Failure of the HeartPrint This Post
Three Heart Failure learning questions:
1. At which stage would a HF patient have moderate cardiac structural damage and symptoms with less than normal exertion?
A. Stage A
B. Stage B
C. Stage C
D. Stage D
2. What medication, besides a diuretic and beta blocker, may be added to address HFrEF in an African American patient who cannot tolerate an ACEI or an ARB, and who is not able to obtain better relief of his/her heart failure symptoms, despite optimal therapy?
3. What does the “yellow- caution zone” of the Congestive Heart Failure Zones Management tool mean?
A. Watch and wait for symptoms to worsen
B. Go to the ER
C. Call your provider
D. Take 20mg of furosemide BID
Scroll down to the end of the article to check your answers.
A 73-year-old Hispanic female patient comes in to the clinician’s office complaining of an exacerbation of her lower extremities, edema, fatigue, and shortness of breath. Her last visit, with a colleague, was two months ago. Because she has been taking her medication, she questions why she is symptomatic. She missed “a couple days” of her “pressure med” when it ran out because she didn’t get a chance to refill it. She explains that she has been not been following her diet as carefully as she used to because her husband who has dementia is becoming harder to care for and she does not have enough time to “take care of myself too.”
The patient believes it is unnecessary to check her blood pressure or blood sugars. “I know when I am feeling bad I have to go to the doctor. That’s why I’m here now.” The patient denies any chest pain, nausea, abdominal discomfort, or dysuria. But she has right sided knee pain when climbing stairs. She coughs a little at night when laying down and sleeps with an extra pillow to elevate her head. She is tired most of the time and she feels “my chest pound” which she believes is due to the demands of her husband. She has not been sick recently and she has not had any falls.
On exam, the patient appears slightly fatigued, well nourished, worried, but pleasant. Blood pressure 154/84, pulse 102, resp 22, temp 98.9, POX 96% on RA. Weight increased by six pounds since her last visit. No JVD is present, no carotid bruits, S1 S2, rate slightly tachy, irregular rhythm (not her norm), no S3 or S4 or murmur appreciated, lungs mild rales LLL, abdomen WNL, no R/R/G, no hepato- or splenomegaly, no hepatojugular reflux appreciated, no upper extremity edema, + crepitus of right knee without effusion or tenderness, left knee WNL, +1 PE bilateral feet and ankles, +1 pedal pulses bilaterally, callous on bilateral feet fifth digits, no open lesions noted. Her past medical history includes: SHF (Stage B, Class II, EF 39%), HTN, Type II DM with peripheral neuropathy, hyperlipidemia, CKD, OA, and mild mixed urinary incontinence.
Her medication regimen includes: enalapril 20mg PO QD, HCTZ 25mg PO QD, simvastatin 40mg PO q PM, glargine 20U q AM, metformin 1000mg BID, gabapentin 100mg PO TID, ASA 81mg QD, MiraLax® one capful PO q AM, and Motrin® as needed.
Labs/tests: hgb 11mg/dL, hct 32%, BUN 24mg/dL, creatinine 1.3mg/dL, serum sodium 134mEq/L, potassium 4.0mEq/L, BNP 800pg/mL, HDL 39mg/dL, LDL 101mg/dL, Tchol 179mg/dL, trig 143mg/dL, FBS 143, A1C 8.4%, TSH 2.6; EKG demonstrates new finding of a-fib.
The clinician discusses the findings with the patient and together they both decide to take her off of her thiazide diuretic and start her on furosemide 20mg BID for the next three days, then decrease to QD, in order to remove her volume overload. Her glargine dose is increased to 22U SQ QD, with continued monitoring of her kidneys while on metformin. She is started on warfarin 2mg QD, based on her calculated CHADS-2 score, for her a-fib. She is taught to use acetaminophen, instead of Motrin for her knee pain, as NSAIDS can exacerbate heart failure, as well as increase bleed risk while on warfarin.
She is further instructed on healthier dietary options including no-salt added choices, no trans-fats, and cautioned about Vitamin K containing foods. She is to drink one to two more eight-ounce glasses of water a day. Written information (grade 5 level, in Spanish) regarding good dietary choices and foods containing Vitamin K are given to her. Also, she is given the Congestive Heart Failure Zones for Management tool, and educated on its use, so she will know what symptoms to watch for and what to do depending on the zone she places herself. The patient’s comprehension of her updated health management plan is determined by having her repeat it back and asking questions, before leaving.
An appointment is made for a referral to a cardiologist. Additionally, a referral is placed with a social worker to discuss care options for her husband, including a dementia caregiver support resource. Further, the social worker will help her obtain a blood pressure monitor, diabetic shoes, and glucometer with diabetic supplies. The patient is encouraged to call her son, who lives locally, to help her with grocery shopping and picking up her medications when she needs refills. The patient is scheduled to return to the clinic for follow-up in the next 3-4 days, but to call the clinic if she worsens or has any new questions or concerns in the meantime.
Several days later, the patient returns for follow-up. She will be seeing the social worker soon and has already received a glucometer and blood pressure instrument and training by the medical assistant. Her cardiology appointment is in two weeks. She is doing fine on her medications with no complaint of abnormal bruising or bleeding. She feels less tired without dyspnea or cough and her weight is almost at baseline. Her lower extremity swelling is minimal now. She is following the dietary guidelines that were recommended to her and she is now using no-salt added canned foods. In addition to the vitals, history and physical assessed at this visit, labs, including PT/INR, are also rechecked. Electrolytes are WNL and BNP is down to 300pg/mL. Serum creatinine remains at 1.3mg/dL and FBG is 119. BP is 132/84 and heart rate 96. Both patient and clinician are pleased with the outcomes and another follow-up appointment is scheduled in one month. The patient will bring her blood pressure and glucometer readings to the next visit. The clinician will also consider the need for a dietician consult and beta blocker at that time.
The heart propels 2000 gallons of blood through the circulatory system day after day. When the heart fails to function, as in the case of heart failure, function and quality of life may ultimately become greatly inhibited. Unfortunately, many within the geriatric population are chronically faced with this health burden.
According to the Centers for Disease Control (CDC), at least 5.1 million Americans are affected by heart failure and among those with this disease, approximately fifty percent will die within five years of being diagnosed. Heart failure is an economic loss with almost thirty-two billion dollars spent annually to cover the expenses incurred due to this disease including medications for treatment, provision of health care, and work days lost. 
Although heart failure can affect people of any age, prevalence of the disease increases as people get older. This is of particular difficulty for the elderly, due to physical changes that occur within their cardiovascular systems over time. In the aging person, the heart’s left ventricle becomes stiffer and less compliant reducing the time it takes for the left ventricle to fill with blood. Diastolic dysfunction ensues and the aging heart becomes less responsive to catecholamines produced during activities such as exercise, causing the heat rate to slow delivering a reduced cardiac output of blood to the organs.  The older heart also has less functional reserve. When it undergoes stressors such as sodium overload or ischemia that activate the neurohumoral reflex (via the renin-angiotensin and sympathetic nervous systems), it cannot counteract vasoconstriction and fluid overload, leading to pulmonary edema. 
Two types of left sided heart failure exist. The first occurs due to diastolic dysfunction which develops when diseases such coronary artery disease, cardiomyopathy, and chronic hypertension stiffen the left ventricle. This stiffening decreases the ventricle’s ability to relax and fill adequately, and decreases compliance of the blood vessels. The ejection fraction usually remains preserved (HFpEF). [4,5] The other type of heart failure occurs in the presence of systolic dysfunction when diseases such as valve stenosis and regurgitation, myocarditis, diabetes, ventricular and supraventricular arrhythmias, and anemia create abnormal functional and structural changes within the myocardium. Such changes create a cyclical activation of the neurohumoral system and remodeling of the left ventricle, which negatively affects myocardial contraction and cardiac output. In this type of heart failure, the ejection fraction is reduced (HFrEF).  Both types of left heart failure often exist concurrently.
The heart can also undergo right sided failure, in which the right ventricular output becomes compromised. This occurs in the presence of left sided failure. As blood backs up from the poorly functioning left ventricle, it creates an increased pressure within the lungs causing the right ventricle to work harder to expel blood into the lungs. The right side of the heart and its contractility weakens producing congestion within the systemic capillaries. This leads to ascites, hepatomegaly, peripheral edema and nocturia. Diseases such as emphysema, pulmonary hypertension, tricuspid or pulmonary stenosis can cause failure of the right heart, left sided heart failure is often the main etiology. 
According to the Framingham Heart Failure Criteria, there are specific major and minor criteria that must be met in order to make a diagnosis of heart failure. Major criteria include presence of rales, S3 gallop, paroxysmal nocturnal dyspnea (PND), acute pulmonary edema, hepatojugular reflux, cardiomegaly (on chest x-ray), increased central venous pressure (over 16cm H2O at the right atrium), and weight loss of over 4.5kg, in five days in response to treatment. Minor criteria include hepatomegaly, nighttime cough, ankle edema (bilaterally), dyspnea with normal activity, pleural effusion, tachycardia (with a heart rate over 120 beats per minute), and vital capacity diminished by one-third from the maximal recorded. Heart failure may be diagnosed when at least two of the major criteria or one major criterion and 2 minor criteria occur at the same time.
Of course, it is still imperative to rule out other differentials of diagnosis. Clinicians can do this by performing a detailed history and physical, and obtain certain labs and tests to determine the presence of heart failure with co-morbidities that may be complicating the condition, such as: hypertension, diabetes mellitus, metabolic syndrome, and atherosclerotic disease. For example, if a patient presents with symptoms of dyspnea on exertion (DOE), orthopnea, paroxysmal nocturnal dyspnea (PND), fatigue, palpitations, or nighttime cough, clinicians can inquire about specifics during the history. These should include tobacco usage, alcohol intake, medications used, salt intake, diet, fluid consumption, changes in functional ability, activity level, and recent weight change. 
During the physical exam, clinicians can auscultate the lungs for the presence of rales and the heart for tachycardia or an S3 gallop, observe the neck for venous distention, palpate the lower extremities for edema, and the abdomen for a hepatojugular reflex. They can also obtain vital signs including pulse oximetry, and perform a six minute walk test (6MWT) to determine the length of time it takes for the patient to become fatigued and dyspneic when ambulating (exercise tolerance).  If clinicians suspect heart failure, a cardiopulmonary exercise test (CPET) can determine cardiopulmonary and muscular functional capacity. 
During the visit, clinicians should keep in mind differentials and complications such as venous insufficiency, COPD, atrial fibrillation, thyroid disease, infection, hyperlipidemia, electrolyte disturbances, renal insufficiency, myocardial infarction (MI), and anemia, as these may aggravate heart failure. Labs can be ordered to check for comorbidities including a CBC, CMP, TSH, fasting glucose, lipid panel, and BNP or NT-proBNP. A chest x-ray for cardiomegaly or effusion, a 12-lead electrocardiogram to check for bundle branch blocks, ischemia, or arrhythmias, as well as a 2D echocardiogram to check for ventricular hypertrophy and movement or valve pathology can be ordered. 
In a patient with coronary artery disease, clinicians could also check coronary angiography (coronary arteriography; cardiac catheterization) to look for blood flow blockage, and check cardiac pressures and oxygenation. Patients with a history of idiopathic dilated cardiomyopathy (DCM), should undergo a family history assessment that encompasses three generations. It has been determined that 20% to 35% of patients with this disease have a “familial syndrome”. Genetic screening of their family members, for cardiomyopathy, may be wise, due to the increased risk of developing heart failure. [9,13]
If clinicians discover their patient has heart failure they can then determine their patient’s ejection fraction, as well as the stage and class of the disease process. Knowing this information will assist in better treatment of patients and help manage their symptoms.
Ejection fraction (EF) is determined by 2D echocardiography. EF is the amount of blood expelled from the ventricles each time they contract. A normal ejection fraction is between 55 to 70 percent. A patient with an EF of 40 percent or less is considered to have heart failure. With an EF under 35 percent morbidity and mortality risk is increased due to a higher chance of developing life threatening arrhythmias. [9,14]
The New York Heart Association (NYHA) has developed categories to determine the class of patients’ heart failure based on their functional status. In class I, patients are asymptomatic without limitation at rest and with normal activity. In class II, patients are fine at rest, but experience symptoms with ordinary activity that limits what they can do. In class III, patients have symptoms with less than normal activity that notably limits what they can do. When resting, though, they are comfortable. Finally, in class IV, patients experience symptoms even when resting. They always experience symptoms when physically active and their function is severely limited. 
The NYHA also has created categories to determine the stage of patients’ heart failure based on the objective findings of structural heart disease and severity of symptoms.
- In stage A, patients have no structural disease and no symptoms.
- In stage B, mild structural changes exist. Patients may be mildly symptomatic only while normally active.
- In stage C, patients have moderately severe structural disease with symptoms doing less than normal activity.
- In stage D, patients have severe structural heart changes that cause them to be symptomatic even at rest. [15,16]
Once armed with the knowledge of what type of heart failure their patients are experiencing, clinicians will then be better able to determine how to manage the disease most effectively. In June 2013, the American College of Cardiology (ACC), along with the American Heart Association (AHA), released an updated version of their guidelines for heart failure management.  This newest version contains comprehensive, expanded evidence based “guideline-directed medical therapy (GDMT)”, based on patient centered recommendations, for the management of both reduced and preserved ejection fraction type heart failures. Strategies recommended are based on the stage and class of heart failure. As each stage and class of HF progresses, management options advance, building upon the options of the former stages and classes.
Patients in Stage A and B and all classes of HF require adequate control of diseases and risk factors that may cause symptoms to develop. This is particularly true with HFpEF, as this is the mainstay of management (outside the use of medication for symptom reduction). Problems with systolic and diastolic hypertension, coronary artery disease, diabetes, and dyslipidemia (statin use recommended), in particular, must be addressed. Risk factor modifying strategies such as sodium reduction, increase in physical activity, quitting tobacco use, blood glucose control, cholesterol and lipid control, treating sleep apnea, and weight reduction are advised. 
There are various types of pharmacological therapies that may be utilized in the management of heart failure. Thiazide-type diuretics (chlorothiazide, hydrochlorothiazide, metolazone) or loop diuretics (bumetanide, furosemide) may be used for aggravating factors such as peripheral edema or pulmonary congestion. Diuretics must be used very carefully in elderly patients with a stiff left ventricle (common in HFpEF) or severe left ventricular hypertrophy (HFrEF), as these meds can greatly reduce preload, leading to hypotension. Additionally, they can affect electrolyte balance and renal function, therefore regular monitoring of these should also be advised. 
Calcium channel blockers (CCB) require cautious use if utilized for treating heart failure. They should be used only when other antihypertensive medications have proven to be ineffective, and only when ejection fraction is preserved. The dihydropyridine, amlodipine, may be used to lower blood pressure (via blood vessel relaxation) and also reduce preload. Non-dihydropyridine CCBs are not used in HFpEF, while CCBs should not be used at all to treat HFrEF due to their cardiac depressive effects. [9,17]
Management of arrhythmias such as atrial fibrillation (a-fib) and tachycardia is very important. This can be done using the antiarrhythmic amiodarone or dofetilide. 
Furthermore, beta blockers (in stable HFrEF, Class I and above and HFpEF, if not contraindicated) such as carvedilol, sustained release metoprolol succinate, and bisoprolol, in particular, are suggested to prevent tachycardia or ischemia and reduce blood pressure.  Angiotensin-Converting Enzyme Inhibitors (ACEIs) or Angiotensin Release Blockers (ARBs) (HFpEF and HFrEF, Class I and above) are used to reduce patients’ blood pressure and reduce their incidence of morbidity and mortality (unless contraindicated). Guideline Determined Medical Therapy (GDMT) medications are used in all stages of both types of left sided heart failure, as well as right sided failure due to a failing left side. They can be used as monotherapy in Stage A, but should be added to a beta blocker at Stage B and higher. ACEIs and ARBs should not be used concurrently due to risk of hyperkalemia, hypotension, and renal insufficiency. ARBs may be used in place of ACEIs when patients cannot tolerate them due to side effects such as cough. 
An anticoagulant, such as warfarin or dabigatran, is recommended for HFpEF and HFrEF (starting in Class I) patients with co-morbid a-fib or risk factors for the development of cardioembolic stroke, as these patients may be more prone to subsequent stroke or MI without it. For patients in Class III HFrEF, anticoagulants are not beneficial and should not be used if they do not have a-fib, do not have a cardioembolic risk factor, or have not experienced a past cardioembolic event. 
Digoxin may be used as an adjunct in HFrEF, particularly in patients with concurrent a-fib who continue to remain symptomatic despite maximal GDMT in order to reduce their need for hospitalization. Plasma levels of the drug should be determined intermittently, to avoid the risk of toxicity. This medicine is contraindicated, however, in patients with sinus or atrioventricular node block who lack permanent pacemaker placement. 
Cardiotoxic drugs such as non-steroidal anti-inflammatory medicines, chemotherapeutic meds (such as trastuzumab and those with an anthracycline base), thiazolidinediones, amphetamines, and cocaine to prevent or reduce risk of symptoms in all types and stages of heart failure are not recommended. CCBs should not be used in HFrEF. 
For HFpEF (stage B) and HFrEF (Stage C) patients who also have CAD and/or have experienced a MI or angina, coronary revascularization surgeries such as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) are suggested. However these surgeries should only be performed in select patients, in order to improve their blood flow and reduce ischemia. [9,l8]
In Stage C, recommendations from the former stages and classes are to be continued. If HF has progressed in patients within these categories, additional management options are provided. For instance, more than one diuretic, inclusive of the loop type, may be cautiously used to further alleviate retention of fluid (Class II to IV). Diuretics must be used with care in older patients with HFpEF and LVH, to prevent hypotension. It remains imperative to monitor renal function and electrolytes such as potassium and magnesium, when using this medication, to prevent further aggravation of HF. 
Hydralazine, a vasodilator, and nitrates, such as isosorbide dinitrate, are suggested for use specifically in patients with HFrEF under 40 percent, especially those of African American descent, whose condition may continue to remain compromised, despite optimal usage of their other medications or if they cannot use ACEIs or ARBS (Class III and IV). Hydralazine and nitrates are not used in HFpEF. 
In patients with HFrEF under 35 percent, aldosterone antagonists, such as eplerenone and spironolactone, are advised for use to further reduce morbidity and mortality if glomerular filtration rate is above 30ml/min/1.73m and serum potassium is below 5.0 mEq (Class II to IV). These medications are not used in HFpEF. 
Nutritional supplements such as Coenzyme Q10 and hormonal therapies are not required for use in Class III or IV HFpEF, as they provide no additional benefits in reducing morbidity or mortality at these levels. But, omega-3 polyunsaturated fatty acids (PUFAs) are suggested for use in HFpHF and HFrEF Classes I to IV, to reduce cardiovascular symptoms that can lead to hospitalization or death. 
Device therapy in Stage C HFrEF is aimed primarily at reducing patients’ risk of sudden cardiac death. For instance, implantable cardioverter defibrillators (ICD) are used with an ejection fraction of 35 or less, in Classes I to III (also in Stage B), on maximal GDMT, who have had a MI over forty days ago, but still have a greater than one year chance of survival. Alternatively, cardiac resynchronization therapy (CRT) is used in patients with an ejection fraction of 35 or less (QRS must be 150 or greater) with left bundle branch block (LBBB) (Classes I to IV) or without LBBB (Classes III and IV only) who are expected to live more than one year. 
When patients progress to Stage C heart failure, the guidelines make additional recommendations for more diligent efforts at behavioral change. Clinicians must encourage and monitor changes in their patients’ behavioral lifestyle in a continued attempt to reduce symptom severity and progression. At this stage, patients are urged to become even more involved in maintaining their health and function. For instance, patients are highly encouraged to engage in a consistent exercise routine, whether that is through participation in formal cardiac rehabilitation or exercise training, or informally just by increasing their daily physical activity. Clinicians and patients can work together to determine what exercise is most beneficial for patients, based on their level of functional ability and willingness to perform, for a minimum of thirty minutes total at least five days a week. Patients are advised to restrict their total sodium intake to no more than 2 grams per day. Patients who experience sleep apnea are encouraged to use a continuous positive airway pressure (CPAP) device, in order to improve their oxygenation and sleep, reducing the strain on the heart. Water restriction is not yet recommended at this stage, but becomes more important if HF progresses to Stage D. 
Once patients have entered Stage D heart failure (usually HFrEF and Class IV), they have reached the most advanced state of the disease. At this level, GDMT maximized strategies may continue to be utilized from the previous stages and classes, even though they no longer can prevent worsening of symptoms, even at rest. Yet, there are still additional options recommended, if appropriate, to maintain function and prolong and increase the quality of patients’ lives.
Use of parenteral inotropes is generally considered to be harmful in Classes III and IV HFrEF. However, use of parenteral inotropes such as milrinone, dobutamine, and dopamine may be used short term as “bridge therapy”, in order to maintain adequate systemic blood flow and prevent end-organ failure in Class I patients in cardiogenic shock due to hypoperfusion. These meds may also be used for a longer period of time in Class II patients receiving palliative care, who are ineligible for heart transplant or devices to maintain circulation. Long term oral inotropes, however, should not be used in any stage, as they can contribute to death by development of fatal arrhythmias. Inotropes of any kind are not used in HFpEF. 
As congestive symptoms may now be very prominent, restriction of fluids is advised. Fluid consumption should be decreased to an intake of no more than two liters per day, particularly in hyponatremic patients. 
For patients who still maintain the possibility of a viable extended period of life, extreme strategies such as mechanical circulatory support (MCS) (EF under 25 percent; Class III and IV) via ventricular assist devices (VAD) and/or cardiac transplantation may be recommended. For those patients with heart failure so severe, whose lives cannot be sustained despite optimal GDMT, including use of therapeutic devices, palliative care and hospice is advised. This type of care will enable patients to remain comfortable via symptom control, in their last days, and eventually die with dignity. 
For those patients who have isolated right sided heart failure, loop diuretics are the main focus of treatment, in order to treat the congestive symptoms. If left sided heart failure is the reason for the failure of the right side of their heart, then management options should also include those recommended by the ACC/AHA heart failure guidelines. 
There is a great amount of information to be found in the updated ACC/AHA 2013 Guidelines and they are very detailed in their specifics. The summary of the guidelines presented above represents only the recommendations that have been made for the ambulatory patient with heart failure. In actuality, the guidelines in their entirety also include recommendations for care of the hospitalized, decompensated heart failure patient. Even after the patient has been stabilized and discharged, it is not unusual for these same patients to become seriously ill again, within a month’s time.
In a study Medicare fee for service data, published in the Journal of the American Medical Association, almost 25% of HF patients required a return to the hospital within 30 days of being discharged. In fact, of those rehospitalized, 61% were readmitted within the first fifteen days after initially being released. Some even required multiple readmissions (9.7% two; 2.8% had three or greater). The average age of heart failure patients needing to go back to the hospital was 80.3 years old. The main reasons for these patients’ return were due to heart failure decompensation (35.2%) and cardiovascular disease (52.8%). 
The high readmission rates prompted the Centers for Medicare and Medicaid Services (CMS) to create the Hospital Readmissions Reduction Program, through Section 1886q of the Social Security Act that is part of Section 3025 of the Affordable Care Act. The purpose of the program, enacted in October of 2012, is to reduce the number of unnecessary hospital readmissions for patients aged 65 years and older, with heart failure (or pneumonia or myocardial infarct), within thirty days of their most recent hospitalization. Hospitals who fail to exercise the expected level of care to prevent such “risk-standardized” re-hospitalizations are subject to loss of Medicare dollars. Risk of payment loss is an attempt, by CMS, to give hospitals an incentive to become more accountable for their patients’ outcomes. This will ensure more effective and higher quality patient centered care. It will eventually lead to an overall cost savings through greater efficiency of this care. 
Through hospital based initiatives and research, several strategies have been derived to combat what may be impeding the process of lowering rehospitalization rates of elderly patients, with a failing heart. Providing adequate staffing is the first step. When hospitals have an adequate number of non-overtime nurses available, they are given more time to provide excellent pre-discharge education to patients and their families/caregivers and answer questions. The nurses can determine their patients’/families/caregivers’ understanding of their discharge information, including medication, by having them repeat what they have been taught.  Furthermore, nurses can teach patients/families/caregivers about what symptoms to look for, that may indicate that their heart failure may be worsening.
The “Congestive Heart Failure Zones for Management” tool is good patient teaching instrument. In the “green- all clear” zone, of the HF tool, patients are considered to be stable, if their symptoms are under control. In the “yellow- caution” zone a patient has developed symptoms such as a two day weight gain of at least three or more pounds or requires more pillows to lay supine more comfortably. In this zone, patients are recommended to call their provider, as their medicines may need adjusting. Finally, in the “red- medical alert” zone, a weight increase of over five pounds within two days or very uncomfortable symptoms, such as wheezing or chest discomfort, warrants an immediate call to the PCP and needs to be assessed right away. 
It is imperative to know which patients are most at risk for poor outcomes. Research has shown that those who are not proficient in the English language and those who are hearing impaired are at higher risk. Having interpreters (including those in sign language) available in the hospital will ensure all communications are well understood by all parties. Patients without health insurance and those receiving Medicaid are at risk too and require better monitoring and assistance. Studies that have utilized nurses in the transitional care of patients from hospital to home, in a coordinated and continuous manner (with outside resources and providers), have demonstrated a reduction of hospital readmissions. These nurses were skilled in being able to determine patients’ needs after leaving the hospital, including the need for home health aides, social services and even palliative care and hospice. 
Another way to reduce readmissions, in geriatric heart failure patients leaving the hospital, is to ensure that they see their primary care provider (PCP) within the first seven days of hospital discharge.  In this way, PCPs can check up on their patients’ health status and address any new concerns or questions. This also provides another opportunity for medication reconciliation, patient education, assessment of depression or anxiety, and to provide encouragement for continued risk factor prevention. Sometimes, patients deemed to be cognitively intact, responsible, and having a good relationship with their provider may even be given the option to make their own medication adjustments (according to previously determined provider instruction) should certain symptoms develop. All patient care should be individualized according to the patient’s needs and health status. Some places may have specialized heart failure clinics, run by midlevel providers, which patients may go to in order to receive this specific type of continued follow up HF care. 
For patients who require more frequent contact with a health care provider, but do not have accessibility due to lack of transportation, companion, or frailty, use of telemonitoring technologies can be of great assistance. For example, transmitters can be used to transmit information regarding a patient’s status (such as weight or vitals) to the provider for close and continuous monitoring.  Computers can also be used to Skype in and/or communicate (chat; e-mail) between patient and provider. If funds are not available for such technology, telephones/mobile phones, and health-care smartphone apps can be used by both provider and patient to touch base with one another. When it is crucial for patients to actually be seen by a provider, yet they are unable to leave their place of residence, home visiting providers can be of invaluable service.
Encouraging collaboration between hospitals and other providers of heart failure patient care, home health agencies, nursing homes, primary care providers, and other specialists (cardiologists and endocrinologists), can ensure that each is aware of why readmission can happen and what is required to manage patient care in an effective, efficient, and comprehensive fashion. Collaboration by everyone involved by sharing patient observations and evidence based strategies can prevent inadvertent HF rehospitalizations. 
Lastly, incentive programs between health care systems and insurance payer that provide “pay for performance” can be of benefit to ensure that healthcare providers do their best to provide quality, effective care to their elderly heart failure patients in order to keep them from returning to the hospital. Programs that “cap” payments provide further incentive, for healthcare systems, to be cost efficient in their provision of quality HF patient care. 
Heart failure is a multi-factorial disease. Management of heart failure in the geriatric patient is a complex and continuous process. With careful attention to evidence based guidelines for care and comprehensive, holistic, and collaborative efforts made by providers, patients and payers, this challenging disease can be tackled both effectively and efficiently.
Karen Digby, BA, BSN, MS, GNP-BC, CWS
GNP Independent Contractor/Writer
Ann Arbor, Michigan
Published April 22, 2014
Karen Digby is a nurse practitioner specializing in geriatrics. She received her training from New York University and the University of Michigan in Ann Arbor. In over ten years of practice, Karen has obtained a wealth of experience in various aspects of health care including home care, outpatient/ambulatory care, dementia care, subacute care, hospice, and assisted living and long-term care. Due to her expertise in geriatrics, Karen was selected as an item writer, by the American Nurses Credentialing Center, for the Gerontological Nurse Practitioner Board Certification Examination. She also co-authored an article on “Falls in the Elderly” in the Plastic Surgical Nursing Journal. Additionally, Karen is certified as a Wound Care Specialist through the American Academy of Wound Management.
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