure should be ongoing and incorporated into as many patient/caregiver interactions as possible, to reinforce key points the patient needs to understand. B. The key education points are summarized in Table 4. C. Suggested patient-directed educational materials can be found within the Depart Tool and are listed in Table 5. Emergency Department I.

Assessment/Diagnosis A. The initial assessment of a patient with acute decompensated heart failure (ADHF) should include a thorough history, physical exam, laboratory assessment, chest x-ray, and perhaps, additional assessment of left ventricular function. 1. Key elements of history salient to ADHF: a. Past medical history. b. Medications prior to admission. c. Dietary compliance with sodium & water. d. Medication adherence e. History of weight gain. f. History of PND, orthopnea, DOE. 2. Key elements of physical exam consistent with ADHF: a. Vital signs with increased heart rate and either decreased or elevated BP. b. Hypoxia. c. Mental status changes. d. Increased JVD. e. + S3 or S4. f. + Hepatojugular or Abdomino-jugular reflex: (a) JVP increase 2 cm above baseline and remains elevated while the abdomen is being compressed. The test should only be done if the baseline JVP is normal. The test is helpful in assessing for occult volume overload. g. Pulmonary congestion. h. Pitting edema. i. Ascites.

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 3. Key laboratory & diagnostic assessments: a. BNP level elevated above patient’s baseline (a) Isolated elevations of BNP in the absence of physical findings suggestive of ADHF are NOT diagnostic for ADHF. b. BUN. c. Cr. d. Electrolytes (Na, K, Mg, Ca). e. Arterial blood gas (if respiratory distress apparent). f. EKG. g. Cardiac enzymes. h. PT, INR, PTT. B. Assessment should include investigation of precipitating causes (medical or dietary noncompliance, acute coronary syndrome, hypertensive crisis, arrhythmias, etc.) and severity of symptoms. C. Based on this information, patients with the diagnosis of acute decompensated heart failure should be stratified based on the presence of symptoms consistent with volume overload or low cardiac output. (Addendum 1). D. Timeline for Assessment (Addendum 2): the diagnosis of ADHF should be established within two hours after presentation to the ED. II. Care Treatment Plan A. Timeline for Treatment (Addendum 2). 1. Once the diagnosis of ADHF has been made, intravenous (IV) therapy for ADHF should be initiated within two hours of establishing the diagnosis (< four hours from the initial ED contact). 2. Within two hours of initiating IV therapy for ADHF, the patient’s response to therapy should be assessed and additional therapy added as necessary. 3. Over the following 6 – 8 hours, reassessment of the patient’s response should continue. Ultimately, within 12 hours of the initial ED contact, the patient’s disposition should be determined (e.g., hospital admission or discharge home). 4. Once the patient’s disposition has been determined, transfer out of ED to the patient’s final destination should proceed within 24 hours of the initial ED contact. B. ADHF Treatment Algorithm (Addendum 1). 1. Treatment of ADHF is generally based on the presence or absence of pulmonary congestion (i.e., volume overload) and an assessment of the patient’s cardiac output. 2. On the left hand side of the algorithm, treatment recommendations are given for ADHF patients experiencing signs and symptoms of volume overload. 3. In the middle of the algorithm, treatment recommendations are given for ADHF patients with acute pulmonary edema and/or severe hypertension. 4. The right hand side of the algorithm provides treatment recommendations for patients with low cardiac output. 5. Although this ADHF treatment algorithm focuses on parenteral therapy during the initial 24 hours, continuation of patients’ chronic HF medications, including chronic beta-blocker therapy, is advised. C. See Inpatient Care for specific treatment recommendations: 1. Treatment of ADHF Patients with Volume Overload.

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 2. Treatment of ADHF patients with volume overload and acute pulmonary edema and/or severe hypertension. 3. Treatment of ADHF Patients with Low Cardiac Output. 4. Treatment of ADHF Patients with Low Cardiac Output and Evidence of Shock. D. Monitoring Recommendations For Patients Hospitalized with ADHF (Minimum) 1. Daily weights a. Documentation of baseline weight in Cerner from the Emergency Department, ideally. 2. Daily documentation of fluid intake and output a. Documentation of fluid intake and output during the Emergency Department stay, ideally, is helpful, particularly for patients who are hospitalized. 3. Daily Electrolytes and Renal function a. May consider repeating assessment of electrolytes & renal function in select patients in the Emergency Department (e.g., extended stay in the Emergency Department, excessive diuretic response, poor diuretic response, etc.). III. Discharge Education and Planning A. Education of patients with heart failure should be ongoing and incorporated into as many patient/caregiver interactions as possible, to reinforce key points the patient needs to understand. 1. For those patients being discharged home from the Emergency Room, discharge education should be initiated as early in the patient care process as the patient demonstrates they are ready to process such information in order to prepare for their own care at home. Discharge education will be provided by the nursing staff. B. The key education points are summarized in Table 4 C. Patient directed educational material can be found within the Depart Tool in the EMR (Table 5) Inpatient Care I.

Assessment/Diagnosis A. The decision to admit patients with ADHF may be guided by the criteria proposed in Table 3. II. Care Treatment Plan A. Inpatient management of ADHF mirrors the acute management in the ED. B. Adjustments in therapy are made based on patients’ response to therapy, adverse effects, and symptom improvement. C. Re-initiation of patient’s previous chronic heart failure regimen, including chronic betablockers, should be done. Initiation and titration of beta-blockers in this setting should be considered. In addition, efforts should be made at optimizing patients’ chronic heart failure regimen, as described earlier. D. ADHF Treatment Algorithm (Addendum 1). 1. Treatment of ADHF is generally based on the presence or absence of pulmonary congestion (i.e., volume overload) and an assessment of the patient’s cardiac output. 2. On the left hand side of, treatment recommendations are given for ADHF patients experiencing signs and symptoms of volume overload.

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE 3. In the middle of the algorithm, treatment recommendations are given for ADHF patients with acute pulmonary edema and/or severe hypertension. 4. The right hand side of the algorithm provides treatment recommendations for patients with low cardiac output. 5. Although this ADHF treatment algorithm focuses on parenteral therapy during the initial 24 hours, continuation of patients’ chronic HF medications, including chronic beta-blocker therapy, is advised. E. Treatment of ADHF Patients with Volume Overload. 1. Diuretics. a. Patients with volume overload (Addendum 1) should be treated with IV diuretic therapy, typically loop diuretics (Addendum 1, box A1). b. In patients taking oral diuretic therapy at home, the initial IV diuretic dose should be equivalent to the total daily dose, with a maximum IV dosage of furosemide 180mg IV. c. Patients not taking oral diuretics at home should be given an IV bolus of furosemide 40 mg, although patients with renal insufficiency may require an even larger dose to produce the desired effect. d. Monitoring of diuretic use is driven by urine output goals. (a) Initial response (i) For patients with normal renal function, the goal urine output is > 500mL in the first two hours (see Addendum 1). (ii) An acceptable urine output for patients with serum creatinine greater than 2.5mg/dL is > 250mL (see Addendum 1). (iii) Alternatively, a goal urine output of ≥ 1ml/kg/hr for the first 2 – 4 hours may be appropriate. (a) Daily urine output goal for patients with ADHF is a net diuresis of 1L/day (total input – total output = -1L or more). e. If the patient fails to attain an adequate diuresis after the initial IV bolus, several options exist, including: (a) Double the previous dose – ideally, within 2 – 4 hours of the first dose to induce a more rapid diuresis. (b) Administer as a continuous infusion (i) Furosemide: 10 – 40mg/hr. (ii) Bumetanide: 0.5 – 2 mg/hr. (c) Use combination diuretics (i) Add metolazone 2.5 – 5mg PO daily-BID (ii) Add chlorothiazide 500 – 1000 mg IV daily-BID f. Once an adequate diuresis has been achieved, continuation of the effective diuretic dose is recommended. g. Electrolyte deficiencies, particularly hypokalemia and hypomagnesemia, are the most common adverse effects experienced with IV diuretic therapy, although hypotension, azotemia, and renal dysfunction are also possible. (a) A management strategy for electrolyte disturbances in this setting has been proposed previously and is included in the standing orders (Addendum 3, bottom of second page).

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE h. Patients with an inadequate response to furosemide should also be assessed for the presence of low cardiac output, worsening volume overload ± pulmonary edema, and/or severe hypertension and, if necessary, additional therapy for ADHF may be required (described below). F. Treatment of ADHF patients with volume overload and acute pulmonary edema and/or severe hypertension. 1. Diuretics a. For dosing and monitoring recommendations, see above in II.C.1. 2. Vasodilators. a. Either IV nitroglycerin or nitroprusside should be added to IV diuretics to produce a more rapid response and more effectively relieve the signs and symptoms of congestion in these patients. (a) IV nitroglycerin dosing (i) Continuous infusion at a rate of 5 – 10 g/min and increased in increments of 10 to 20 g/min as often as every 5 minutes as necessary (Table 2). (ii) Doses as high as 140 – 160mcg/min may be required to achieve the desired hemodynamic effects. (b) If nitroprusside is used, it should be administered in the ICU, starting at a rate of 0.3 – 0.5mcg/kg/min, and may be titrated as often as every 5 minutes as necessary. (c) Nitroglycerin SL 0.4mg PRN may be used to acutely relieve symptoms of volume overload/congestion until IV therapy can be initiated if necessary. (d) Hypotension is the most common adverse effect from both IV nitroglycerin and nitroprusside. (e) Medications should not be held or discontinued for asymptomatic hypotension. G. Treatment of ADHF Patients with Low Cardiac Output. 1. Inotropes. a. Patients with evidence of low cardiac output should be considered for inotropic support. b. Drug selection may be based on several variables, including hemodynamic stability, baseline blood pressure, and presence of concomitant beta-blocker therapy. (a) ADHF patients with low cardiac output and systolic blood pressure < 90 mmHg should be treated with dobutamine initially. (i) These patients may require vasopressor support if symptomatic hypotension develops or there is baseline evidence of shock. (b) Patients with low cardiac output and adequate blood pressure (systolic blood pressure > 90 mmHg) who are also taking beta-blockers chronically may be given milrinone preferentially. (i) If dobutamine is used in patients taking chronic beta-blockers, higher doses of dobutamine may be necessary or a temporary reduction in betablocker dose may be considered. c. Patients with low cardiac output and adequate blood pressure without concomitant beta-blocker therapy may receive either dobutamine or milrinone.

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE d. Dobutamine dosing (a) Typically initiated at a rate of 2.5 g/kg/min and may be increased by increments of up to 2.5 g/kg/min as often as every 5 – 15 minutes, if necessary, to achieve the desired response. (Table 2) e. Milrinone dosing (a) Typically initiated at a rate of 0.1 – 0.375 g/kg/min (depending on renal function and/or baseline blood pressure). (b) To avoid hypotension, administration of an IV bolus (50 g/kg IV over 10 minutes) of milrinone is NOT recommended. (c) Milrinone has a half-life of approximately 2 – 3 hours; therefore, dose titration must occur slowly, no more frequently than every 4 – 6 hours. (Table 2). Treatment of ADHF Patients with Low Cardiac Output and Evidence of Shock. 1. Typically, these patients require admission to an intensive care unit for close monitoring and may require the placement of a pulmonary artery catheter to more accurately assess their hemodynamics. 2. Those patients with very low cardiac output will likely require inotropic support, may require vasopressors, and may be considered for mechanical circulatory support or even referral for heart transplantation. All patients hospitalized for ADHF should also be considered for the following: 1. Immunizations a. Pneumococcal vaccination every 5 years b. Influenza vaccination annually 2. Smoking cessation therapy, if appropriate a. Nicotine replacement therapy b. Buproprion during inpatient stay, if appropriate. Monitoring Recommendations for Patients Hospitalized with ADHF (minimum) 1. Daily Weights 2. Daily documentation of fluid intake and output 3. Daily electrolytes & renal function a. May need to be monitored more frequently in select patients (e.g., poor baseline renal function, excessive diuretic response, poor diuretic response, etc.). Dietary Recommendations 1. Fluid restriction ( 250ml within 2 hrs of IV furosemide

Titration Parameters

Nitroglycerin

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Symptom relief Vital signs every 15 minutes until on stable dose, then every 30 minutes for 1 hr, then every 4 hrs Urine output May require ICU stay to titrate infusion If pulmonary artery catheter in place, PCWP, SVR, CI

 

Starting dose: 5 – 10 g/min Dose can be increased by increments of 10 – 20 g/min every 5 minutes if necessary until desired response achieved

Symptom relief Vital signs every 15 minutes until on stable dose, then every 30 minutes for 1 hr, then every 4 hrs Urine output Requires ICU stay for titration & monitoring If pulmonary artery catheter in place, PCWP, SVR, CI Evidence of cyanide and/or thiocyanate toxicity

 

Starting dose: 5 – 10 g/min Dose can be increased by increments of 10 – 20 g/min every 5 minutes if necessary until desired response achieved

Telemetry Symptom relief Vital signs every 15 minutes until on stable dose, then every 30 minutes for 1 hr, then every 4 hrs Urine output May require ICU stay to titrate infusion If pulmonary artery catheter in place, PCWP, SVR, CI

Dobutamine  Dose can be increased by increments of up to 2.5 g/kg/min every 5 – 15 minutes if necessary until desired response achieved

  

Nitroprusside

     

Inotropes

     

Milrinone  May take several hours to reach steady-state concentrations  Consider 50 g/kg IV bolus over 10 minutes if immediate response desired and BP will tolerate (SBP > 100mmHg)  Dose titration should occur slowly

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE Table 3. Disposition Criteria Criteria for Hospital Admission Sustained ventricular tachycardia or other symptomatic arrhythmia Unstable vital signs Signs/symptoms of acute coronary syndrome Refractory electrolyte disturbances Total urine output < 1000ml OR < 0.5ml/kg/hr (~30ml/hr) Persistent dyspnea

Discharge Criteria Symptomatic improvement Patient ambulating Heart rate < 100bpm at rest Vital signs stabilized (individualized to patient) Total urine output > 1000ml AND > 0.5ml/kg/hr (~30ml/hr) Normal cardiac enzymes No complaints of chest pain No documented arrhythmias Normal(ized) electrolytes

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UNIVERSITY OF ILLINOIS MEDICAL CENTER AT CHICAGO CLINICAL CARE GUIDELINE Table 4 : Key Patient Education Points Activity Level Medications

Weight Monitoring

Diet

Follow up Appointments

What to do if symptoms worsen Smoking Cessation

Patients should be advised of any restrictions regarding activity and in general should be encouraged to remain as active as possible. Patients should be advised as to the importance of never missing any doses of their prescribed medications. (NOTE: Patients should be provided with a list of their discharge medication, provided either by the PharmD handout, or on the Discharge Notification Form). If the patient has difficulty paying for his/her medications, he/she should be referred to the Medication Assistance Program in the outpatient pharmacy. Patients should be advised that daily weights are required to determine fluid status between clinic visits. They should be advised that a weight gain of greater than 3-5 pounds which persists for 3-4 days should prompt a call to their physician’s office. Patients should be advised to follow a low sodium diet, specifically less than 2000 mg of sodium a day. If the patient has difficulty understanding how to adhere to a low sodium diet, he/she should be referred to the Nutrition and Wellness Center for dietary teaching. The DASH diet is also appropriate for this population (http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf ). Patients should be advised as to the importance of regular follow up and close monitoring due to their chronic condition. They should also be provided with a list of their follow-up clinical appointments, or advised to schedule a follow-up appointment within 1-2 weeks after discharge Patient should be advised as to the appropriate course of action if their symptoms should worsen. Patients who smoke should be advised to quit. If the patient exhibits readiness to quit smoking, he/she should be referred to the smoking cessation clinic in the Nutrition and Wellness Center. If the patient is a former smoker (within the past year), they should be advised to remain smoke-free.

Table 5: Suggested Patient directed educational materials found in Cerner 1. Heart Failure (required) includes JCAHO core measures 2. What is Heart Failure? 3. Heart Failure: Warning signs of a flare up. 4. Heart Failure: Medications to help your heart. 5. Heart Failure: Making changes to your diet. 6. Heart Failure: Tracking your weight.