Outpatient Management of Heart Failure

Second Edition 

Outpatient Management of Heart Failure 

Program Development and Experience in Clinical Practice 

A Monograph for the Healthcare Professional 

AUTHORS: 

Marc A. Silver, MD 

Pamela Cianci, RN, MSN, APN, BC 

Carol L. Pisano, RN, BSN, CCRN 

The Heart Failure Institute and Heart Failure Center, Advocate Christ Medical Center, Oak Lawn, Illinois



Release date: November 2004 

Expiration date: November 2005 

Estimated time to complete activity: 1.5 hours 

Sponsored by the Postgraduate Institute for Medicine 

This activity is supported by an educational grant from the following: 

This activity has been planned and produced in accordance with the ACCME Essential Areas and Policies. 

©2004 by the Center for Healthcare Education and Research

Target Audience 

This activity has been designed to meet the educational needs of 

cardiologists, registered nurses, and other healthcare professionals 

involved in the management of patients with heart failure (HF). 

Statement of Need/Program Overview 

HF is responsible for approximately 900,000 hospitalizations every 

year, utilizing extraordinary amounts of healthcare resources. 

There are significant benefits to treating patients with HF in an outpatient 

setting. This publication provides an overview of the structure 

and treatment approaches used at the Advocate Heart Failure 

Institute and presents the lessons learned in developing and implementing 

a comprehensive outpatient HF management program. 

Purpose 

Provide an overview of the structure and treatment approaches 

used at the Advocate Heart Failure Institute and present the lessons 

learned in developing and implementing a comprehensive outpatient 

HF management program. 

Educational Objectives 

On completion of this activity, participants should be better able to 

• Describe the core components of a HF disease management 

program. 

• Explain the transition process of a patient from inpatient to 

outpatient management. 

• Discuss drug treatment protocols used in HF. 

Faculty 

Marc A. Silver, MD 

Director, Heart Failure Institute 

Advocate Christ Hospital and Medical Center 

Oak Lawn, IL 



Oak Lawn, IL 


Manager, Congestive Heart Failure Clinic 


Oak Lawn, IL 

Disclosure Statements 

The Postgraduate Institute for Medicine (PIM) has a conflict of 

interest policy that requires course faculty to disclose any real or 

apparent commercial financial affiliations related to the content of 

their presentations and materials. It is not assumed that these financial 

interests or affiliations will have an adverse impact on faculty 

presentations; they are simply noted here to fully inform participants. 

Marc Silver, MD 

Consultant: Abbott Laboratories, Medtronic, Cardiodynamics, 

Paracor, GlaxoSmithKline 

Speakers’ Bureau: Scios, Inc.; Aventis Pharmaceuticals; Biosite 

Visiting Faculty for Vascular Biology Working Group: Medcon 


Speakers’ Bureau: GlaxoSmithKline; Scios, Inc. 


Speakers’ Bureau: Medtronic; Scios, Inc. 

Physician Continuing Medical Education 

Accreditation Statement 

This activity has been planned and implemented in accordance 

with the Essential Areas and Policies of the Accreditation Council 

for Continuing Medical Education (ACCME) through the joint 

sponsorship of the Postgraduate Institute for Medicine and the 

Center for Healthcare Education and Research. The Postgraduate 

Institute for Medicine is accredited by the ACCME to provide continuing 

medical education for physicians. 

Credit Designation 

The Postgraduate Institute for Medicine designates this educational 

activity for a maximum of 1.5 category 1 credits toward the 

AMA Physician’s Recognition Award. Each physician should 

claim only those credits that he/she actually spent in the activity. 

Nursing Continuing Education 

CNA/ANCC 

This educational activity for 1.8 contact hours is provided by 

Postgraduate Institute for Medicine. Postgraduate Institute for 

Medicine is an approved provider of continuing education by the 

Colorado Nurses Association, an accredited approver by the American 

Nurses Credentialing Center’s Commission on Accreditation. 

California Board of Registered Nursing 

The Postgraduate Institute for Medicine is approved by the 

California Board of Registered Nursing, Provider Number 13485 

for 1.8 contact hours. 

Method of Participation 

There are no fees for participating and receiving CME credit for 

this activity. During the period November 2004 through November 

30, 2005, participants must (1) read the learning objectives and 

faculty disclosures; (2) study the educational activity; (3) complete 

the posttest by recording the best answer to each question in the 

answer key on the evaluation form on page 31; (4) complete the 

evaluation form; and (5) mail or fax the evaluation form with 

answer key to the Postgraduate Institute for Medicine. 

A statement of credit will be issued only upon receipt of a completed 

activity evaluation form and a completed posttest with a 

score of 70% or better. Your statement of credit will be mailed to 

you within three weeks. 

Disclosure of Unlabeled Use 

This educational activity may contain discussion of published 

and/or investigational uses of agents that are not indicated by 

the FDA. PIM; the Center for Healthcare Education and Research; 

Scios, Inc.; Cardiodynamics; and Biosite do not recommend the 

use of any agent outside of its labeled indications. 

The opinions expressed in the educational activity are those of the 

faculty and do not necessarily represent the views of PIM; the 

Center for Healthcare Education and Research; Scios, Inc.; 

Cardiodynamics; and Biosite. Please refer to the full Prescribing 

Information for each product for discussion of approved indications, 

contraindications, and warnings. 

Disclaimer 

Participants have an implied responsibility to use the newly 

acquired information to enhance patient outcomes as well as their 

own professional development. The information presented in this 

activity is not meant to serve as a guideline for patient management. 

Any procedures, medications, or other courses of diagnosis 

or treatment discussed or suggested in this activity should not be 

used by clinicians without evaluation of their patients’ conditions 

and possible contraindications or dangers in use, review of any 

applicable manufacturer’s product information, and comparison 

with recommendations of other authorities.

Left to right: Carol L. Pisano, RN, BSN, CCRN; Marc A. Silver, MD; Pamela Cianci, RN, MSN, APN, BC 

Authors 

Marc A. Silver, MD, is Chairman of the Department of Medicine, Director of the 

Heart Failure Institute, and Associate Director of the Cardiovascular Disease 

Fellowship at Advocate Christ Medical Center in Oak Lawn, Illinois. He is also 

Clinical Professor of Medicine at the University of Illinois School of Medicine. 

A leading authority on heart failure, Dr. Silver has served as principal investigator for 

more than 60 large-scale clinical trials, is co–Editor-in-Chief of Congestive Heart 

Failure, and serves on the editorial boards of 11 professional journals, including the 

American Journal of Cardiology, Journal of Cardiac Failure, and Journal of the 

American College of Cardiology. 

Dr. Silver is a Fellow of the American College of Physicians, the American College 

of Cardiology, and the American College of Chest Physicians. He is also the author of 

“Success with Heart Failure,” a patient- and family-focused educational primer to 

heart failure. 

Pamela Cianci, RN, MSN, APN, BC, is a Clinical Nurse Specialist/Certified Advanced 

Practice Nurse at Advocate Christ Medical Center. Ms. Cianci has authored articles 

published in the Journal of Cardiovascular Nursing, Critical Care Nurse, and the 

Journal of the American College of Cardiology. She is a member of the American 

Heart Association, American Association of Critical Care Nurses (CCRN 

1989–1992), Sigma Theta Tau Honor Society of Nursing, and the Heart Failure 

Society of America. 

Carol L. Pisano, RN, BSN, CCRN, manager of the Heart Failure Center at Advocate 

Christ Medical Center, created and developed the Heart Failure continuum of care 

initiatives including the outpatient clinic in 1995. With more than 25 years of 

cardiac nursing experience, Ms. Pisano is a member of the American Association 

of Critical Care Nurses and the Heart Failure Society of America. 

♥ 2

TABLE OF CONTENTS 

Introduction................................................................................................................................................... 4 

Overview of Outpatient Heart Failure Disease Management.................................................................. 4 

The Experience at Advocate Health Care ............................................................................................ 4 

Components of an Outpatient Management Program for Heart Failure............................................... 6 

Facilities and Staffing ........................................................................................................................... 6 

Knowledge Base of Staff...................................................................................................................... 6 

Patient Management ............................................................................................................................. 6 

Medications................................................................................................................................. 6 

Laboratory Testing ...................................................................................................................... 6 

Ancillary Testing...........................................................................................................................7 

Weight Maintenance ................................................................................................................... 7 

Follow-up .................................................................................................................................... 7 

Family Support............................................................................................................................ 7 

Patient Support Groups............................................................................................................... 7 

Clinic Communications With Other Medical Personnel ............................................................ 7 

Transitioning Management From Inpatient to Outpatient ...................................................................... 9 

Selection of Appropriate Patient Candidates for Outpatient Management.......................................... 9 

Referral for Outpatient Heart Failure Management ............................................................................. 9 

Drug Treatment Protocols in Heart Failure...............................................................................................11 

Guidelines.............................................................................................................................................11 

Diuretic Titration ..................................................................................................................................11 

Patient Instructions......................................................................................................................11 

Treatment ....................................................................................................................................11 

Angiotensin-Converting Enzyme Inhibitor Titration ...........................................................................11 

Laboratory Testing ......................................................................................................................11 

Metoprolol (Lopressor ® ) and Metoprolol-XL (Toprol-XL ® ) Slow Titration........................................12 

Carvedilol (Coreg ® ) ..............................................................................................................................12 

Nesiritide (Natrecor ® ) Outpatient Infusion...........................................................................................12 

Pharmacology/Mechanism of Action..........................................................................................12 

Indications for Nesiritide Use.....................................................................................................13 

Contraindications ........................................................................................................................13 

Pharmacokinetics ........................................................................................................................13 

Dosing and Administration .........................................................................................................14 

Follow Up Serial Infusions of Natrecor ® (FUSION I) ...............................................................14 

Cardiac Resynchronization Therapy ....................................................................................................15 

Indications for Cardiac Resynchronization Therapy ..................................................................15 

Prioritization for Cardiac Resynchronization .............................................................................15 

Putting It All Together..........................................................................................................................15 

Case Studies in Heart Failure Management ..............................................................................................16 

Other Issues, Considerations, and Informational Resources...................................................................21 

Sample Forms 

Congestive Heart Failure Orders (Emergency Department) ................................................................22 

Congestive Heart Failure Orders (Admission).....................................................................................23 

Patient Discharge Instructions..............................................................................................................25 

Heart Failure Homecare Guidelines .....................................................................................................26 

Physician Referral Letters ....................................................................................................................27 

Homecare Referral to Outpatient Heart Failure Clinic ........................................................................28 

Posttest.........................................................................................................................................................................29 

Evaluation Form ...........................................................................................................................................30 

Note to the reader: Medicine remains an inexact science and every patient is unique. The material contained 

in this publication is for educational purposes only. Although this monograph includes specific 

medications, dosages, and other relevant clinical information, it is important that this information not 

be taken as direct prescriptive advice for any individual patient in the absence of consultation with 

the responsible physician or other healthcare personnel. Full Prescribing Information should be consulted 

before considering the use of any medication referred to in this publication. 

♥ 3

Introduction 

♥4 Heart failure (HF), the heart’s inability to pump an adequate 

volume of blood to the tissues, is the only major cardiovascular condition 

that continues to increase in incidence in the United States 

today. 1 For most physicians, the concept of HF conjures up an image 

of the decompensated, critically ill patient, and most often one who 

is hospitalized. This reflects the fact that in the majority of cases 

modern medicine is brought to bear in HF treatment in the hospital 

environment and typically in the most congested settings with overcrowded 

conditions—emergency departments (ED), and intensive 

care and telemetry units. 

Nearly 5 million patients are currently diagnosed with HF in 

the United States today. The American Heart Association estimates 

that between 400,000 and 700,000 new HF cases develop each year. 2 

This condition is responsible for an estimated 900,000 hospitalizations 

annually—more than any other medical condition among 

the elderly. 3 

Approximately 6.5 million hospital days each year are 

attributed to and related to HF and as many as one third of those 

patients are readmitted for treatment of symptom recurrence within 

90 days. Thus, it is not surprising that the cost of providing 

advanced medical care for the millions of patients suffering from 

HF is extraordinarily high—now estimated at more than $38 billion 

annually. 4 The problem is further complicated by inadequate reimbursement 

to the treating hospitals, which places an inordinate 

economic burden on the overall healthcare system. From this has 

sprouted an increasing awareness among healthcare professionals 

that delivering appropriate care for patients with HF in the outpatient 

setting (thus reducing hospitalizations and the associated 

costs) is of distinct clinical benefit to most patients with HF as well 

as financially stressed hospitals. 

After many years of dedicated effort in caring for patients with 

HF and their families, the authors share the belief of many other field 

professionals that in most cases HF should be considered an outpatient 

condition, and experience has shown that with the absence of 

EDs, critical care units, and hospital beds, the outpatient arena provides 

an optimal setting for appropriate diagnosis, treatment, clinical 

improvement, and ultimately perhaps even the prevention of HF. 

The authors have dedicated 2 decades to the development and 

implementation of a number of HF centers, thus combining prior 

clinical experience with HF evidence-based medicine to advance 

the concept of outpatient treatment. We have been fortunate to work 

within a healthcare system of more than 9 area institutions that 

share the commitment (and foresight) to make excellence in HF 

care a system-wide priority. Moreover, the entire system has 

achieved Disease Specific Certification in Heart Failure by the Joint 

Commission on Accreditation of Healthcare Organizations, reflecting 

this center’s emphasis on coordination of care and support of 

patient self-management, effective use of evidence-based guidelines 

to manage care, and measurement and improvement of health outcomes. 

These accomplishments (the result of the hard work and 

dedication of many healthcare professionals who maintain a daily 

focus on the mission, values, and philosophy of the Advocate Health 

Care System) can be readily replicated in other US medical centers. 

This publication is designed to provide an overview of the 

Advocate Heart Failure Institute and the Heart Failure Center, as 

well as supporting patient care and research arms. The overall 

objective of this effort is to focus on the structure and treatment 

approaches employed in this center and share with a wider profes- 

sional audience the lessons learned in the development and implementation 

of a comprehensive outpatient HF management program. It 

is hoped that this Institute’s experience will further encourage the 

establishment of such centers at other institutions that are similarly dedicated 

to optimal disease management outside the hospital 

environment for the benefit of the many millions of patients with HF. 

Overview of Outpatient Heart Failure 

Disease Management 

Results of the first randomized clinical trial of a HF disease 

management program by Rich and colleagues 5 demonstrated that 

patients participating in an outpatient clinic program who subsequently 

required readmission to the hospital for HF were less acutely 

ill and required a shorter period of hospitalization. This study and 

others have shown that availability of a HF outpatient management 

program leads to reductions in 30% to 44% in all-cause admissions 

and more than a 50% decrease in the rate of admissions for HF. 6–8 

Some common features of successful 

disease management programs include 

disease specificity, promotion of patient 

self-management, and patient-specific 

treatment and intervention plans. 

The common features of such disease management programs 

include disease specificity, promotion of patient self-management, 

standardized delivery of care method in accordance with clinical 

guidelines and/or evidence-based practice, patient-specific treatment 

and intervention plans, comprehensive care along the 

continuum of the disease and healthcare delivery systems, and 

measurement and analysis of clinical outcomes to improve treatment 

plans. 

In addition to the obvious benefit of reducing the number of 

patients who may require hospital readmission for HF within 30 

days of discharge, experience has shown the significant cost/benefit 

potential in establishing an outpatient HF management program. 

Recognizing the chronic shortages of inpatient bed availability in 

most hospitals today, any reduction in the hospitalization rate for 

HF is clearly advantageous for each individual institution as well as 

for the healthcare system as a whole. 

The Experience at Advocate Health Care 

In 1995, the first system-wide continuous quality improvement 

project to optimize the health of patients with HF and reduce 

rehospitalizations was established by Advocate Health Care. This 

continuum of care program was developed by a 20-member implementation 

team and physician advisory group comprised of 

cardiologists, clinical nurse specialists, pharmacists, and quality 

management personnel. 

The principal objectives of this comprehensive outpatient HF 

management program were to (1) ensure close collaboration between 

physicians and the multidisciplinary HF team, (2) provide an intermediary 

care site between physician offices and the acute care 

institution, and (3) enhance quality of care and patient satisfaction. 

The overall program was designed to shift patient management from 

the “crisis intervention” mode to a more comprehensive care

approach delivered in hospital, home, and outpatient settings. Core 

components of this effort included patient evaluation, delivery of 

comprehensive care, close individualized patient monitoring, ready 

access to clinic staff to permit immediate response to any patient 

crisis, intensive patient and family education and reinforcement, 

and compliance tracking to ensure patient adherence to the prescribed 

multidimensional treatment regimen. 

As stated in the Heart Failure Institute’s formal mission statement, 

this integrated, systematic approach to patient care incorporates 

proactive interventions, measurements, and refinements designed to 

provide patients with HF with the self-care skills and educational support 

necessary for understanding and effectively managing their 

condition. In addition to understanding the disease process itself, 

participants assume an active role in their own clinical management 

by maintaining a proper diet, monitoring their fluid intake, and 

tracking their weight on a daily basis. 

During the 7 years since inception of this outpatient HF management 

program, the scope of its services, staffing needs, treatment 

approaches, and goals has continued to evolve as the result of ongoing 

clinical experience. Typically, an HF clinic nurse first identifies 

the patient during hospitalization and then schedules an initial visit 

to explain the program, its objectives, and potential long-term management 

benefits. This is followed by initiation of the patient 

education process, working with the inpatient staff to prepare the 

patient for discharge, and subsequently following up to ensure establishment 

of an appropriate outpatient and/or homecare program. 

Following initial assessment, the HF nurse and cardiologist 

develop an appropriate plan for implementation of both medical and 

nonpharmacologic treatments, based on current American College of 

Cardiology/American Heart Association (ACC/AHA) guidelines 

(http://www.acc.org/clinical/guidelines/failure/pdfs/hf_fulltext.pdf). 

Rather than classifying patients with HF according to the degree 

of exertion required to produce symptoms (as per the New York 

Heart Association [NYHA] functional classifications I-IV), the 

ACC/AHA classification assesses HF as a continuum, beginning 

with patients at risk for HF (stage A) and then progressing to those 

with asymptomatic left ventricular dysfunction (stage B), those 

with symptomatic HF (stage C), and patients suffering from 

advanced irreversible HF (stage D). The relationships between the 

various ACC/AHA stages and NYHA functional classes are shown 

in Table 1. 

As with any evaluation of this type, it is important to identify 

reversible causes of HF so that appropriate surgical interventions 

can be optimized (eg, revascularization, valve replacement, cardiac 

resynchronization therapy, left ventricular assist device placement, 

or heart transplant evaluation). Patients also are evaluated as potential 

participants in ongoing clinical research trials of newer pharmacotherapeutic, 

device, and surgical approaches to HF treatment. 

♥ 5 

TABLE 1 9 

Classification of HF: Relationship Between ACC/AHA HF Stage and NYHA Functional Class 

ACC/AHA HF Stage 10 NYHA Functional Class 11 

A At high risk for HF but without 

structural heart disease or symptoms of heart 

failure (eg, patients with hypertension or 

coronary artery disease) 

B Structural heart disease but without symptoms I Asymptomatic 

of HF 

C Structural heart disease with prior or current II Symptomatic with 

symptoms of HF moderate exertion 

III Symptomatic with 

minimal exertion 

D Refractory HF requiring specialized 

interventions 

IV Symptomatic at rest 

ACC/AHA = American College of Cardiology/American Heart Association; 

NYHA = New York Heart Association. 

The 1994 Cardiology Preeminence Roundtable assessed the 

results of HF patient management and strongly recommended the 

clinic approach. 12 It gave its highest rating to structured outpatient 

programs as most likely to generate significant reductions in total 

cost of care. The Advocate Heart Failure Center’s outpatient management 

program facilitated an overall reduction in the 30-day 

readmission rate for HF from 10% in 2000 to 7% in 2001.

Components of an Outpatient 

Management Program for Heart Failure 

Based on the authors’ experience, specific considerations in 

establishing an outpatient clinic for the management of HF are outlined 

below. 

Facilities and Staffing 

The facilities required for an HF clinic are largely dependent 

on the anticipated scope of the program and size of the target 

patient population. The Advocate Heart Failure Clinic opened in 

1995, with only one office and a single examining room but rapidly 

expanded to meet its growing needs. 

Clinic facilities should include a 

reception area (with reclining chairs) 

and 1 or 2 examining rooms… 

At a minimum, clinic facilities should have a reception area 

(with reclining chairs) for registration, waiting, and billing; 1 or 2 

examining rooms; telemetry monitoring; and oxygen delivery. 

Administration needs include a telemanagement area, adequate 

office space, storage space for equipment and medical 

records, and a TV/VCR room for educational purposes. 

Experience has shown that at the outset an outpatient HF 

management clinic can function effectively with 1 physician (who 

is highly committed to the program) serving as medical director, a 

program manager, and 2 or more staff registered nurses (RNs) or 

advanced practice nurses. The nursing staff should possess at least 

3 to 5 years of cardiovascular nursing experience, strong communication 

skills, and the desire to work with chronically ill patients. 

Knowledge Base of Staff 

There are specific training and educational necessities that 

will ensure the clinic functions effectively as an HF outpatient management 

center. 

Personal direction by a cardiologist with particular experience 

in the management of HF should be available to all staff. This 

will ensure mastery of professional practice patterns and assessment 

skills. 

The staff should (1) have complete familiarity with current 

HF guidelines as well as pharmacologic and nondrug treatment 

strategies; (2) receive instruction on optimal patient/family education 

and counseling support; and (3) be well-versed on advanced 

physical assessment. 

Patient Management 

Medications. Many medications employed in the treatment 

of HF require titration over time as well as careful monitoring of 

the patient’s clinical response. Because most patients with HF are 

receiving multiple pharmacotherapies (often as many as 8 to 15 

daily), close supervision of all medication regimens is essential to 

confirm dosing, scheduling, and compliance. 

Of course, current medications must be reviewed at every 

visit and patients must present all their medications (in their original 

containers) at least monthly, but a number of patient-specific 

accommodations can be made to help ensure compliance (Table 2). 

6 ♥ 6 

TABLE 2 

Tools for Medication Compliance 

• Utilize once-daily dosing when possible. 

• Provide premade pill dispensers. 

• Print dosing instructions in large type whenever a change is made. 

• Make sure patients always have current medications list. 

All program participants are strongly advised to avoid taking 

any nonprescription over-the-counter agents without prior consultation 

with, and approval by, the clinic staff. The use of medications 

such as nonsteroidal anti-inflammatory drugs can exacerbate the 

condition of a patient with HF. 

Laboratory Testing. Clearly, one of the key aspects of both 

inpatient and outpatient management of the HF patient is knowledge 

of several multifunctional laboratory measurements. 

Typically, measurement of a complete blood count and chemistry 

panel are helpful in order to identify etiologic or aggravating factors 

of a patient’s HF (eg, anemia). Also, factored into the design of an 

outpatient management program is an understanding of other critical 

target organs that need to be considered. For example, the 

patient with impaired liver or kidney function greatly alters the use 

of certain approaches and may mandate others. In addition, as a 

routine a urinalysis and evaluation of thyroid function should be 

part of the evaluation if not already performed. 

B-type natriuretic (BNP) hormone is a peptide synthesized 

and released predominantly from the heart and serves a variety of 

homeostatic functions in health and disease. Recently, detection of 

BNP levels has become available and is rapidly becoming a standard 

diagnostic for patients with HF. 

The utility for BNP testing is continuing to expand and has 

been demonstrated in the following areas: 

• To help triage patients presenting to the ED with dyspnea; 

• for assessment of HF disease severity; 

• for prognosis in patients with acute coronary syndromes; and 

• to aid in the diagnosis of diastolic HF. 

BNP testing is under further investigation for the following 

clinical applications: 

• For potential screening in higher-risk populations; 

• utilizing BNP value as a hospital discharge criteria; 

• monitoring efficacy of pharmacologic therapy; and 

• assessment of hydration status of patients on hemodialysis. 

It is clear that BNP testing plays a major role in the laboratory 

investigation of any patient being considered for outpatient 

disease management and will likely serve as an important biomarker 

that disease management teams will help define. 

Frequently clinicians follow an algorithm for either inpatient 

or outpatient that incorporates BNP into decision making. Such an 

algorithm for patients presenting with acute dyspnea is summarized 

in Figure 1.

FIGURE 1 13 

Evaluation and Treatment of Patients with Acute Dyspnea 

BP = blood pressure; ECG = electrocardiogram; COPD = chronic obstructive pulmonary disease; 

BUN = blood urea nitrogen; Creat = creatinine, CrCl = creatinine clearance; CKD = chronic kidney disease. 

Reprinted with permission of MedReviews, LLC. Maisel A. B-type natriuretic peptide measurements 

in diagnosing congestive heart failure in the dyspneic emergency department patient. Rev 

Cardiovasc Med. 2002;3(suppl 4):S10-S17. Reviews in Cardiovascular Medicine is a copyrighted 

publication of MedReviews, LLC. All rights reserved. 

Currently, there are several FDA-approved assays that measure 

BNP. It is important to note that the molecules and their 

measurements differ per the various assays. In general, one should 

become familiar with the assay used at their institution. The rapid 

point-of-care assay affords the ability to obtain the BNP measurement 

in the office, which allows the practitioner to decide 

immediately whether to send the patient to the emergency room or 

obtain a cardiology consult. The rapid point-of-care assay also facilitates 

the tracking of outpatient BNP levels. This helps to guide 

therapy and to promote interventions that may delay HF progression. 14 

The Triage ® BNP Meter has been well accepted by our laboratory 

personnel and our clinicians who both consider it quite useful. 

Ancillary Testing. Other laboratory measurements are guided 

by the patient’s disease status and an understanding of their HF etiology. 

Frequently, patients with HF also are maintained on chronic 

oral anticoagulation and the HF clinic may take on the role of managing 

this important medicine, particularly during a time of other 

medication adjustment. 

Impedance cardiography is gaining wider acceptance as a 

tool that accurately, reliably, and safely predicts noninvasive hemodynamic 

information. Recent information from the PREDICT trial 15 

suggests that a composite of bioimpedance measurements may 

accurately identify patients likely to have decompensation over the 

short term. Further analysis and publication is pending. 

Bioimpedance measurements are also useful in determining 

hemodynamics in patients who may need outpatient intravenous 

therapies. Perhaps the key issue is to have a readily accessible 

repository of laboratory tests that can better outline changes in lab 

markers over extended periods of time. 

Weight Maintenance. An essential aspect of HF care is 

aggressive management of the disease through the effective use of 

diuretics and careful adherence by the patient to all diet, fluid 

intake, and weight management directives. 

Patients must inform staff 

of any 2-day 3-lb weight gain 

or 1-week 3- to 5-lb gain. 

Patients are asked to weigh themselves at the same time each 

morning after urinating, while wearing similar clothing and using 

♥7 the same scale as the last time they weighed themselves. A scale is 

provided for any patient who is unable to afford one. 

Patients are instructed to advise clinic staff of any 2-day 

weight gain of 3 lb, or a 3- to 5-lb weight gain over 1 week. 

Depending on the patient’s renal function and other clinical findings, 

diuretics may be administered or changes made to current 

medication regimens. The key objective is to identify any early 

signs of decompensation and volume overload and initiate treatment 

promptly to avoid potential worsening of the HF condition 

and the subsequent need for hospitalization. 

Follow-up. Maintaining frequent contact with these patients 

is essential in helping reinforce the clinic’s educational program 

and in tracking patient compliance. For those occasions when a 

patient is unable to return to the clinic for any reason, follow-up 

telephone contact represents an important outpatient tool. 

Effective telemanagement involves a series of specific questions 

to ascertain the patient’s understanding of the disease process, 

assess compliance, and accurately determine the individual’s current 

clinical status. This approach enables the HF nurse to 

(1) reinforce patient education efforts, (2) notify the physician in 

the event of any changes in the patient’s condition, and (3) make 

any necessary medication adjustments. 

Family Support. In addition to the informational resources 

described above, various communication vehicles have proven 

particularly useful in reinforcing treatment plans such as presenting 

a “What to Expect” pamphlet prior to each hospital discharge, 

giving written discharge instructions after each hospitalization 

and after each HF clinic visit, ensuring they have the most current 

medications list, and generating a quarterly newsletter for all 

clinic patients. 

Patients are encouraged to telephone and speak with the HF 

clinic nurse any time they wish without delay. Patients have a direct 

paging number for ready access to the clinic manager and clinical 

specialist after hours. 

Patient Support Groups. For those patients with HF who 

are not homebound because of their medical problems and have 

access to suitable transportation, monthly support group meetings 

serve as a highly effective management tool. In addition to providing 

important patient follow-up, support groups allow patients to 

interact with their peers, engage in open discussion, and ask any 

questions that they might have. 

A number of specific topics have proved to be of great interest 

when addressed in a support group setting. These include HF 

awareness, signs and symptoms of HF, coping with HF, how HF 

medications work, activity tolerance with HF, need for and implications 

of restricting salt intake, Medicare and health maintenance 

organization issues, the effect of mood on heart function, new 

advances in therapy, diabetes and HF, dietary tips for eating out, and 

hospice care. 

Clinic Communications With Other Medical Personnel. 

In addition to the importance of communicating effectively with 

patients with HF and their families, the complexity of outpatient HF 

management obviously requires close communication and interrelationships 

between primary care physicians, cardiologists, case 

managers, office staff, and multidisciplinary team members. This 

begins with a written communication to the patient’s physician on 

discharge from the hospital, encouraging prompt referral to the HF 

outpatient clinic. 

Following treatment in the HF clinic of any patient with an 

emergent problem, the respective physicians are telephoned imme-

diately. Throughout the course of treatment, written documentation 

keeps the patient’s physicians abreast of all medication changes, 

clinical findings, laboratory results, plan of care, and response to 

therapy. The office of each referring cardiologist also receives an 

ongoing list of current HF clinic patients to ensure that this information 

is updated accordingly. 

Finally, outcomes data are regularly presented at hospital 

department meetings to keep all primary physicians fully informed 

of the HF clinic’s services and to document the impact of outpatient 

management on clinical outcomes and cost effectiveness. Clinic 

staff members are in frequent communication with hospital case 

managers to identify current HF inpatients and devise a follow-up 

plan for postdischarge care. This process is multidisciplinary in 

nature and involves such other team functions as social services, 

homecare, and dietary counseling. 

♥ 8

Transitioning Management 

From Inpatient to Outpatient 

Although greater emphasis increasingly is placed on HF outpatient 

management, most patients first come to the attention of the 

HF team in conjunction with a hospital admission, after which they 

are transitioned to outpatient care. The staff at the Advocate Heart 

Failure Institute believes that patients without advanced disease 

should not be hospitalized more than once for an HF-related diagnosis. 

With early detection and aggressive intervention, this outpatient 

management program aims to achieve clinical stabilization early after 

presentation and to avoid unnecessary hospitalizations in patients 

with HF and symptoms of acute decompensation. 

For example, currently at our institution an estimated 10% of 

all patients presenting to the ED with HF are sufficiently stabilized 

to be discharged home safely, although the ultimate objective is to 

increase this percentage to as high as 40% to 50%. The most appropriate 

patient candidates for early discharge are those with mild left 

ventricular dysfunction and/or hypertension. Older patients who 

have a history of ischemic heart disease and/or multiple comorbidities 

typically are not suitable candidates for this treatment approach. 

A number of standing orders have been developed at the 

Institute. These documents are designed to help ensure that HF care 

is efficiently managed at each step, while initiating appropriate progression 

to the outpatient setting. 

Selection of Appropriate Patient Candidates 

for Outpatient Management 

A number of specific criteria have been established by the 

Advocate Heart Failure Center for use in evaluating a patient’s condition 

in the ED to determine if discharge to outpatient care is 

warranted. An important decision point in making this clinical 

assessment is at 2 hours post intravenous (IV) diuretic administration. 

At this time, the patient must meet the criteria set forth in 

Table 3 to be considered an appropriate candidate for discharge. If 

eligible, the patient will be discharged with a detailed outpatient 

follow-up plan, including written discharge instructions (see 

page 25) and their first HF clinic appointment the very next day. 

TABLE 3 

Emergency Department Criteria for Transition to Outpatient* 

• Adequate diuresis (urine output > 500 mL and associated weight loss) 

• Relief of dyspnea 

• Evidence of clinical stabilization (eg, heart rate [HR] < 100/min, serum potassium (K + ) level of 4.0 

to 4.5 mEq/dL and oxygen saturation > 94% on room air) 

*Determined 2 hours postadministration of diuretics 

The patient also is provided with access to telephone 

informational support (the Advocate health advisory system) for up 

to 2 postdischarge consultations as needed. A key aspect is to make 

sure follow-up and continuity are assured for the recently decompensated 

patient within the subsequent 2 to 3 days at most. 

Those patients who require further treatment and/or monitoring 

may be admitted to the hospital’s extended cardiac care unit for 

additional observation. In the event that the presenting symptoms 

do not resolve within an appropriate period of time and the discharge 

criteria are not met, the patient then is admitted for inpatient 

care. Increasingly, the goal is to resolve the presenting symptoms 

and avoid admission if possible. This approach is generally favored 

by patients and their families. 

♥ 9 

Because homecare may be the most suitable next level of care 

for some patients, we (in collaboration with our Homecare Services) 

have designed a homecare program that focuses on HF outcomes. 

Educating the homecare nurses and offering some treatment guidelines 

make this more than just an observer/reporter function and 

truly integrate homecare as an alternative venue for HF outpatient 

care. Representative homecare guidelines for selection of patients 

eligible to be enrolled in this protocol are shown on page 26. 

Referral for Outpatient Heart Failure Management 

Before being considered for referral to the outpatient management 

program, every patient with HF first undergoes a detailed 

clinical evaluation, including a comprehensive history and review 

of all available medical records. This assessment includes the etiology 

and stage of the patient’s HF, left ventricular ejection fraction 

(LVEF), comorbidities, electrocardiogram (EKG) rhythm, blood 

pressure, functional status/6-minute walk test, quality of life, 

assessment of volume status (eg, jugular venous distention, hepatojugular 

reflux, lung sounds, edema), impedance cardiography 

measurement, laboratory values (sodium, K, blood urea nitrogen 

[BUN], creatinine, complete blood count [CBC], B-type natriuretic 

peptide [BNP]), evaluation of the patient’s understanding of the disease 

process, medication history, compliance with medications, diet 

and fluids, and screening for symptoms of sleep apnea (see pages 

27 and 28). 

After 7 years of experience at the Advocate Heart Failure 

Center, considerable insight has been gained into the most effective 

means of initiating HF patient referrals. This process begins with 

daily clinic staff rounds on the inpatient units. By accessing daily 

census lists and physician orders and direct interaction with case 

managers and other staff members, patients with HF are identified 

and visited to initiate them to the clinic’s program and services. 

Through consultation with the attending physician and cardiologist, 

a specific management plan is developed for each patient, beginning 

first with comprehensive patient education. 

Extensive experience at many hospitals has shown a direct 

relationship between the need for frequent hospital readmissions 

for HF and inadequate patient education. Those factors that most 

often contribute to otherwise avoidable rehospitalizations generally 

relate to inadequate diet, medications, activity guidelines, daily 

weight monitoring, being alert to symptom changes, and timely 

postdischarge follow-up. It is clear that these potential limitations to 

effective HF management largely can be overcome by educational 

efforts directed toward all patients with HF. 

Unfortunately, however, it also is apparent that the hospital 

setting may be the least conducive for patients and families to 

receive the information they need to improve overall disease management. 

The acutely ill hospitalized patient is likely to be under 

considerable stress, and family members’ frequent inability to 

absorb information concerning their relative’s condition and clinical 

management in this highly stressful situation is not at all surprising. 

To overcome these significant limitations, the HF nurse 

arranges to meet with the patient in the hospital and schedule a 

postdischarge appointment in the outpatient clinic. During the first 

hospital visit, the patient is also given a copy of the Advocate clinic 

publication, “Congestive Heart Failure—A Patient Guide,” to provide 

a more comprehensive overview of the overall disease process 

and its optimal management from the patient perspective. The overall 

content of this informational resource, provided in the form of a

3-ring binder to permit ease of revision as needed, is shown in Table 4. 

This information also is supplemented by arranging for the patient to 

view educational videotapes, as well as providing access to a library of 

other informative publications with specific reference to HF. 

TABLE 4 

Contents of “Congestive Heart Failure—A Patient Guide” 

• Pictorial representation of heart function 

• What is congestive heart failure (CHF)? 

• Causes of CHF 

• Signs and symptoms 

• Diagnostic testing 

– BNP levels 

– Echocardiogram 

– Multiple gated acquisition scan 

– Stress test 

– Cardiopulmonary stress test 

– Stress echocardiogram 

• Treatment 

– Diet 

– Fluid limits 

– Daily weight information 

– Benefits of exercise 

– Use and safety of oxygen 

– Review of medications (angiotensin-converting enzyme [ACE] inhibitors, diuretics, 

digoxin, beta-blockers) 

• Importance of spiritual strength in living with a chronic illness 

• Support group information, learning assessment, outpatient management, smoking cessation 

• Patient self-management considerations 

To ensure continuity of care prior to enrolling in the outpatient 

management program, each patient with HF receives detailed instructions 

on hospital discharge (see page 25). These explicit directives 

address the important issues listed in Table 5. 

TABLE 5 

Discussion Topics at Discharge 

• The necessity for a balanced diet 

• The need to reduce sodium in the diet and limit fluid intake to avoid counteracting the effects 

of diuretic therapy 

• Daily weight checks to guard against fluid retention 

• Instructions to carry a list of all current medications, dosages, and dosing frequencies 

• What the patient should expect relative to energy and activity levels 

• Specific follow-up visit instructions 

The HF nurse is then responsible for ensuring that the 

referred patient presents for the first scheduled clinic appointment, 

establishing his/her formal participation in the outpatient HF management 

program. 

10 

♥

Drug Treatment Protocols in Heart Failure 

Extensive clinical experience and new drug development 

efforts over the past decade have had a dramatic impact on the ability 

to effectively manage the care of patients with long-term HF on 

an outpatient basis. The availability of a growing number of proven 

therapeutic agents (ranging from diuretics and ACE inhibitors to 

inotropes, vasodilators and newer, more advanced pharmacologic 

approaches) has reinforced the importance of specific treatment 

protocols to ensure the optimal administration of these life-saving 

therapies. 

The Heart Failure Society of America (HFSA) has published 

the HFSA Practice Guidelines, 16 reviewing current pharmacologic 

approaches for the management of patients with HF caused by left 

ventricular systolic dysfunction. In this document, the HFSA 

emphasizes the essential role of ACE inhibitors and diuretics in 

the optimal management of HF and the recent clinical data reinforcing 

the important therapeutic benefits of digoxin. Administered 

once daily in combination with other agents, the HFSA noted that 

digoxin is the only orally effective drug with positive inotropic 

effects that has been approved by the US Food and Drug 

Administration (FDA) for use in treating mild to moderate HF. 

Although the development of comprehensive treatment protocols 

for all potentially useful therapeutic agents is clearly beyond the 

scope of this publication, following are a number of guidelines that 

relate to the administration of specific agents and/or drug classes that 

play essential roles in the management of HF at the Advocate Heart 

Failure Center. Although these treatment protocols represent the 

combined first-hand experience of many hundreds of medical professionals 

in the administration of these therapeutic agents to 

patients with HF, it is recognized that every individual hospital will 

develop its own treatment guidelines in accordance with the experience 

generated by that institution’s medical staff. 

The drug protocols described below reflect the cumulative 

clinical experience at the authors’ center. Each is based on medication 

usage and dosing recommendations developed by the 

respective pharmaceutical manufacturers, which appear in the 

approved prescribing information for each specific pharmacotherapeutic 

agent. It is hoped that the following guidelines will be 

helpful to readers, and if deemed appropriate, may be considered 

for possible incorporation into similar treatment protocols for HF 

developed for use at other medical centers. 

Guidelines 

Diuretic Titration 

Patient Instructions 

• Weigh yourself first thing each morning. Remember to wear 

clothing similar to what you wore last time you weighed yourself. 

Chart recorded weights for inspection at each clinic appointment. 

• Restrict how much sodium you have each day to about 2300 mg 

and do not add salt to your food. Read labels and count your 

sodium. 

• Class III or IV HF patients as well as those with multiple hospital 

readmissions should not have more than 2 qt of fluid each day. 

• Immediately report any of the following to the clinic staff: 

– weight increase of 3 to 4 lb over 1 to 2 days (or 5 lb in 1 week) 

♥ 11 

– other symptoms of impending exacerbation, such as shortness of 

breath, paroxysmal nocturnal dyspnea, orthopnea, lower 

extremity swelling, increased abdominal girth, early satiety, and 

nausea or vomiting after meals. 

Treatment 

• If the patient experiences weight gain or other symptoms as noted 

above, DOUBLE the present daily diuretic and K + doses for 1 to 2 

days and have the patient call daily to report weight and 

symptoms. 

• If weight drops by 1 to 2 lb (but not back to baseline) and symptoms 

are beginning to resolve, continue with increased daily dosages of 

diuretic and K + . When weight has returned to baseline, return to 

original diuretic and K + doses. 

• If weight increases occur more than once or twice per month, 

consider an increase in the daily dosages along with possible 

follow-up evaluations of BUN, creatinine, and electrolytes 

(including magnesium). 

• If there is little or no response to a doubling of diuretic and K + 

doses, add metolazone (Zaroxolyn ® ) 2.5 mg for 1 day, along with 

20 mEq K-Dur ® (if creatinine < 2.5 mg/dL). If weight returns to 

baseline, return to initial diuretic and K + doses. 

• If little or no response after 3 days, schedule follow-up clinic 

evaluation as soon as possible. 

Always reinforce sodium and fluid restrictions and instruct 

patient to go to the ED if symptoms worsen. 

A variety of protocols have simplified some of the common 

potassium-related issues that arise during outpatient care of patients 

with HF. Some of these are noted in Table 6. 

TABLE 6 

Outpatient Potassium Replacement Protocol 

Creatinine K + Level 

< 3.2 3.2–3.59 3.6–3.99 4.0–5.4 > 5.4 

< 1.5 Call MD 60 mEq 40 mEq No Rx Call MD 

1.5–2.0 Call MD 40 mEq 20 mEq No Rx Call MD 

2.0–2.8 Call MD 20–40 mEq 20 mEq No Rx Call MD 

> 2.9 Call MD Call MD Call MD No Rx Call MD 

Remember to check magnesium. MD = medical doctor; Rx = treatment. 

Angiotensin-Converting Enzyme Inhibitor Titration 

Angiotensin-Converting Enzyme (ACE) inhibitor therapy is 

recommended for all patients with decreased ejection fraction, and 

for any patient who has experienced a myocardial infarction. The 

dosage titration guidelines in Table 7 are employed for each respective 

ACE inhibitor until optimal dosing is attained. The indicated 

dosage increase WILL NOT be initiated, or a 1- to 2-week decrease 

in dose to the previous level will be made, if the patient exhibits 

signs and symptoms of intolerance (eg, postural lightheadedness, 

symptomatic hypotension with systolic blood pressure (SBP) < 85 

mmHg, systemic vascular resistance (SVR) < 700 dyne/sec/cm -5 or 

significant increase in creatinine [> 5 mg/dL]). Any further increase 

in dosage will then await resolution of symptoms, laboratory findings, 

and/or impedance cardiography results.

Laboratory Testing 

First and last visit: BNP, BMP (basic metabolic profile), magnesium, 

impedance cardiography. 

Each visit (approximately every 2 weeks until titrated to maximum 

tolerated dose): BUN, creatinine, electrolytes, impedance 

cardiography. 

TABLE 7 

ACE Inhibitors Dosing Titration Guidelines 

Lisinopril 

Captopril Enalapril (Prinivil ® , Fosinopril Quinapril Ramipril 

Week (Capoten ® ) (Vasotec ® ) Zestril ® ) (Monopril ® ) (Accupril ® ) (Altace ® ) 

1 6.25 mg tid 2.5 mg bid 2.5 mg qd 10 mg qd 5 mg bid 2.5 mg qd 

3 12.5 mg tid 5.0 mg bid 5 mg qd 20 mg qd 10 mg bid 5.0 mg qd 

5 25 mg tid 7.5 mg bid 10 mg qd 30 mg qd 15 mg bid 7.5 mg qd 

7 37.5 mg tid 10 mg bid 15 mg qd 40 mg qd 20 mg bid 10 mg qd 

9 50 mg tid 15 mg bid 20 mg qd 30 mg bid 

11 20 mg bid 40 mg bid 

bid = 2 times a day; day 

qd = every day; tid = 3 times a day. 

Metoprolol (Lopressor ® ) and Metoprolol-XL (Toprol-XL ® ) 

Slow Titration 

Start with 5 mg orally bid (can begin as low as 1 mg bid with 

history of beta-blocker failure, remote asthma, or class IV HF symptoms 

despite adequate diuresis and full ACE inhibitor titration). See Table 8. 

TABLE 8 

Metoprolol and Metoprolol-XL Slow Titration Guidelines 

Metoprolol 200 mg/200 mL syrup (1 mg/1 mL solution) 

Titrate upward at weekly intervals (monitor weight, IV drip, 

blood pressure [BP], HR) 

Week Dose and Frequency (Total) 

1 5 mg tid (15 mg/d) 

2 10 mg bid (20 mg/d) 

3 10 mg tid (30 mg/d) 

4 

Then 

20 mg bid (40 mg/d) 

Switch to metoprolol-XL 

5 25 mg bid (50 mg/d) 

6 25 mg tid (75 mg/d) 

7 50 mg bid (100 mg/d) 

It may be necessary to increase diuretic and/or inotrope 

dosages intermittently until full titration is achieved (then wean off 

inotropes and slowly reduce diuretic after switching to metoprolol- 

XL). Monitor every 2 to 3 weeks and instruct patient to advise of 

any change in condition and/or 2- to 3-lb weight gain. 

It may be helpful to use impedance cardiography technology 

when titrating beta-blockers or ACE inhibitors. SVR should be kept 

to approximately 1000 to 1200 dynes/sec/cm -5 to maximize CI. 

Carvedilol (Coreg ® ) 

The patient should already be receiving an ACE inhibitor and 

possibly digoxin, diuretics, and spironolactone (Aldactone ® ). The 

patient should be as euvolemic as possible (not hypotensive and 

with no signs or symptoms of fluid overload). 

The patient should always eat some food before taking 

carvedilol, and space out carvedilol and other medications that may 

♥ 12 

decrease BP (eg, carvedilol at breakfast and dinner, once-a-day 

ACE inhibitor at lunch; a large diuretic dose can be taken upon 

arising, and carvedilol 1 hour later, after breakfast). 

Advise the patient of the possible need to adjust diuretic (and 

perhaps other drugs) dosages during the first few weeks or months. 

Monitor weight strictly and let the clinic know if there is a 3-lb 

increase or if symptoms worsen. This drug takes time to work, and 

patients may feel worse before they improve. Table 9 defines specific 

dosing recommendations. 

TABLE 9 

Carvedilol Dosing Guidelines 

Week Dose and Frequency (Total) 

1–2 3.125 bid 

3–4 6.25 mg bid 

5–6 12.5 mg bid 

7–8 25 mg bid 

9–10 In patients >187 lb and HR > 0.60— 

consider 50 mg bid 

Note: Slower titration may be needed if frequent diuretic dose 

adjustments are needed, with SBP in the 90s or resting apical 

pulse < 60; however, target dosages should be reached, if at all 

possible, if patient remains stable with no signs of HF exacerbation. 

Nesiritide (Natrecor ® ) Outpatient Infusion 

Higher-risk, class III-IV, stage C/D patients with HF who 

have experienced frequent hospitalizations are treated for low cardiac 

output in the HF clinic, with occasional, brief, short-term 

inotrope therapy and, more recently, the use of a recombinant form 

of human BNP (hBNP) (nesiritide) as treatment for acute decompensated 

HF. 

In the presence of apparent volume overload and likelihood 

of diuretic resistance coupled with clinical evidence of low cardiac 

output, nesiritide therapy may be initiated in the outpatient area. 

Nesiritide is indicated for use in treating acutely decompensated HF 

in the presence of dyspnea at rest or with minimal exertion, with 

clinical evidence of fluid overload and SBP > 90 mmHg. This 

aggressive treatment approach combines rapid natriuresis, diuresis 

and, vasodilatation, and it was shown to be safe and effective 

for hospitalized patients with HF in both the VMAC 17 and 

PROACTION 18 trials. IV nesiritide may be administered concomitantly 

with diuretics and other agents commonly used for the 

chronic management of HF. In those patients with HF who remain 

at high risk for early decompensation, consideration may be given 

to the repeated administration of nesiritide as needed on an outpatient 

basis. 

The nesiritide treatment algorithm currently in use at the 

Advocate Heart Failure Institute is shown in Figure 2. 

Pharmacology/Mechanism of Action. Nesiritide is a naturally 

occurring cardiac neurohormone secreted by the cardiac 

ventricles in response to ventricular volume expansion and pressure 

overload. Levels of hBNP are elevated in HF, binding to 

vascular smooth muscle and endothelial cells and activating cyclic 

guanosine monophosphate, leading to smooth muscle relaxation. 

Nesiritide reduces preload and afterload and has no direct inotropic 

effect. It also suppresses the renin-angiotensin-aldosterone and 

sympathetic nervous systems, promoting natriuresis and diuresis.

Is SBP < 90 mmHg 

and/or SVR < 800 dyne/sec/cm -5 

? 

No 

Any evidence of 

low cardiac output syndrome— 

hypovolemia / 

azotemia / oliguria / 

tachycardia? 

No 

Any recent diarrhea, 

vomiting, poor 

fluid intake? 

No 

Does SBP reflect severe 

hypertension? 

Indications for Nesiritide Use. Nesiritide is indicated for 

the treatment of acute decompensated CHF (patients with dyspnea 

at rest or with minimal activity) to reduce pulmonary capillary 

wedge pressure and improve dyspnea. 

Other standard treatments for CHF, such as oral ACE 

inhibitors, aldosterone inhibitors, digoxin, and beta-blockers should 

be maximized. 

Contraindications. Patients in cardiogenic shock, with SBP 

< 90 mmHg, systemic vascular resistance < 800 dyne/sec/cm -5 ,or 

suspected hypovolemia, should not receive nesiritide. 

Pharmacokinetics. Nesiritide’s half-life is 18 minutes, but if 

hypotension occurs, it may last for several hours; onset of action is 

within 15 minutes (bolus dose) and within 15 to 30 minutes when 

administered by infusion. Dosage adjustment is not required in 

patients with renal impairment. 

Table 10 compares nesiritide, dobutamine, and nitroglycerin 

in the treatment of acute decompensated CHF. 

Yes 

No 

Yes 

Yes 

Yes 

Yes 

FIGURE 2 

Advocate Christ Nesiritide Therapy Algorithm 

Patient with 

decompensated CHF 

NYHA class III - IV (dyspnea at rest)— 

check BNP level (if > 100 pg/mL, HF is likely) 

and impedance cardiography. 

Assess volume status jugular 

venous pressure (> 7 cm, 

hepatojugular reflux edema rales, 

serum NA < 135, dry, cool skin). 

Is patient cool and wet? 

Nesiritide may not be indicated— 

may need to address other causes. 

Does patient have aortic stenosis 

or renal artery stenosis? 

Give IV loop diuretic 

(typically 2x oral dose) 

and start IV nesiritide in 

separate, dedicated IV line 

(2 µg/kg bolus, 

then 0.01 µg/kg/min). 

♥ 13 

No 

Yes 

Yes 

No 

Nesiritide therapy is 

NOT indicated. 

Nesiritide may not be indicated— 

consider inotropic therapy and 

address causes of decompensation. 

Access response in 4 hr—Monitor BP, urine output, weight, intake and 

output. 

– If symptomatic hypovolemia occurs, reduce or decrease infusion 

and support BP. Nesiritide may be restarted at a 30% reduced 

dose with no bolus, once symptoms resolve. 

•• Patient may remain on oral ace-inhibitors, digoxin, and betablocker 

therapy while nesiritide infuses, but do not infuse other 

vasoactive IV therapies (milrinone or nitroglycerin) with nesiritide. 

– If urine output < 1000 mL w/creatinine < 20 or urine output 

< 500 mL w/creatine >20, consider furosemide IV gtt, or higher 

dose of IV furosemide every 6 hr (up to 360 mg). 

Assess response at least every 4 hr—if adequate response to therapy, 

infusion may be continued for 24–48 hr (Check K + and replace 

appropriately every 12–24 hr if urine output is > 1000 mL). Consider 

transfer to intensive care unit w/continuous hemodynamic monitoring 

if not improved in 12–24 hr or if urine output < 50 mL/hr. 

TABLE 10 

Comparison of Selected Agents for Treatment of Acute Decompensated HF 17,18,19 

Characteristic NS DB NT 

Rapid decrease in PCWP Yes No Yes(NS > NT) 

Vasodilatory effects (venous and arterial) Yes No Yes 

Neurohormonal effects Yes No No 

Diuretic/natriuretic effects 

Inotropic effects (increase force 

Yes No No 

of contraction of cardiac muscle 

Increases myocardial 

No Yes No 

oxygen consumption No Yes No 

Induces tachycardia No Yes No 

Arrhythmogenic 

Induces tachyphylaxis 

No Yes No 

(tolerance to drug) No Yes Yes(NT > DB) 

Induces hypotension Yes No Yes 

Requires invasive monitoring No No No 

Usually requires titration No Yes Yes 

DB = dobutamine; NS = nesiritide; NT = nitroglycerin; PCWP = pulmonary capillary wedge 

pressure.

Dosing and Administration. Table 11 shows the dosing 

recommendations for nesiritide 1.5-mg single-dose vials. 

TABLE 11 20 

Dosing and Administration Recommendations for Nesiritide 1.5-mg Single-Dose Vials 

Reconstitution Preparation and Administration Dose Adjustments 

Reconstitute vial using Add reconstituted vial to 250 mL Dose titration usually 

preservative-free diluent* bag of recommended diluent * (final concentration 6 µg/mL) 

unnecessary 

Swirl gently to mix; do not shake 

vial Withdraw bolus from prepared 

infusion bag and administer 

Store reconstituted solution at room 2 µg/kg over 1 minute 

If inadequate clinical 

response occurs, 

administer 1 µg/kg bolus 

and increase infusion 

temperature 20°–25°C (68°–77°F) 

or refrigerate 2°–8°C (36°–46°F) 

Use reconstituted vial within 24 hours 

Then immediately administer 

0.01 µg/kg/min continuous 

IV infusion 

Maintain infusion over 24–48 

hours (as needed) 

by 0.005 µg/kg/min 

increments to maximum 

of 0.03 µg/kg/min 

Monitor blood pressure closely, 

if symptomatic hypotension 

occurs, discontinue nesiritide 

and restart infusion once 

patient is clinically stable 

*IV = intravenous. 

*Recommended diluents: 5% dextrose for injection (D5W), 0.9% sodium chloride for injection, 5% dextrose 

and 0.45% sodium chloride for injection, or 5% dextrose and 0.2% sodium chloride for injection. 

Follow Up Serial Infusions of Natrecor ® (FUSION I). 21 A 

number of high-risk patterns suggest a strong likelihood that a 

specific patient will require hospital readmission for HF. Recently, 

the FUSION I trial results were published. This pilot trial was 

designed to study the safety and feasibility of applying outpatient 

infusions of nesiritide to a population of patients with advanced 

HF (Stage C, FC III-IV) who were at high risk of rehospitalization 

and decompensation. Several markers of advanced heart failure 

(> 2 HF hospitalizations within the previous 6 months, NYHA functional 

class III or IV despite current medical therapy, 400 m in total 

distance during a 6-minute walk test) were key inclusion criteria in 

the FUSION I study with the use of nesiritide. Additionally, 32% of 

these patients had 4 or more markers of severe and advanced HF. 

Particularly for this very high-risk group, there was demonstrated 

safety and efficacy, with strong signals suggesting benefit when 

applied to an appropriate patient population. Of particular interest 

was the fact that in the high-risk group there was a statistically significant 

increase in the number of days alive and out of hospital for 

the nesiritide treated patients only. Based on the pilot work and finding 

of the FUSION I trial, a larger FUSION trial has been designed 

and is now underway with recruitment. 

Patients were stratified into high-risk and low-risk groups 

based on their Risk Assessment Score (RAS) (Table 12), in accordance 

with the number of specific RAS characteristics they displayed. 

TABLE 12 

FUSION I Risk Assessment Criteria 

• Serum creatinine > 2.0 mg/dL within the last 30 days 

• NYHA class IV for the last 60 days 

• > 65 years of age 

• History of sustained ventricular tachycardia 

• Ischemic etiology of HF 

• Diabetes 

• Outpatient use of nesiritide or inotropic agents during the preceding 6 months 

Patients with 4 or more of the above conditions were deemed to 

be at high risk, whereas those with less than 4 RAS were considered low 

risk. Among the 3 treatment groups, low-risk patients comprised 67% to 

71% of the study participants, and 29% to 33% were at high risk. 

♥14 Patients were randomized to 1 of 3 study arms—(1) standard 

care (long-term cardiac medications with or without intravenous 

inotropes); (2) serial infusions of nesiritide 0.005 mcg/kg/min; or 

(3) serial infusions of nesiritide or 0.01 mcg/kg/min. Nesiritide 

patients continued to receive their usual long-term cardiac medications, 

excluding intravenous inotropes. Each patient in a nesiritide 

group received a weekly 4- to 6-hour infusion of nesiritide for 12 

weeks, followed by a 30-day follow-up period. At the investigator’s 

discretion, patients were able to receive up to 3 Natrecor infusions 

in any given week or to skip an infusion; however, each patient was 

required to receive at least one nesiritide infusion every other week. 

Both dosage levels of nesiritide proved to be safe, with only 

6% to 7% of the study patients terminating therapy due to an 

adverse event (AE). The most frequent AE was worsening of CHF, 

experienced by 38% to 44% of patients in the 3 study treatment 

groups. Symptomatic hypotension, asymptomatic hypotension, and 

renal AEs (including increased BUN, abnormal kidney function, 

acute kidney failure, increased creatinine, and oliguria) occurred in 

8% to 14%, 13% to 22%, and 13% to 23% of patients in the 3 study 

groups, respectively. Among the low-risk patients, only 1 significant 

difference was noted between the 3 treatment groups—a lower 

incidence of asymptomatic hypotension in those receiving standard 

care (8%) compared with the 2 nesiritide groups (22% to 23%). 

However, among high-risk patients, the rates of occurrence for all 

of the above-noted AEs were substantially lower in the nesiritidetreated 

groups than in those receiving standard care. 

With respect to efficacy, clinical outcomes were significantly 

better among patients in both nesiritide-treated groups. Through 

week 12 of the study, 51% to 54% of nesiritide patients were alive 

and never hospitalized, deaths occurred in 4% to 8%; and 44% to 

48% were hospitalized due to all causes. This result compared with 

42% of standard-treatment patients who were alive and never hospitalized, 

death in 10%; and 54% with all-cause hospitalizations. 

Moreover, all 3 of these clinical outcomes were dramatically 

improved among the high-risk patients who received nesiritide (35% 

to 58%, 4% to 5%, and 42% to 60%, respectively) versus 22%, 17%, 

and 74%, respectively, for those who received standard care. 

Table 13 shows that in the high-risk patient stratum, statistically 

significantly greater reductions in mortality were observed with 

nesiritide compared with standard care for all group comparisons 

(low-dose nesiritide, P=.074; high-dose nesiritide, P=.122; and all 

nesiritide patients, P=.029). The investigators’ Global Clinical Status 

assessments of subjects treated with nesiritide also were statistically 

significantly (P

TABLE 13 21 

Mortality (High-Risk Strata) 

Standard 

Nesiritide 

Care Low Dose High Dose All Patients 

12 Weeks (n=23) (n=24) (n=20) (n=44) 

Deaths 4 1 1 2 

Mortality 

Rate (%) 

17.4 4.2 5.3 4 

P value compared — 0.146 0.213 0.079 

to standard care 

16 Weeks 

Deaths 5 1 1 2 

Mortality 

Rate (%) 

22 4.2 5.3 4.6 

P value compared — 0.074 0.122 0.028 

to standard care 

TABLE 1421 Clinical Outcomes Through Week 12 

(High-Risk Patients) 

Standard 

Natrecor ® 

Clinical Care Low Dose High Dose All Patients 

Outcome 

Patients alive and 

(n=23) (n=24) (n=20) (n=44) 

never hospitalized 5 (22%) 14 (58%) 7 (35%) 21 (48%) 

Deaths 4 (17%) 1 (4%) 1 (5%) 2 (5%) 

All-cause 

hospitalization 

Days alive and out 

17 (74%) 10 (42%) 12 (60%) 22 (50%) 

of hospital 

• Mean ±SD 

• 25th percentile 

67.2 ± 22.3 

61.2 

76.3 ± 16.8 

74.6 

77.2 ± 14.0 

75.3 

76.7 ± 15.5 

75.0 

The investigators concluded that nesiritide was safe for outpatient 

administration; its use increased the percentages of subjects 

who were alive and out of the hospital compared with standard care, 

reduced overall mortality, and significantly improved physician 

assessments of patients’ clinical status. The FDA-approved dose of 

nesiritide (2 mcg/kg bolus followed by 0.01 mcg/kg/min infusion) 

appeared to significantly increase the minimum number of days 

alive and out of hospital compared with the low-dose regimen, 

whereas both nesiritide dosages clearly were superior to standard 

care alone. In summary, the addition of nesiritide to a standard-care 

regimen proved to be safe and highly effective in the clinical management 

of outpatients with severe HF. 

Based on the pilot work and finding of the FUSION I trial, a 

larger FUSION trial has been designed and recruitment is underway. 

FUSION II will examine, amongst other endpoints, the effect 

of nesiritide on mortality in a patient population with advanced HF. 

For more information, please see http://www.clinicaltrials.gov. 

Cardiac Resynchronization Therapy 

An emerging new therapy for patients with advanced HF and 

desynchronization has been pacemaker-based resynchronization. 

Our approach to this new therapy is delineated below. 

Indications for Cardiac Resynchronization Therapy 

• Moderate to severe HF 

• QRS (130 ms on 12-lead electrocardiogram [ECG]) 

• Left ventricular ejection fraction (35%) 

• On stable, optimal medical therapy 

♥ 15 

(Note: Although QRS is an indication of dysynchrony, ventricular 

wall motion on echocardiogram is a more definitive finding, 

especially in patients with a QRS range of 120 to 130 ms) 

Postimplant optimization of the cardiac resynchronization 

(CRT) device and arteriovenous delay should be made. 

Prioritization for Cardiac Resynchronization 

Patients who meet the indications and are experiencing the following: 

• Worsening of symptoms 

• Severe symptoms 

• Moderate symptoms 

• Patients with QRS

Case Studies in Heart Failure Management 

Achieving optimal management of HF is often one of the most difficult challenges faced by any medical practitioner. In addition to 

the obvious pathophysiologic factors that have directly caused the cardiac dysfunction, clinicians also must take into account such individual 

factors as patient lifestyle, emotional concomitants, and family interrelationships to effectively stabilize the patient’s condition and 

implement a long-term management plan. These and other relevant considerations can best be seen in the context of actual case studies of 

patients who have been successfully treated at the Advocate Heart Failure Center. 

The following case histories of 3 patients presenting with symptoms of HF are representative of the day-to-day diagnosis and clinical 

management of HF. These case studies illustrate initial patient work-up, treatments implemented, the need for inpatient admission, rapid 

transitioning to appropriate homecare, and initiation into the outpatient HF management program. 

CASE 1 

Background A woman aged 79 years was referred to the HF clinic after being hospitalized with a decompensated episode of HF. The 

patient is stage C (NYHA class III) HF with ischemic cardiomyopathy. She has a history of coronary artery disease, with 

coronary artery bypass graft in 1992. She lives alone but still drives and eats many meals in a small restaurant around 

the corner from her apartment. Her eldest daughter lives close to her and usually drives her to appointments. 

Assessment BP 124/60, HR 72. Weight is down 11 lb from hospitalization. Lungs with scattered crackles, 1+ edema, + jugular 

and Findings venous distention. Still complains of shortness of breath and weakness with minimal activity. Her doctor had previously 

tried a low-dose beta-blocker but told her to stop when she complained of fatigue. 

Echocardiogram: EF 25%; ECG: Atrial fibrillation 

Medications Captopril 25 mg tid 

Furosemide 40 mg bid 

KCL 20 mEq qd 

Digoxin 0.125 mg qd 

Warfarin 5 mg half strength 

Atorvastatin 20 mg half strength 

Spironolactone 25 mg qd 

Goals Education, aggressive diuresis, initiate and titrate medication protocols. 

Treatment • HF teaching (signs and symptoms, diet, medications, follow-up) 

Plan • IV diuretics to improve symptoms and decrease volume overload 

• ACE inhibitor titrated and changed to daily dosing 

• Once patient compensated, start beta-blocker therapy and titrate to tolerance 

Outcomes Over a 6-month period, the patient and family had a better understanding of HF and how to be active participants in 

her care. 

Patient lost 15 lb, symptoms improved, quality of life score and 6-minute walk improved. ACE inhibitor was changed 

to lisinopril 20 mg qd; carvedilol was titrated to 25 mg bid. Patient did have some initial problems tolerating the 

carvedilol and was followed with close assessment, laboratory work-up, and diuretics. 

The patient knew what to expect and when to call us. The relationship was built over time, the key components being 

communication and trust. 

After beta-blocker titration, she was more active with NYHA functional class I symptoms and became more active with 

her social clubs. Her daughter commented that she had believed her mother was dying, but that she now seemed to 

be her old self again. 

Commentary This is an example of a patient with advanced symptoms, a low ejection fraction, and a recent hospitalization so she was 

certainly at high risk for further decompensation. We believed, however, that of the major interventions and education, that 

dietary restriction of sodium and initiation of a beta-blocker were the most important and evidence based. 

These steps clearly changed this patient from one who was fairly limited to someone enjoying life again. She now visits the 

Heart Failure Center occasionally and gives first-hand advice to other patients about the virtues of sodium restriction. 

16 

♥

CASE 2 

Background A man aged 46 years presented with dilated idiopathic cardiomyopathy. He is stage C (class II) HF. Patient was 

referred from the cardiologist’s office following his visit. 

Assessment BP 100/60, HR 68. Lungs clear, shortness of breath with activity, mild edema. Patient is very depressed. 

and Findings Echocardiogram: EF 15%; ECG: Paced with automatic implantable cardioverter/defibrillator 

Medications Torsemide 50 mg bid 

Trandolapril 2 mg qd 

KCL 20 mEq bid 

Alprazolam 0.25 mg tid 

Digoxin 0.125 mg qd 

Metoprolol-XL 25 mg qd 

Magnesium Oxide 400 mg tid 

Allopurinol 300 mg qd 

Goals Education, increase beta-blockers and ACE inhibitor to maximum doses. 

Treatment • HF education for patient and family 

Plan • Consult for depression 

• Monitor compliance and motivation 

• Increase ACE inhibitor and monitor laboratory work-up and clinical response 

• Increase beta-blocker to patient tolerance 

Outcomes Patient was so depressed that he was not able to absorb information effectively and be an active partner in his care. 

He missed appointments, did not follow the low sodium diet, and did not take his medications as prescribed. We tried 

to work with his wife, who was very angry and overwhelmed. Ultimately this patient needed psychologic counseling 

and medication for his depression. Once he was stabilized and motivated to come back to the HF clinic, we began 

very slowly with his treatment goals. This process took a long time and is still ongoing with close supervision 

and monitoring. 

Commentary Often there are steps needed in the care of patients beyond those that seem obvious and evidence based. This is often 

particularly true for younger patients who develop HF. The hospital setting and even the busy office visit may not be 

appropriate settings to delve deeper into patient or family concerns. The periods spent in the HF center allow some time 

to get to know the patient and the family. It is often here that the “real” issues emerge and the team can focus on providing 

all that is needed to make clinical management of this patient a success. 

CASE 3 

Background A man aged 66 years with stage C (class IV) HF was brought by his daughter to the ED complaining of extreme shortness 

of breath, especially at night. Denied chest discomfort. Stated that he does not weigh himself but thinks he gained 

weight recently. His legs have been swelling, his stomach bloated, his appetite poor, and he spent a few restless nights 

prior to this event using 3 to 4 pillows to prop himself up to decrease his anxiety and shortness of breath. 

Extremities were dry but warm. Posterior myocardial infarction displaced laterally; jugular venous pressure 10 cm at a 

45° angle, and lungs have inspiratory crackles half way up bilaterally. Liver engorgement present, along with + hepatic 

jugular reflex. Lower extremity edema 2+ to midcalf bilaterally. 

His only history is of coronary after bypass surgery about 5 years ago and borderline hypertension. The patient is emotionally 

upset that his daughter brought him to the hospital—“Can’t afford it!” He has not followed up with a cardiologist 

since the bypass and rarely sees his family doctor. He states that he stopped smoking a few years ago, and he still works 

part-time construction as an assistant electrician but rarely gets any cardiovascular exercise. He reports it is too hard to 

walk more than 50 feet at a time; he gets breathless. He admits to drinking 2 to 3 beers daily and sometimes more. He 

has been divorced for more than 20 years. He reports he has been in 2 other hospitals in the past 3 months for similar 

symptoms. He says, “They give me a shot to make me pee, and I feel better for a few days.” 

♥ 17

CASE 3 (continued) 

Assessment On examination, there is evidence of volume overload (jugular venous distension, lung crackles, hepatomegaly, 2+ leg 

and Findings edema) as well as low output (cool skin and decreased urination). 

Initial vital signs: O2 oximeter on room air 93%; BP 196/100; pulse 110, respiratory rate 32; scaled weight per HF 

protocol 200 lb; height 6 feet, no allergies. 

Medications Aspirin 2 daily for “aches and pains of old age.” Patient vaguely remembers being given other medications previously 

but he stopped taking them because they were too expensive. 

Goals Education, increase beta-blockers and ACE inhibitor to maximum doses. 

Treatment Initial treatment in ED per HF protocol. 2 L oxygen per nasal cannula, 12-lead EKG, chest radiograph, noninvasive 

Plan biopedance measurement (intake and output). Laboratory work-up: Troponin, creatinine kinase-MB, CBC, complete metabolic 

profile, BNP, thyroid-stimulating hormone. Medications: Furosemide 40 mg intravenous push (IVP), topical 

nitroglycerin. Impedance cardiography: CI a bit low at 2.2, SVR very high. 

2 HOURS LATER 

Vital signs: BP 170/92, pulse 100, respiratory rate 24; intake 100 mL; output 500 mL. 

Laboratory work-up: Essentially within normal limits (cardiac enzymes negative) except BNP elevated at 900 pg/mL, 

hyponatremia with Na + 130; creatinine 1.5; slight anemia. EKG showed sinus tachycardia. Chest radiograph showed 

pulmonary congestion and increased heart size. O2 oximeter on 2 L per nasal cannula 95%. 

Diagnosis: Ischemic cardiomyopathy/CHF 

Plan 

• Admit to telemetry and continue HF standing orders. 

• Continue 2 L O2 per nasal cannula, daily weight, and input and output. 

• Begin nesiritide IV glucose tolerance test (GTT), 2 µg/kg bolus over 1 min with 0.01 µg/kg/min GTT. 

• Begin IV furosemide GTT in separate IV line, to infuse 120 mg during next 24 h. 

• Check K + again in 6 hours (maintain K + 4.0 to 4.5). 

• Begin oral ACE inhibitor in the morning (enalapril 2.5 mg bid). 

• 2-D echocardiogram in the morning to determine left ventricular ejection fraction (LVEF) and any structural 

heart disease (no record of previous echocardiogram or measurement of LVEF). 

• HF education and social work consult to plan for discharge needs. 

Day 2. Furosemide drip was stopped and oral loop diuretic continued after urine output 2200 mL > intake, patient lost 

5 lb overnight, and dyspnea and paroxysmal dyspnea markedly improved. Vital signs better (BP 130/80, pulse 88, respiratory 

rate 22). CI 2.6, SVR 1600 dynes/sec/cm-5 (better). Examination showed clear lungs, mildly elevated jugular 

venous pressure, and only trace edema. Echocardiogram showed LVEF 25% with mild mitral regurgitation. 

Visit from HF outpatient clinic nurse who gave him HF education binder, medication teaching, and began instructing 

patient and daughter on plans for discharge. Homecare nurse to visit. 

Outcomes Day 3. Clearly improved with additional 2-lb weight loss. Patient is able to walk the halls without dyspnea and normal 

oxygenation. On examination, he is non-edematous. 

Digoxin started at 0.125 mg orally daily, enalapril titrated up to 5 mg bid. Impedance cardiography: showing CI 2.5 

L/min/ms and SVR 950 dynes/sec/cm-5 . Vital signs: BP 110/72, pulse 82 and regular, respiratory rate 20. Labs: Better, 

NA + coming up, now 134; K + within normal limits (4.1). 

Hospital discharge to home with homecare. Plan to continue HF center involvement after homecare nurse discharges patient. 

Commentary This case illustrates a number of common paradigms of HF: 

• use of the ED as portal of entry 

• lack of continuity in HF care 

• role of noncompliance in HF symptom recurrence 

• frequency of complicating pyschologic issues 

♥ 18

CASE 4 

Background This woman aged 63 years had coronary artery bypass surgery 7 years ago for angina pectoris. At the time of surgery, 

she had mild left ventricular dysfunction and trace mitral regurgitation. Beginning 2 years ago, she began to have 

symptomatic HF and the LVEF was found to be 26%. 

Beginning 1 year ago, she had worsening symptoms of HF and has had 5 such hospitalizations in the past 6 

months (all marked by volume overload and decompensation). When hospitalized, she was treated with dobutamine, 

which prompted some diuresis but needed to be stopped due to excessive ventricular arrhythmia. The same pattern 

occurred with milrinone. With each admission, her baseline BNP level rose sharply. Following the past 2 admissions, 

despite diuresis, the baseline level remained above 900 pg/mL. 

She noted that her oral diuretics were less effective, and this was becoming a more frequent occurrence. Even occasional 

IV diuretics do not markedly improve her symptoms, and she was concerned that she would need further hospitalization. 

Oral diuretic dose had escalated, and she began to have worsening renal function. 

Due to her advanced functional status and lack of responsiveness to standard therapy, we discussed evaluation for heart 

transplantation. She refused because of her concern regarding the care of her husband. Additionally, one of her best 

friends had undergone heart transplantation. Our patient was the regular driver for her friend’s outpatient visits and 

biopsies. Her friend died with sepsis less than 2 years following the procedure. 

She routinely attends the HF center and takes her medications on a regular basis. She is a retired dietician and is keenly 

aware of sodium content in food. There is no alcohol or drug use. She cares for her husband who lives at home but suffers 

from advancing dementia due to Alzheimer’s disease. 

Assessment Stage C (NYHA functional class III) 

and Findings Etiology: Ischemic 

Last catheter: 9 months ago with patent left internal mammary artery to the left anterior descending and all vein grafts patent 

Echocardiogram: LVEF 22% with mild to moderate mitral regurgitation 

PVO2: 14.6 mL/kg/m2 BNP: 926 pg/mL 

QRS duration: 100 ms 

Medications ACE inhibitor, beta-blocker, digoxin, diuretics, spironolactone 

Goals Our goals in this patient were to improve volume status, symptoms, and survival. 

Treatment • Patient referred to an electrophysiologist who implanted an ICD (she was not a suitable candidate for biventricular pacing). 

• Patient was given outpatient nesiritide infusion for 4 hours, which included a standard bolus of 2 µg/kg followed by an 

infusion of 0.01 µg/kg/min. She was given IV diuretic and diuresed well. Because this seemed to attenuate her heading 

toward severe decompensation, we continued to give her weekly outpatient nesiritide infusions for 5 weeks. 

• Weekly laboratory work-up (as well as impedance cardiography measurements) was obtained just prior to the infusion, 

and those data are summarized below. 

Week 

1 2 3 4 5 

Weight (lb) 157 154 150 148 145 

NYHA functional class III III II II I 

BNP level (pg/mL) 926 721 645 398 245 

Sodium (mg/dL) 130 132 134 137 137 

BP (mmHg) 90/58 90/60 92/64 94/64 101/70 

Cardiac index (L/min/m2 ) 1.9 2.2 2.4 2.6 2.5 

Outcomes This woman continues to have functional class I-II HF but has markedly improved her activity. She is now a volunteer 

at an Alzheimer’s spouses group that meets weekly. Her diuretic dose has been markedly reduced and she has had no 

further hospitalizations in the past 12 months. Her ICD checks have shown no firings. A recent echocardiogram shows 

her LVEF is now 36% and she has no mitral regurgitation. 

♥ 19

CASE 4 (continued) 

Commentary This patient seems typical of so many patients we care for in that she was doing all the right things and taking all the 

right drugs and still had progressive HF marked by recurrent volume overload and frequent admissions. 

Her examination and BNP levels indicated increased filling pressures and volumes, yet she clearly had diuretic 

resistance. Mitral regurgitation will only lead to more dysfunction unless it is diminished significantly. 

Her personal decisions limited some of her options, such as heart transplantation or even consideration of mitral valve 

surgery; however, using just outpatient nesiritide she was able to effectively diurese and reset many of the triggers for 

her endogenous BNP synthesis and release. 

Placing an ICD decreased her risk of sudden death and normalizing her left ventricular filling pressures coupled with 

prescribed medical therapy also may increase her chance of survival. This approach has been investigated in the FUSION 

trial. Additional study of this approach, including determination of candidates, dosing regimens, and biomarkers for 

evaluation are all clearly needed. 

♥ 20

Other Issues, Considerations, and 

Informational Resources 

Throughout this publication, frequent references have been 

made to the ACC/AHA Guidelines for the Evaluation and 

Management of Chronic Heart Failure in the Adult. This document 

provides important insight into the most current recommendations 

for effective HF management. The complete updated guidelines are 

available for downloading on the internet at 

http://www.acc.org/clinical/guidelines/failure/pdfs/hf fulltext.pdf 

Another informative guidelines document, the HFSA Practice 

Guidelines, is available in its entirety at http://www.hfsa.org. 

A number of other considerations enter into the clinical management 

of HF. One of these is the importance of clinical research 

into the development of major new pharmacotherapeutic agents, 

and the benefits of an institution’s participation as an investigative 

center in randomized clinical trials. 

With the limited number of heart transplantion procedures 

that can currently be performed for patients with no other available 

management options, the significance of the availability of major 

treatment advances cannot be overstated. Most recently, nesiritide, 

a hBNP, became the first new medication to be approved in more 

than a decade for use in treating acutely decompensated HF. 

However, offering patients with HF the opportunity to participate 

as clinical trial subjects in studies of newer investigative agents 

is dependent on each individual hospital’s assessment of its own 

ability to allocate the necessary institutional resources toward this 

effort. An active clinical trial program represents a substantial commitment 

of professional, administrative, organizational, and financial 

support in the face of increased budgetary pressures that are impacting 

all hospitals today. For example, significant costs and staff time 

must be devoted to the establishment of a suitable Institutional 

Review Board to assume oversight responsibility for all investigational 

and clinical research activities and study participation. 

Nonetheless, in most instances, the institutional and patientcare 

benefits of serving as a participating center in clinical 

investigations of new therapeutic agents for HF far outweigh the 

associated costs. 

Another reality for all healthcare professionals actively 

involved in the management of patients suffering from congestive 

HF is the extremely high risk of mortality that is associated with this 

serious condition. Particularly in the case of those with advanced 

disease, any comprehensive HF program must necessarily address 

end-of-life considerations when this final outcome can no longer be 

avoided. This should include appropriate discussions on establishment 

of a living will, determining the patient’s “power of attorney” 

for healthcare questions, and any specific directives relative to ultimate 

resuscitation efforts. 

Adequate examination of the many emotional, ethical, and religious 

issues that must be confronted in this regard is clearly beyond 

the scope of this publication. Certainly, the decision to raise this 

painful issue with a patient and family members can be made only 

when it becomes clear that all available treatment options have been 

exhausted. At such time, however, the active involvement of a 

patient’s religious advisors, hospice counselors, and medical 

end-of-life and ethics committees is invaluable in providing necessary 

support and guidance for patients who are confronting the 

ultimate reality of death and for their families. 

21 

♥ 

In conclusion, management of the patient with HF is the 

most challenging of all medical endeavors. Continuing advances in 

available treatment options (as well as increasing emphasis on identifying 

patients whose longer-term clinical care can be most 

appropriately administered in the outpatient setting) offer greater 

hope to millions of patients with HF, and the expectation of a 

longer, more fulfilling life. 

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1. Silver MA. Heart Failure. In: Rakel RE, Bope ET (ed). Conn’s Current 

Therapy 56th Edition. W.B. Saunders. 2004:341-345. 

2. American Heart Association: 1998 Heart and Stroke Statistical Update. 

Dallas, TX: American Heart Association; 1997. 

3. O’Connell JB, Bristow MR: Economic impact of heart failure in the United 

States: time for a different approach. J Heart Lung Transplant. 1994;13:S107- 

S112. 

4. Crowther M, Maroulis A, Shafer-Winter N, Hader R. Evidence-based development 

of a hospital-based heart failure center. Online J Knowl Synth Nurs. 

2002;9:5C. 

5. Rich MW, Vinson JM, Sperry JC, et al. Prevention of readmission in elderly 

patients with congestive heart failure. Results of a prospective, randomized 

pilot study. J Gen Intern Med. 1993;8:585-590. 

6. Riegel B, Thomason T, Carlson B, et al. Implementation of a multidisciplinary 

disease management program for heart failure patients. Congest Heart Fail. 

1999;5:164-170. 

7. Chapman DB, Torpy J. Development of a heart failure center: a medical 

center and cardiology practice join forces to improve care at a community 

hospital. Am J Manag Care. 1997;3:431-437. 

8. Knox D, Mischke K. Implementing a congestive heart failure disease management 

program to decrease length of stay and cost. J Cardiovasc Nurs. 

1999;14:55-74. 

9. Farrell MH, Foody JM, Krumholz HM. Beta-Blockers in heart failure: clinical 

applications. JAMA. 2002;287:890-897. 

10. Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis, et al. 

GSACC/AHA guidelines for the evaluation and management of chronic heart 

failure in the adult: executive summary. A report of the American College of 

Cardiology/American Heart Association Task Force on Practice Guidelines 

(Committee to revise the 1995 Guidelines for the Evaluation and Management 

of Heart Failure). J Am Coll Cardiol. 2001;38:2101-2113. 

11. New York Heart Association/Little Brown and Company, 1964. 

12. Cardiology Preeminence Roundtable: Beyond four walls: cost-effective management 

of chronic congestive heart failure. Washington DC: Advisory Board 

and Company; 1994. 

13. Silver MA, Maisel A,Yancy CW, et al. BNP Consensus Panel 2004: A Clinical 

Approach for the Diagnostic, Prognostic, Screening, Treatment Monitoring, 

and Therapeutic Roles of Natriuretic Peptides in Cardiovascular Diseases. 

Cong Heart Failure. 2004;10(suppl 3):1-30. 

14. Young JB, Correia NG, Francis GS, Maisel A, Michota F. Testing for B-type 

natriuretic peptide in the diagnosis and assessment of heart failure: What are 

the nuances? Cleve Clin J Med. 2004;71(suppl 5):S1-S17. 

15. Packer M. ICG Prognostic Role: Results from the PREDICT Trial. Paper presented 

at: 8th Annual Scientific Meeting; Monday, September 13, 2004; 

Toronto, Canada. 

16. Heart Failure Society of America HFSA practice guidelines. HFSA guidelines 

for management of patients with heart failure caused by left ventricular systolic 

dysfunction—pharmacological approaches. J Card Fail. 1999;5:357-382. 

17. Publication Committee for the VMAC Investigators (Vasodilation in the 

Management of Acute CHF): Intravenous nesiritide vs nitroglycerin for treatment 

of decompensated congestive heart failure: a randomized controlled trial. 

JAMA. 2002;287:1531-1540. 

18. Peacock WF, Emerman CL, on behalf of the PROACTION study group: Safety 

and efficacy of nesiritide in the treatment of decompensated heart failure in 

observation patients. Abstract presented at: American College of Cardiology, 

Annual Meeting March 30–April 2, 2003; Chicago, IL. 

19. Dobutamine [package insert]. Deerfield, IL: Baxter Healthcare Corporation. 

1999. Available at: http://www.fda.gov/cder/ogd/rld/20255s6.pdf. Accessed on 

November 1, 2004. 

20. Natrecor® [package insert]. Fremont, CA: Scios Inc.; 2004. Available at 

http://www.natrecor.com/pdf/natrecor_pi.pdf. Accessed on October 6, 2004. 

21. Yancy CW, Saltzberg MT, Berkowitz RL, et al. Safety and feasibility of using 

serial infusions of nesiritide for HF in an outpatient setting (from the FUSION 

I trial). Am J Cardiol. 2004;94:595-601. 

22. Stevenson LW. Tailored therapy to hemodynamic goals for advanced heart 

failure. Eur J Heart Fail. 1999;1:251-257.

Congestive Heart Failure Orders (Emergency Department) 

Orders Time 

1. Primary Diagnosis: CHF 

Secondary Diagnosis: 

2. CHF History ■ First-time failure ■ Readmission Etiology: 

LVEF < 40% ■ Yes _______% ■ No ■ Unknown 

3. Consult(s): _______________________________________________________________________________ 

________________________________________________________________________________________ 

4. Notify CHF coordinator M–F 7:30 AM to 5:30 PM (pager 2428 or ext 4552) 

5. Allergies ■ Yes (list) ____________________________________________________________________ 

■ No known allergies 

6. SCALED WEIGHT in ED ___________ lb OR __________ kg 

7. Record Intake and Output 

8. IV Access ■ Yes ■ No ■ Type ____________________________ 

9. Old Charts to ED ■ Yes ■ No ■ Comment:___________________________________ 

10. Diuretic: Choose one and if urine output < 200 mL within 30 min, consider redosing, increasing the dose, or other therapies. 

Furosemide IVP ■ 20 mg ■ 40 mg ■ 80 mg ■ __________ 

Torsemide IVP ■ 10 mg ■ 20 mg ■ 50 mg ■ __________ 

Metolazone ■ 2.5 mg ■ P05 mg po 

IV _______________________________________________________________________________ 

Other _______________________________________________________________________________ 

11. ACE Inhibitor 

Captopril ■ 6.25 mg ■ 12.5 mg ■ 25 mg ■ 50 mg ___ mg po q ______hr 

Enalapril ■ 2.5 mg ■ 5 mg ■ 10 mg ■ 20 mg ___ mg po q 24 hr 

Ramipiril ■ 2.5 mg ■ 5 mg ■ 10 mg ___ mg po q 24 hr 

12. Other 

Digoxin (dose and route) ____________________________________________________________________ 

Nitroglycerin ■ Sublingual 0.4 mg ■ Topical __________ ■ Oral ___________ 

13. IV Vasodilating Agents 

■ Nesiritide 2 µg/kg bolus over 1 min with 0.01 µg/kg/min GTT in dedicated line 

(only if SBP > 90 mmHg, and do not use with any other vasodilating IV agent) 

■ Nitroglycerin Start at 0.3 µg/kg/min to 0.5 µg/kg/min and titrate 

14. IV Inotropes (if clinical signs and symptoms of low cardiac output) 

Milrinone 

Loading dose ■ 0 bolus ■ 25 µg/kg ■ 50 µg/kg for_____ min 

Maintenance (µg/kg/min) ■ 0.25 µg/kg/min ■ 0.375 µg/kg/min ■ 0.5 µg/kg for_____ min 

Dobutamine (µg/kg/min) _________________________ for_____ hr 

SAMPLE 

15. Other Medications _________________________________________________________________________ 

16. ■ Arterial blood gases (ABG) ■ Pulse oximetry O2 Therapy_______L/min ■ Nasal cannula (NC) ■ Nonrebreather (NRB) 

17. 

■ Venturi-mask____________FiO2% Noninvasive ventilation ■ Continuous Positive Airway Pressure (CPAP) 

■ Bilevel Positive Airway Pressure (BIPAP) 

Start with I 10, E 4, FiO2 variable. Adjust to ABG results, SaO2, and patient’s level of comfort 

■ Intermittent Positive Pressure Breathing (IPPB)_________________ ■ Other____________________________________________ 

ED Labs/Tests 

■ BMP ■ Chest radiograph 

■ BNP (do not draw if patient on IV neseritide) 

■ CBC 

■ Magnesium 

■ Digoxin level (order only if signs of toxicity) 

■ EKG 

18. Additional Labs/Tests ■ Urinalysis ■ Lipid profile ■ Creatinine phosphokinase (CPK) ■ Troponin 

19. Foley Catheter ■ Yes ■ No 

20. Impedance Cardiography ■ HR ■ Mean Arterial Pressure (MAP) ■ CO ■ CI ■ SVR 

■ Accelerated Index (ACI) ■ Thoracic Fluid Content (TFC) 

21. ED Discharge Disposition ■ Home ■ Observation ■ Mobile Intensive Cardiological Care Unit (MICCU) Bed: ■ Monitored 

■ Nonmonitored 

22. Attending Physician ________________________________________________________________________ 

Admitting Physician ________________________________________________________________________ 

23. ED Physician ___________________________________________________________________________ 

♥22 ED RN ___________________________________________________________________________

Congestive Heart Failure Orders (Admission) 

The following order set is for use on any floor or unit. We have encouraged attendings and housestaff to use these for any HF admission. 

Copies also are made available to physicians in their offices for patients admitted directly from home or office. 

Orders Time 

1. Primary Diagnosis: CHF 

Secondary Diagnosis: 

2. CHF History ■ First-time failure ■ Readmission Etiology: 

LVEF < 40% ■ Yes _______% ■ No ■ Unknown 

3. Echocardiogram if not done in previous 6 months ■ Yes ■ No 

4. 

If done in previous 6 months, obtain OLD REPORT. 

Consult(s): _______________________________________________________________________________ 

________________________________________________________________________________________ 

5. Notify CHF coordinator M–F 7:30 AM to 5:30 PM (pager 5432, otherwise leave a message at ext. 1234) 

6. Allergies ■ Yes (list) ____________________________________________________________________ 

■ No known allergies 

7. Old Charts to Unit: ■ Yes ■ No 

8. Vital Signs: ■ Unit routine ■ q __________ hr 

9. SCALED WEIGHT On admission: ______________ 

DAILY WEIGHT, use bedside scale and instruct patient about doing daily weights at home 

10. Record all intake and output on bedside flowsheets. Total after 24 hr 

11. Fluid restriction 2000 mL/24 h OR ___________________ mL/24 hr 

12. Diet: ■ _______ 2 Na restricted ■ _______ American Diabetes Association Diet ■ Other___________ 

13. Nutritional Consult: ■ No ■ Yes ■ 2 g ■ 4 g ■ Other___________ 

14. ■ ABG ■ Pulse oximetry O 2 Therapy ____L/min ■ NC ■ NRB 

■ Venturi-mask _________FiO 2% noninvasive ventilation ■ CPAP ■ BIPAP 

Start with I 10, E 4, FiO 2 variable. Adjust of ABG results, SaO 2 and patient’s level of comfort 

■ IPPB___________________ ■ Other______________________________ 

Recheck pulse oximetry on Hospital day 2. Contact MD for order to DC O 2. 

15. BMP with Magnesium q AM x 2 days 

16. ■ Impedance Cardiography Measurements daily x 3 days 

17. Fasting Lipid Profile: (IF NOT DONE IN ED) ■ Yes ■ No 

18. Labs/Tests (direct admits only) 

■ BMP ■ Chest radiograph 

■ BNP (do not draw if patient on IV neseritide) 

■ CBC 

■ Magnesium 

■ Digoxin level (order only if signs of toxicity) 

■ EKG 

19. Additional Labs/Tests: Consider ■ CPK________ ■ Troponin____________ 

Other:_____________________________________________________________ 

20. Activity level: ■ Bedrest ■ Bathroom privileges with assistance ■ Chair ■ Up as desired 

21. ■ Cardiac rehabilitation OR ■ Physical therapy consult for initial assessment of functioning level and treat with progressive activity plan 

22. ■ Refer to CHF Program postdischarge for evaluation and treatment as needed. Call extension 1234. 

23. IV Access ■ Yes ■ No ■ Type ____________________________ 

SAMPLE 

♥ 23 23

24. IV Inotropes (if clinical signs and symptoms of low cardiac output) 

Milrinone 

Loading dose ■ 0 bolus ■ 25 µg/kg ■ 50 µg/kg for______min 

Maintenance (µg/kg/min) ■ 0.25 µg/kg/min ■ 0.375 µg/kg/min ■ 0.5 µg/kg for______min 

Dobutamine (µg/kg/min) _________________________ for______hr 

25. IV Vasodilating Agents 

■ Nesiritide 2 µg/kg bolus over 1 min with 0.01 µg/kg/min GTT in dedicated line 

(only if SBP > 90 mmHg, and do not use with any other vasodilating IV agent) 

■ Nitroglycerin Start at 0.3 µg/kg/min to 0.5 µg/kg/min and titrate 

26. Diuretic: Choose one and if urine output < 200 mL within 30 min, consider redosing, increasing the dose, or other therapies. 

Furosemide IVP ■ 20 mg ■ 40 mg ■ 80 mg ■ __________ 

Torsemide IVP ■ 10 mg ■ 20 mg ■ 50 mg ■ __________ 

Metolazone ■ 2.5 mg ■ 5 mg 

IV _______________________________________________________________________________ 

Other _______________________________________________________________________________ 

27. Potassium Chloride: ■ 10 mEq ■ 20 mEq ■ 40 mEq 

■ Elixir ■ Extended Release tabs ■ po q ________ hr 

28. 

■ IV Rider ________________________________ 

ACE Inhibitor 

Captopril ■ 6.25 mg ■ 12.5 mg ■ 25 mg ■ 50 mg ___ mg po q ______hr 

Enalapril ■ 2.5 mg ■ 5 mg ■ 10 mg ■ 20 mg ___ mg po q 24 hr 

Ramipiril ■ 2.5 mg ■ 5 mg ■ 10 mg ___ mg po q 24 hr 

29. Angiotesin Receptor Antagonists (if documented allergy to ACE-inhibitor) 

Losartan (Cozaar ® ) ■ 12.5 mg ■ 25 mg ■ 50 mg ■ 100 mg Q 24 hr (target 50–100 qd) 

Irbesartan (Avapro ® ) ■ 75 mg ■ 150 mg ■ 300 mg ■ (target dose 150–300 mg daily) 

30. Aldosterone Antagonists 

Spironolactone ■ 25 mg ■ 50 mg ■ po q 24 hr 

31. PO Beta-Blocking Agents FDA-approved for HF: 

Carvedilol (Coreg ® ) ■ 3.125 mg ■ 6.25 mg ■ 12.5 mg ■ 25 mg _______po bid 

Metoprolol _______________ mg po _________________ (frequency) 

Metoprolol Extended-release (Toprol XL ® ) ■ 12.5 mg ■ 25 mg ■ 50 mg ■ 100 mg q 24 hr or __________ 

32. Digoxin ■ 0.125 mg ■ 0.25 mg ■ ______mg ■ IVP ■ po q________ 

33. Non-IV Nitrates 

■ Nitroglycerin ■ Sublingual 0.4 mg ■ Topical ___________ ■ Oral ___________ 

34. Deep Vein Thrombosis Prophylaxis: ■ TEDS ® hose ■ Sequential compression device 

■ Subcutaneous (SQ) heparin ________________________ dose/frequency 

■ Enoxaparin (Lovenox ® ) 40 mg SQ daily 

35. ■ Smoking cessation packet with follow-up appointment if indicated 

36. ■ Sleep study if indicated 

37. Other Medications: (dose, route, and frequency) 

38. Additional Orders: 

SAMPLE 

39. Attending Physician ________________________________________________________________________ 

Admitting Physician________________________________________________________________________ 

Physician Signature________________________________________________________________________ 

♥ 24 

24

DIET/FLUIDS 

A balanced diet is important to promote health. Most people with 

HF should eat less sodium (salt) and limit fluid. Sodium attracts 

water and makes the body hold fluid. This extra fluid makes the 

heart work harder. Diuretics (“water pills”) may make you more 

thirsty. This does not mean your body needs more fluids. Be 

careful not to try to replace the fluid removed by the diuretics. 

Sugar-free hard candy may help ease a dry mouth. 

Diet _______________mg sodium 

Fluid restriction _________ ounces/day 

BODY WEIGHT 

Dry weight is your weight without excess fluid in your body. 

Weigh yourself every day, before breakfast, to check if you are 

retaining fluid. Use the same scale to record your weight every 

day. Sudden weight increase usually is due to fluid retention 

rather than fat. This is a major sign that the kidneys are holding 

sodium and water in the body. Make sure you know your hospital 

discharge weight (dry weight), so you know about how much 

you should weigh on your home scale. 

Hospital dry weight___________________________________ 

Home weight, first day at home__________________________ 

Additional signs of HF include shortness of breath, frequent 

hacking cough, loss of appetite, or swelling in abdomen or 

ankles/legs. Notify your physician if these signs are present. 

MEDICATIONS 

Take all the medications on your list as instructed by the doctor 

or nurse. Do not stop taking them or change the amount or times 

without calling your doctor or the Heart Failure Center nurses. 

Carry a list of medications, including dosage and frequency, with 

you. Know why you are taking them and their potential side 

effects. If you experience any problem, notify your physician. 

Check with your physician before taking any additional 

medications (over-the-counter or prescribed). 

Patient Discharge Instructions 

♥ 25 

ACTIVITY 

It is normal to feel more tired some days than others. You need 

to gradually build up your activity level. Space your activities to 

avoid extreme fatigue. Take rest periods when necessary. Elevate 

your feet to reduce ankle swelling. 

If you have stairs at home, climb them slowly while holding on 

to the railing. If you become tired by stair-climbing, limit your 

trips at first to conserve energy. 

FOLLOW-UP 

Remember to take your medication list and body weight chart to 

all your physician/clinic appointments. 

Call for office visit: 

Dr. ________________________________________________ 

for appointment in ____________________________________ 

Dr. ________________________________________________ 

for appointment in ____________________________________ 

Notify Dr. __________________________________________ 

at__________________________________________________ 

if your weight increases by 3 lb in 1 day, or 5 lb in 1 week 

from your dry weight 

Visiting nurse? ■ Yes ■ No 

Agency ____________________________________________ 

Agency telephone number ______________________________ 

SAMPLE 

First visit (date) ______________________________________ 

Services planned ______________________________________

Heart Failure Homecare Guidelines 

Inclusion Criteria 

All patients with a diagnosis of HF will be screened by the homecare liaison and inpatient HF program nurse to determine home healthcare needs. For those patients 

who meet 2 or more of the criteria, a home health nursing referral will be requested from their physician. 

• Homebound (Medicare and Medicaid patients) 

• New diagnosis of HF 

• Repeat HF admission within 90 days 

• Patients with additional comorbidities including insulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, renal insufficiency, atrial fibrillation 

• Noncompliance with HF regimen (medication, diet, weight) and/or poor support system 

• Durable medical equipment needs 

Goals 

• Surveillance for signs, symptoms, and laboratory evidence of worsening HF and appropriate and aggressive treatment of patients demonstrating clinical instability 

• Promotion and uptitration of optimal doses of ACE inhibitors and beta-blockers according to guidelines 

• Promotion of daily sodium intake of < 2 g 

• Promotion of and increased strength and activity levels according to HF exercise guidelines 

Homecare Standing Orders 

1. Duke Activity Specific Index assessment at first visit and at discharge visit to objectively measure functional capacity. Encourage steady increase in activity 

and light weight/strengthening HF exercises 

2. Pulse oximeter on room air on first visit, at discharge every visit, and as needed for signs or symptoms, shortness of breath, or volume overload 

3. Daily weight, BP, apical pulse, and respiratory rate every visit and record 

4. 2 g NA restricted diet 

5. Fluid restriction: ■ 1500 ■ 2000 ■ 2500 ■ other____________________ 

6. Daily intake and output 

7. Draw BNP at admission (if not obtained within past 30 days) 

8. Draw BUN, creatinine, and lytes/mg+ as needed for signs or symptoms of hypokalemia or hypomagnesia (muscular weakness, postural hypotension) 

9. Discuss standardized HF binder at each visit and evaluate compliance of diet, medications, daily weight, and patient/family understanding of above and when 

appropriate to notify nurse and physician. 

10. **IF WEIGHT INCREASED 3 LB OR MORE IN 2 DAYS OR 5 LB IN 1 WEEK AND HAS SIGNS OF VOLUME OVERLOAD (increased shortness of breath, paroxysmal 

nocturnal dyspnea, orthopnea, lower extremity edema, abdominal girth, early satiety, nausea, or vomiting after meals): 

Day 1 – Double daily doses of oral diuretic and potassium for 1 day 

Day 2 – Contact patient next day to assess effectiveness of diuresis 

• If patient responds and returns to target weight, return to original doses of diuretic and K + . Draw BUN, creatinine, electrolytes, and magnesium at next 

scheduled home visit. Use K + replacement protocol x1 dose. 

SAMPLE 

• If weight has dropped 1 to 2 lb (but not back to target weight), repeat the dose of double diuretic and K + for 1 more day, then return to original doses 

if then back to target weight. 

• If weight has NOT dropped, or if no response to double doses after 1 day, give Zaroxolyn 2.5 mg po plus double diuretic and double daily K + . 

Day 3 – If still no or very little response, visit home, draw BUN, creatinine, electrolytes, and magnesium and administer Lasix 40 mg IVP. Use K + replacement protocol 

x1 dose. 

Day 4 – Visit the patient the day following administration of IVP to assess for diuresis, reevaluate the treatment plan, and administer oral K + replacement per 

protocol if necessary. Call physican’s office to obtain follow-up appointment and/or orders to uptitrate daily diuretic/K + doses. 

**If at ANY time the nurse feels the patient may need further assessment and intervention, call or instruct the patient to visit the CHF Center at 809-223-1234. 

11. Consider referral to HF Center for outpatient support on discharge from homecare (utilizing referral form). 

Order received by:_______________________________________________ Date:__________________________ 

Physician signature:______________________________________________ Date:__________________________ 

26 ♥

Dear Doctor: 

After having seen your patient today, we feel that on discharge he/she may benefit from some of the services we provide at the 

Heart Failure Center and have checked them below. 

■ Enrollment in the Heart Failure Center for teaching and ongoing follow-up. 

Pharmacologic intervention based on ACC/AHA consensus guidelines 

■ ACE inhibitor initiation/titration to target dose 

■ Beta-blocker initiation/titration to target dose 

■ Weekly outpatient assessment to determine need for additional IV diuretics or medication adjustments 

■ IV infusion for a limited time (preprinted orders attached for your completion) (all IV infusion therapy patients will be evaluated 

by the CHF multidisciplinary team at scheduled patient care conference) 

■ HF cardiac rehabilitation program (home exercise program based on a 6-minute walk for outcome measurement). Order required. 

Pamphlet enclosed. 

■ Candidate for HF research trial 

Thank you for the opportunity to collaborate in the care of your patient with HF. Our objectives are to improve the patient’s quality 

of life, prevent recurrent admissions, and hopefully improve long-term prognosis in accordance with consensus guidelines. 

If you concur, please write an order and also indicate which healthcare practitioner(s) from your office will be assigned to follow 

this patient so we can contact them with assessment updates. Should you have any questions, please do not hesitate to call us. 

Sincerely, 

Heart Failure Team Nurses 

cc: John Doe, MD (Director, Division of Cardiology) 

Dear Doctor: 

Our Heart Failure Team has been working to improve outcomes for patients with HF. One of the important aspects of care is initiation of 

ACE-inhibitor therapy. This therapy has been shown to improve symptoms, decrease hospitalizations, and reduce deaths. It is mandated 

by all guidelines and of course is our local standard as well. 

From our review, we could not determine if your patient is on ACE-inhibitor or is ACE-inhibitor intolerant. Please either initiate or 

reinstitute ACE-inhibitor therapy. If there is a medical reason for not initiating ACE-inhibitor therapy, please document in the chart and 

indicate what alternatives are being used. 

Another national standard is documentation in the record of a left ventricular ejection fraction (LVEF). If done previously and 

recorded clearly in the chart, this need not be repeated. 

From our review, we cannot find documentation of your patient’s LVEF. If previously obtained in the hospital or your office, please 

indicate that in the progress note. Our clerical associates can help you retrieve previously performed studies. If not done and you plan 

to order the test after hospital discharge, please indicate this. 

We are committed to making sure patients treated for HF at our medical center are getting the best care possible. If the Heart 

Failure Center can help you with initiation of an ACE inhibitor for your patient or with any aspect of HF care, please do not hesitate 

to call us at 555.555.5555. 

Sincerely, 

Heart Failure Team Nurses 

cc: John Doe, MD (Director, Division of Cardiology) 

Physician Referral Letters 

SAMPLE 

27 ♥

Date__________________________________ 

Patient_______________________________________________________________________________ Phone ________________________________________ 

This patient is being discharged from Cardiology Homecare. Please include in outpatient follow-up program services, which may include individual or group 

visits, telephone calls, participating in the Heart Failure Support Group, and receiving the monthly newsletter. 

From______________________________________ Office __________________________________________________________________________________ 

Pager_____________________________________ Voice Mail ___________________________________ Fax ________________________________________ 

This patient is able to (Check Yes or No) Yes No 

• Identify his/her HF symptoms. ■ ■ 

• Demonstrate the ability to properly weigh him/herself daily. ■ ■ 

Weight at discharge from Home Services___________ 

• Respond to a weight gain of 2 lb by calling the physician or nurse. ■ ■ 

• Discuss medication regimen (drug dosage, action, timing, side effects). ■ ■ 

• Identify foods high in sodium. ■ ■ 

• Identify individual factors for having HF. ■ ■ 

Questions: 

Are there any compliance barriers? If yes, please list. ■ ■ 

______________________________________________________________________________________ 

______________________________________________________________________________________ 

______________________________________________________________________________________ 

Does patient have next physician visit and blood draw scheduled? ■ ■ 

If yes, when?________________________________________________________________________ 

Does the patient have transportation needs? ■ ■ 

Has the medication sheet been faxed? ■ ■ 

Cardiologist/Physician 

Name_____________________________________________________________Phone ____________________________________________________________ 

Heart Failure Coordinator 

Name_____________________________________________________________Phone ________________________________________________________________ 

Fax_______________________________________________________________Pager ____________________________________________________________ 

THANK YOU! 

Homecare Referral to Outpatient Heart Failure Clinic 

SAMPLE 

♥ 28



Posttest 

1. Results of a clinical trial demonstrated that an outpatient 

HF management program is advantageous because ___ . 

a. it resulted in a 50% decrease in the admission rate 

for HF 

b. it resulted in a decrease in readmission for HF within 

30 days of a prior discharge 

c. it showed a significant cost/benefit potential 

d. all of the above 

2. Core components of an outpatient HF management 

program include which of the following? 

a. Close patient monitoring 

b. Ready access to clinic staff to permit immediate response to 

any patient crisis 

c. Intensive patient and family education and reinforcement 

d. Compliance tracking to ensure patient adherence 

e. All of the above 

3. The ACC/AHA HF stage C (current heart disease with 

prior or current symptoms of HF) is equivalent to the 

NYHA functional class(es) ___. 

a. I 

b. II 

c. III 

d. IV 

e. b and c 

4. Which of the following recommendations for patient 

management is NOT correct? 

a. A simplified, once-a-day dosing regimen should be used 

whenever possible. 

b. Patients should receive an updated list of the medications 

they are receiving on a regular basis. 

c. Current medications must be reviewed once every 2 months. 

d. Patients should be advised to avoid all over-the-counter 

medications without first consulting their physician or HF 

clinic staff. 

5. Of the patients presenting to the ED with HF, the most 

appropriate patient candidates for early discharge are 

those with mild left ventricular dysfunction and/or 

hypertension. 

a. True 

b. False 

♥ 29 

6. When selecting appropriate patient candidates in the ED 

for outpatient management, the Advocate Heart Failure 

Center’s criteria include ___ as an important point in 

evaluating the patient’s condition. 

a. making the clinical assessment at 1 hour after the 

administration of IV diuretics 

b. making the clinical assessment at 2 hours after the 

administration of IV diuretics 

c. making the clinical assessment at 2 hours after 

administration of inotropic therapy 

d. making the clinical assessment only after dyspnea is 

relieved 

7. Which of the following statements about outpatient 

management is NOT correct? 

a. There is a direct relationship about the need for frequent 

hospital readmissions for HF and inadequate patient 

education. 

b. The hospital setting is the least conducive for patients and 

families to receive information due to the high level of 

stress they experience at that time. 

c. A HF nurse should meet with the patient in the hospital to 

schedule a postdischarge appointment to the outpatient 

clinic and supply the patient with printed materials about 

the disease. 

d. No attempt to supply the patient with information should be 

made until he/she has been discharged from the hospital. 

8. Comparisons of dobutamine, nesiritide, and nitroglycerin 

reveal that dobutamine may induce tachycardia or 

arrhythmia, whereas nitroglycerin and nesiritide have the 

potential to cause hypotension. 

a. True 

b. False 

9. In patients presenting to an emergency setting with acute 

dyspnea plus a BNP level of _______, a diagnosis of HF is 

very probable/likely: 

a. < 100 pg/ml 

b. 150 

c. 100-500 

d. > 500 

10. Intravenous nesiritide may be administered concomitantly 

with diuretics and other agents commonly used for the 

chronic management of HF. 

a. True 

b. False

Postgraduate Institute for Medicine (PIM) respects and appreciates your opinions. To assist us in evaluating the effectiveness of this 

activity and to make recommendations for future educational offerings, please take a few minutes to complete this evaluation form. 

You must complete this evaluation form to receive acknowledgement of participation for this activity. 

Please answer the following questions by circling the appropriate rating: 

5 = Outstanding 4 = Good 3 = Satisfactory 2 = Fair 1 = Poor 

Extent to Which Program Activities Met the Identified Purpose 

Provide an overview of the structure and treatment approaches used at the 5 4 3 2 1 

Advocate Heart Failure Institute and present the lessons learned in developing 

and implementing a comprehensive outpatient HF management program. 

Extent to Which Program Activities Met the Identified Objectives 

Upon completion of this activity, participants should be better able to: 

• Describe the core components of a heart failure disease management program. 5 4 3 2 1 

• Explain the transition process from inpatient to outpatient management. 5 4 3 2 1 

• Discuss drug treatment protocols in heart failure. 5 4 3 2 1 

Overall Effectiveness of the Activity 

Evaluation Form 


theheart.org website 

Project ID: 2490 ES 13 

• Was timely and will influence how I practice 5 4 3 2 1 

• Will assist me in improving patient care 5 4 3 2 1 

• Fulfilled my educational needs 5 4 3 2 1 

•Avoided commercial bias or influence 5 4 3 2 1 

Impact of the Activity 

The information presented: (check all that apply) 

■ Reinforced my current practice/treatment habits ■ Will improve my practice/patient outcomes 

■ Provided new ideas or information I expect to use ■ Enhanced my current knowledge base 

Will the information presented cause you to make any changes in your practice? ■ Yes ■ No 

If yes, please describe any change(s) you plan to make in your practice as a result of this activity: 

How committed are you to making these changes? 5 (Very committed) 4 3 2 1 (Not at all committed) 

Future Activities 

Do you feel future activities on this subject matter are necessary and/or important to your practice? ■ Yes ■ No 

Please list any other topics that would be of interest to you for future educational activities: 

♥ 30

Follow-up 

As part of our ongoing continuous quality improvement effort, we conduct postactivity follow-up surveys to assess the impact of 

our educational interventions on professional practice. Please indicate your willingness to participate in such a survey: 

■ Yes, I would be interested in participating in a follow-up survey 

■ No, I am not interested in participating in a follow-up survey 

Additional comments about this activity: 

If you wish to receive acknowledgement of participation for this activity, please complete the posttest by selecting the best 

answer to each question, complete this evaluation verification of participation and mail or fax it to the following: 

Postgraduate Institute for Medicine 

PO Box 260620 

Littleton, CO 80163-0620 

Fax 303.790.4876 

Posttest Answer Key 

1 2 3 4 5 6 7 8 9 10 

Request for Credit 

Name_______________________________________________________________ Degree ______________________________ 

Organization__________________________________________________________ Specialty ____________________________ 

Address __________________________________________________________________________________________________ 

City, State, Zip______________________________________________________________________________________________ 

Telephone______________________________ Fax___________________________E-Mail ______________________________ 

Physician Continuing Medical Education 

I certify my actual time spent to complete this educational activity to be: 

■ I participated in the entire activity and claim 1.5 credits. 

■ I participated in only part of the activity and claim _____ credits. 

Registered Nurse Continuing Education 

■ I participated in the entire activity and claim 1.8 credits. 

■ I participated in only part of the activity and claim _____ credits. 

Signature__________________________________________ Date Completed ______________________________________ 

♥ 31

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M392

Outpatient Management of Heart Failure

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