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Michigan Quality Improvement Consortium …

January 2017 Eligible Population Key Components Adults with suspected heart failure, with reduced ejection fraction Evaluation Management Counseling and

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January 2017Eligible PopulationKey ComponentsAdults with suspected heart failure, with reduced ejection fractionEvaluationManagementCounseling and care with heart failure with reduced ejection fractionApproved by MQIC Medical Directors Dec. 2002; Jan. 2005, 2007, 2009, 2011, 2013, 2015, 2017 b Michigan Quality Improvement Consortium GuidelineAdults with Heart Failure with Reduced Ejection FractionThe following guideline recommends diagnostic evaluation, pharmacologic treatment and education that support effective patient self-management. Recommendation and Level of EvidenceThis guideline lists core management steps. It is based on the 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure; and 2013 ACC/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Developed in Collaboration With the American College of Chest Physicians, Heart Rhythm Society and International Society for Heart and Lung Transplantation. Individual patient considerations and advances in medical science may supersede or modify these assessment should include:Thorough history and physical examination [C], including depression screening, and assessment for coronary artery disease and risk factorsTesting includes: chest X-ray, 12-lead electrocardiogram, lipid profile, CBC, electrolytes, calcium, magnesium, BUN, creatinine, blood glucose, liver function tests, TSH, urinalysis, and echocardiography with Doppler [C]BNP is useful for diagnosis, and not for serial monitoringSerial monitoring should include: weight, volume status, electrolytes, renal function and activity toleranceRecommended for routine use:ACE inhibitors [A] or angiotensin receptor blocker/neprilysin inhibitor (AR/NI) [A] or ARB's [A] in all patients, unless contraindicated1, but drugs from these classes should not be used together Diuretics and sodium restriction for evidence of fluid retention [A]Beta-blockade using carvedilol, sustained-release metoprolol, bisoprolol in all stable patients, unless contraindicated1,2 [A]Vaccination against influenza and pneumococcalRecommended for use in select patients:Ivabradine for patients with symptomatic HF, LVEF <35%, on maximally tolerated (or target) beta blocker dose, in sinus rhythm with rate >70 bpm, and if hospitalized within the last yearSpironolactone for patients with symptoms of heart failure, preserved renal function (creatinine < in women; creatinine < in men) and normal serum potassium concentration [A]Consider hydralazine and isosorbide dinitrate for patients who cannot tolerate ACE inhibitors or ARBs, or African-American patients who remain symptomatic despite therapy [A]Digoxin should only be used for patients who remain symptomatic despite diuretics, ACE inhibitors and beta blockers [A]Consider referral for evaluation for implantable defibrillator in patients with LVEF <35% and either symptomatic heart failure or ischemic cardiomyopathyConsider referral for biventricular pacemaker for patients with symptomatic heart failure and QRS duration 120 mescConsider referral of complex patients to an advanced heart failure management programEngage patients in office-based care management and self-management: w Careful review of medication regimen with patient and caregivers at hospitalization or other changes in treatmentw Daily self-monitoring of weight and adherence to recommended patient action planw Recognition of symptoms and when to seek medical attentionw Moderate dietary sodium restriction ( , 2,000-2,500 mg sodium/day)w Risk factor modification (regular exercise 5 times per week as tolerated [B]; smoking cessation; control of BP, DM, lipids)w Avoid excessive alcohol intake, illicit drug use, and the use of NSAIDSw Discuss goals of care, prognosis, advance directives, and palliative care1 Contraindications include: life-threatening adverse reactions (angioedema or anuric renal failure), pregnancy, hypotensive patients at immediate risk of cardiogenic shock, systolic blood pressure < 80 mm Hg, serum creatinine > 3 mg/dL, bilateral renal artery stenosis, or serum potassium > Contraindications include: patients with current or recent fluid retention history, unstable or poorly controlled reactive airway disease, symptomatic bradycardia or advanced heart block (unless treated with a pacemaker), or recent treatment with an intravenous positive inotropic of Evidence for the most significant recommendations: A = randomized controlled trials; B = controlled trials, no randomization; C = observational studies; D = opinion of expert panel

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