Managing Patients With Heart Failure

Margaret T. Bowers, DNP, FNP-BC

ABSTRACT
Adults with chronic heart failure (HF) are living longer. Thus, management of symptom
exacerbation related to this chronic illness is paramount to improving quality of life and
reducing hospitalizations. This article provides key recommendations for nurse practitioners
from the 2013 American College of Cardiology Foundation/American Heart Association
guideline for how to effectively manage patients with HF, including a review of the major
classes of medications to treat chronic HF. The article concludes with a brief discussion of
selected areas of new research.

Keywords: heart failure, nurse practitioner, primary care, symptom management

Ó 2013 Elsevier, Inc. All rights reserved.

O ver the past decade, the advent of improved

medical and therapeutic interventions for
the treatment of heart failure (HF) has
increased the number of years patients are living with
as a clinical syndrome that results in cardiac
dysfunction from myocardial loss or dysfunction and
is characterized by left ventricular hypertrophy,
dysfunction, or both.3,4 As a syndrome, HF stimulates
chronic HF. Despite this longevity, the mortality rate a cascade of neurohormonal and circulatory responses
for Medicare patients with HF remains at 50% after that are reflected in the signs and symptoms
an HF hospitalization.1 According the American commonly associated with HF: shortness of breath,
Heart Association, by 2030 there will be a 46% fatigue, reduced exercise tolerance, and fluid
increase in the number of chronically ill patients with retention.5
HF.1 The cost burden associated with this prevalence Endothelial dysfunction in the cardiac, coronary
is estimated to increase from $21 billion to $53 billion vascular, and peripheral vascular systems may be
in direct costs during this period. The increased the primary factors in pump dysfunction, leading to
prevalence and cost, along with associated morbidity ventricular dilation.3 After ventricular dilation, the
and mortality, provide incentives to develop strategies remodeling (which occurs as a consequence of neu-
to effectively manage episodes of acute decompen- rohormonal stress, cytokine activation, and hemo-
sation and address targets for prevention of this dynamic compromise) may be halted or reversed
burdensome illness.1,2 Managing HF symptom exac- through medications and therapeutic interventions
erbation in the primary care setting is paramount to such as cardiac resynchronization therapy and left
improving quality of life and reducing hospitalizations ventricular assist devices. The trajectory of HF begins
for this population. with pathophysiologic changes and continues in a time
This article provides nurse practitioners (NPs) a progression that, if not stopped, results in symptomatic
review of the key recommendations from the 2013 decline as a consequence of reduced cardiac output and
American College of Cardiology Foundation/ pump failure.3
American Heart Association (ACCF/AHA) guideline
for how to effectively manage patients with HF, COMORBID CONDITIONS
including a supplemental review of the major classes Comorbid conditions, such hypertension (HTN),
of medications used to treat chronic HF. diabetes, sleep apnea, atrial fibrillation, coronary heart
disease (CHD), gout, dyslipidemia, and reactive
OVERVIEW OF HF PATHOPHYSIOLOGY airway disease, are just a few of the conditions that
An understanding of the definition and pathophysi- affect how a patient responds to treatment for HF.
ology of HF has evolved over the years. HF is defined Effective management of each of these conditions by

634 The Journal for Nurse Practitioners - JNP Volume 9, Issue 10, November/December 2013
the NP will impact the disease trajectory. These categorized as either having systolic or diastolic
comorbid conditions, individually, impart a signifi- dysfunction.
cant economic burden. For example, a study of over
4,500 patients with a diagnosis of HF, atrial fibrilla- DIAGNOSTIC TESTING
tion, CHD, diabetes, and chronic lung disease were According to the 2013 guideline, 2-dimensional
shown to independently contribute to the increase echocardiography with doppler remains the preferred
cost of HF care.6 The full spectrum of HF is impacted method of diagnostic evaluation of left ventricular
by these comorbid conditions, along with other ejection fraction (LVEF), LV size, wall thickness, and
triggers that push the patient beyond the tipping valve function.5 As an alternative, radionuclide
point. Common triggers include consumption of ventriculography is also a diagnostic tool that is useful
foods with high sodium content, excessive fluid for measuring LVEF and LV volumes.
intake, nonadherence to medical therapy, recurrent In patients with angina or suspected ischemia who
ischemia, or worsening valvular heart disease.4 are potential candidates for revascularization, coro-
nary angiography is recommended. NPs should keep
TREATMENT GUIDELINES TO MANAGE PATIENTS in mind that revascularization may be achieved
WITH HF through percutaneous coronary intervention or cor-
Guidelines for HF treatment have been available onary artery bypass surgery (as deemed appropriate
for over a decade. Initially published in 1999, the based on the coronary anatomy).
first guideline focused on HF caused by left ven- An anterior/posterior chest X-ray (CXR) and
tricular systolic dysfunction and consisted primarily of 12-lead electrocardiogram (ECG) are also considered
recommendations for pharmacological treatment. key diagnostic tools for NPs to use in discerning
The 2013 ACCF/AHA guideline provides evidence an HF diagnosis. A CXR should be evaluated for
for the management of HF with reduced ejection the following abnormalities: cardiomegaly, pulmo-
fraction (HFrEF) and recommendations for man- nary infiltrates, pleural, and pericardial effusions.
agement of HF with preserved ejection fraction A 12-lead ECG in a patient with HF may reveal
(HFpEF), with discrete definitions for HFpEF that is ischemic changes, left ventricular hypertrophy, left
borderline or improved. Table 1 outlines the new bundle branch block (LBBB), right bundle branch
definitions of HF,4 which provide increased clarity to block (RBBB), or a rhythm disturbance, such as atrial
discriminating differences in patients previously fibrillation or tachycardia.

Table 1. Terminology and Definitions of Heart Failure (HF)

Previous Ejection
New Terminology for Classification of HF Terminology Fraction Key Points
HF with reduced ejection fraction (HFrEF) Systolic dysfunction < 40% Most of the subjects to date in randomized
clinical trials of HF have included this group of
patients.
The most efficacious therapies to date have
been with this group of patients.
HF with preserved ejection fraction Diastolic HF > 50% A very heterogeneous group of patients
HFpEF Diagnosis is challenging, largely one of
2 subgroups within this classification: exclusion (of other noncardiac causes of
HFpEF borderline (or intermediate) symptoms suggestive of HF).
patients with an EF of 41%-49% No definitive therapies have been shown to
HFpEF with EF > 40% who had previously be efficacious with this group
had HFrEF (EF < 40%) but improvement or More research is needed to determine which
recovery was noted in EF therapies are effective in improving outcomes
in this mixed group of patients.
Data from Yancy et al.4

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Biomarkers known to cause HF. Additional recommendations for
The 2013 clinical guideline recommends specific patients in Stage A are to control diabetes mellitus,
biomarkers, such as natriuretic peptides (BNP or NT- tobacco use, and obesity and avoid cardiotoxic sub-
proBNP), based on the evidence for use in the stances (eg, alcohol, cocaine).
diagnosis, exclusion, and prognosis for HF in the For patients in Stage B, although they remains
ambulatory setting. It is often challenging for NPs asymptomatic, the recommendation is to initiate
and other clinicians to discern fluid volume status in angiotensin-converting enzyme (ACE) inhibitors
patients with chronic HF. Thus, the most recent (or if intolerant, use an angiotensin receptor blocker
guideline endorses BNP- or NT-proBNP to guide [ARB]) along with beta-blockers for patients with
HF therapy for clinically euvolemic patients (ie, those HFrEF, regardless of whether or not they have a
patients who have a stable fluid status) in an effort to history of a myocardial infarction (MI). However, for
guide clinical decision making and achieve optimal patients who have had a prior MI, statin therapy is
dosing of medical therapy. also recommended in Stage B for secondary pre-
Natriuretic peptide levels may be elevated for a vention of ischemic heart disease.
variety of reasons, and recognition of these factors by Patients who develop HF symptoms enter Stage
NPs will facilitate accurate interpretation of this C, and the therapeutic goals are to control symptoms,
biomarker in the clinical setting. Cardiac causes for improve health-related quality of life, reduce hospi-
elevated BNP (or NT-proBNP) levels include acute talization, and prevent mortality. The recommended
coronary syndrome, left ventricular hypertrophy, therapeutic interventions for HFrEF include implan-
valvular heart disease, atrial fibrillation, pericardial table devices, such as implantable cardioverter de-
disease, myocarditis, cardioversion, and cardiac sur- fibrillators (ICDs) and cardiac resynchronization
gery. Common noncardiac causes of elevated BNP therapy (CRT). In selected patients with HFrEF in
(or NT-proBNP) levels include anemia, kidney Stage C, the addition of digoxin can be beneficial to
failure, advanced age, obstructive sleep apnea, severe manage HF symptoms. A combination of hydralazine
pneumonia, pulmonary hypertension, and metabolic and isosorbide dinitrate are also indicated for African
insults, including cancer.4 Americans with HFrEF, for patients with kidney
dysfunction, or for those who are intolerant to ACE
HF Stages inhibitor or ARB therapy.4
In keeping with the prior set of guidelines, the 2013 For patients with HFpEF in Stage C, diuretic
guideline categorizes HF into 1 of 4 stages, Stages therapy is aimed toward relieving congestion. The
A-D. These stages are used to identify patients at risk primary focus for patients with HFpEF is to manage
for the development of HF (Stage A) through those comorbid conditions and refer for revascularization
patients who have refractory symptoms and require or valvular repair if indicated.
specialized interventions (Stage D).4 New York The transition to Stage D occurs when HF is
Heart Association (NYHA) classifications I through refractory, despite medical therapy as recommended
IV may be used with these stages and are fluid to by the guideline. During Stage D, advanced HF
reflect the degree of symptom severity at any given treatment options should be reviewed, including
period. Staging assists the provider in identifying cardiac transplantation, chronic inotropes, and tem-
patients who are risk for the development of HF porary or permanent mechanical support. During this
(Stage A) and to implement treatment strategies to period, discussion of palliative care and hospice ther-
prevent the advancement to structural heart disease apy, along with end-of-life goals, should be a priority.4
without HF symptoms (Stage B).
GUIDELINE-DIRECTED MEDICAL THERAPY
Treatment for Stages A prominent feature of the updated 2013 guidelines
For patients in Stage A, there is strong evidence to is the use of the term guideline-directed medical therapy
support the goal of treatment to control chronic (GDMT), as opposed to previous term of optimal
conditions (eg, HTN and dyslipidemia) that are medical therapy. GDMT focuses on initiating

636 The Journal for Nurse Practitioners - JNP Volume 9, Issue 10, November/December 2013
medications, such as ACE inhibitors, when patients RISK SCORING SYSTEMS
are in Stage B with a reduced EF or recent history of The updated guideline also endorses the use of risk
MI or acute coronary syndrome with strong evidence scoring systems to predict outcomes in HF. These
to reduce mortality, symptomatic HF, and cardio- types of risk scoring systems may be useful for NPs in
vascular events.4 The vast array of cardiovascular the primary care environment to use as a framework
medications that are recommended for HF manage- to share information about disease trajectory with
ment are listed in Table 2. As in the past guidelines, patients and their families. One example of a risk
ACE inhibitors, beta-blockers (only those approved scoring system for chronic HF is the Seattle Heart
by the Food and Drug Administration for HF), Failure Model (SHFM).4 The SHFM, available as a
diuretics, and aldosterone antagonists continue to be free application for iPhone, uses clinical variables that
the mainstay of therapy for patients with HFrEF, are readily accessible in an ambulatory setting.
according to the 2013 guideline.3,4 The Heart Failure Survival Score is an example of
There are medications, however, that are consid- a tool that can be used to make decisions regarding
ered potentially harmful to patients with HFpEF that referral for cardiac transplantation and predict 1-year
are asymptomatic after an MI. Such medications in- mortality for patients with severe HF. It also includes
clude nondihydropyridine calcium channel blockers variables that are readily available to the primary
(eg, nifedipine) because these agents have negative care NP.7
inotropic effects. Patients may have been started Risk scoring system to predict outcomes in
on these agents for resistant HTN or refractory angina, patients with acutely decompensated HF are also
but alternatives for management of these concurrent available. The AHA Get with the Guidelines Risk
conditions should be considered if the patient Score is an example of a tool that can be imple-
develops HF. mented by NPs in an acute care setting to determine
The 2013 HF Guidelines continue to support the in-hospital mortality risk and assist in guiding clinical
recommendation for placement of an ICD in patients decisions.7
with HFrEF with an LVEF of
30% with asymp-
tomatic ischemic cardiomyopathy that are 40 days NONPHARMACOLOGIC INTERVENTIONS
after MI, on GDMT (eg, ACE inhibitors, beta- According to the 2013 guideline, sodium restriction
blockers, diuretic, and aldosterone antagonist), and is a reasonable strategy for NPs to implement for
have an expected survival with good functional status patients with HF who are symptomatic to reduce
of more than 1 year.4 In addition, ICD therapy for congestion. Dietary sodium should be restricted to
primary prevention of sudden death is recommended 2-3 grams per daily in patients with both HFrEF and
for patients with symptomatic HF (Stage C; NYHA HFpEF and < 2 grams of sodium per day in patients
II or III), regardless of whether they have an ischemic with moderate to severe HF symptoms. As in past
or nonischemic etiology. Chronic resynchronization guidelines, fluid restrictions are not advised overall,
therapy (CRT), through the use of a biventricular unless a patient is in Stage D or has hyponatremia
pacemaker, is indicated for patients with NYHA with a sodium < 130 mEq/L. A fluid restriction of
Class II-IV, who have an EF of
35%, are in sinus less than 2 L/day is also recommended for patients
rhythm, have a LBBB with a QRS duration of 150 with persistent fluid retention who are receiving high
ms or greater, and are on GDMT. dose diuretics and adhering to a dietary sodium
At this time there is no clear evidence that CRT is restriction. Excessive fluid restriction (ie, < 1 L/day)
beneficial in patients with an RBBB. However, will potentiate thirst and make it more difficult to
PACE-RBBB is an ongoing, randomized, double- adhere to these recommendations.8,9
blind clinical trial with a primary focus on determining Nutritional supplements, such as multivitamins,
whether or not right ventricular pacing improves are recommended in patients with HF; however, the
symptoms in patients with moderate to severe HF and use of nutraceuticals is not advised. Recent research
RBBB (refer to http://clinicaltrialsfeeds.org/clinical- on the use of Coenzyme Q10 postulates that, as an
trials/show/NCT01169493 for more information). antioxidant involved in the production of cellular

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638

Table 2. Common Medications Used to Treat Heart Failure (HF)

Medication Generic (Trade) Names of Agents
The Journal for Nurse Practitioners - JNP

Class Used for HF Mechanism of Action Most Common Adverse Effects Key Points in Monitoring
Angiotensin Enalapril (Vasotec) Blocks the conversion of Volume depletion Blood pressure (BP)— evaluate for
converting Ramipril (Altace) angiotensin I to angiotensin II Worsened kidney function orthostasis if patient is symptomatic
enzyme Captopril (Capoten) (potent vasoconstrictor) Cough Serum electrolytes to evaluate
inhibitors Lisinopril (Zestril/Prinivil) enhancing vasodilation, Hypotension kidney function (potassium, BUN,
(ACE-I) Trandolopril (Mavik) reducing fluid volume, and *Angioedema and creatinine)
Quinapril (Accupril) reducing peripheral vascular (mouth or lip edema) with or
Benazepril (Lotensin) resistance without anaphylaxis (a rare but
After myocardial infarction, serious side effect)
reduces ventricular remodeling

Angiotensin II Candesartan (Atacand) Similar action to ACE-I, resulting Worsened kidney function Same as ACE-I
receptor Irbesartan (Avapro) in vasodilation, reduced blood Hyperkalemia
blockers Losartan (Cozaar) volume, and prevention of Not likely to cause a cough
Valsartan (Diovan) ventricular remodeling Less likely to cause angioedema
Aldosterone Spironolactone (Aldactone) Inhibits aldosterone, resulting in Hyperkalemia Monitor serum potassium 1 day, 1
antagonists Eplerenone (Inspra) retention of ion potassium and Gynecomastia week, and 1 month after starting
(also known as excretion of Naþ/Cl-/water (10% incidence) Avoid foods or medications high in
potassium potassium
sparing Avoid salt substitutes containing
diuretic) potassium
Beta Blockers* Bisoprolol (Zebeta) Blocks sympathetic nervous Bradycardia HR, BP, and heart rhythm
(only use beta- Carvedilol (Coreg) system resulting in decreased Heart block Orthostasis, if dizzy
blockers that Metoprolol (Lopressor or Toprol) BP, heart rate (HR), and Hypotension Wheezing in patients with RAD
Volume 9, Issue 10, November/December 2013

are FDA myocardial oxygen demand Severe bronchospasm in patient Peripheral edema and weight gain
approved for Blocks renin release from with reactive airway disease (RAD) in patients with HF
use in HF) nephrons Temporary fluid retention in Educate patients with diabetes to
Helps decrease angina in patients with HF monitor for hypoglycemia
patients with HF from ischemic Fatigue
etiology Depression
May mask signs of hypoglycemia
www.npjournal.org
Digoxin Digoxin (Lanoxin) Weak inotrope, slows Cardiac dysrhythmias, especially in Heart rate and rhythm
Digoxin dosing and therapeutic atrioventricular conduction patients with hypokalemia or Adjust dose for age, lean body
levels are lower than previously hyperkalemia mass, and renal function
recommended—digoxin level Bradycardia Observe for signs of digoxin
0.8-2.0 ng/ml Heart block toxicity: nausea, vomiting, diarrhea,
Starting dose: 0.125 mg daily if Digoxin toxicity fatigue, yellow or blurred vision, flu-
older than 70 and 0.25 mg daily if like symptoms
less than 70 and normal renal
function19

Diureticse Furosemide (Lasix) Blocks reabsorption of Naþ/Cl- Hypotension BP for hypotension and orthostasis
Loop Torsemide (Demadex) and water at Loop of Henle Volume depletion HR if BP decreases (reflex
Bumetanide (Bumex) Dehydration tachycardia)
Electrolyte abnormalities: Overdiuresis: dizziness, oliguria,
hypokalemia, hypomagnesemia, thirst, excessive weight loss
hyponatremia, or hyperglycemia Serum electrolytes
May worsen kidney function Ototoxicity
Hyperuricemia
Ototoxicity, more common in high
doses or if given with other
ototoxic medications

Thiazide Hydrochlorothiazide (HCTZ) Blocks reabsorption of Naþ/Cl- Same as loop Same as loop diuretics
Chlorthalidone and water No ototoxicity
Metolazone, a thiazide-like diuretic Same as above, administered
30 minutes before loop diuretic
to enhance effect of loop for
patients with HF
The Journal for Nurse Practitioners - JNP

Nitrates Nitroglycerin various routes: Vascular smooth muscle Headache BP

Sublingual—spray or tablet dilation in periphery and Dizziness Do not administer within 24 hours of
Oral—short and long acting forms coronary arteries Reflex tachycardia sildenafil or 48 hours of tadalafil
Transdermal Flushing Vardenafil is contraindicated with
Intravenous Syncope nitrates
Ensure a nitrate-free interval of 10-
12 hours
Hydralazine Hydralazine (Apresoline) Direct vasodilator through Reflex tachycardia BP
arteriolar smooth muscle Fluid retention HR, especially if BP drops
relaxation
639
energy, patients with chronic HF would benefit from episodes of HF decompensation associated with fluid
this treatment. Small randomized clinical trials have overload. Dosing guidelines and method of intrave-
shown promising results; however, these studies need nous (IV) drug administration have never been
to be replicated in larger samples to have broader studied for efficacy and have been guided by the
application.10 prescriber’s judgment. In addition, an area of concern
Medically supervised physical activity has been regarding the administration of diuretic therapy is
shown to be beneficial to improve functional status and that high doses affect kidney function and, ultimately,
is safe and effective in patients with HF.4 Evidence to may worsen clinical outcomes.
support this recommendation primarily stems from the As a result, the Diuretic Optimization Strategies
HF ACTION trial, which enrolled over 2,300 subjects Evaluation (DOSE) Trial was undertaken for 2 rea-
with an LVEF < 35%.11 The subjects were randomized sons: to compare low-dose (equivalent to oral dose)
to aerobic training versus usual care and were followed and high-dose IV therapy (2.5 times oral dose) and to
for over 4 years. Although all-cause mortality did not compare dosing by bolus administration versus a
improve with the intervention, a substudy found that continuous IV infusion (ie, which was better).12,13
exercise was safe and beneficial in this group of patients. The trial, which included 308 patients with HF,
The benefits of exercise were related to the amount of found no difference in clinical outcomes comparing
time spent exercising and the frequency of the activity, the high and low dose group and that the higher dose
which were evident through increased functional ca- diuretic strategy was associated with worsening
pacity and oxygen uptake. More importantly, patients kidney function in the short term (ie, 60 days).7
who exercised reported fewer symptoms of fatigue and Furthermore, patient symptoms did not differ based
breathlessness and had an overall improved quality of on the method of IV administration.12 Based on this
life.11 Thus, exercise training, through a medically study, implications for NPs are that it does not matter
supervised program is recommended for patients with which method diuretic therapy is given (IV versus
HF so that the duration, frequency, and intensity may oral dose); however caution should be used when
be monitored with the goal of at least 30 minutes/day, 5 considering higher doses, especially in patients with
days a week. compromised kidney function.
In June 2013 the Centers for Medicare and Another study, the Aliskiren Trial on Acute Heart
Medicaid Services announced its intention to com- Failure Outcomes (ASTRONAUT) trial, investi-
plete a national coverage determination to consider gated whether adding a direct renin inhibition, alis-
coverage of chronic HF as an indication for cardiac kiren, as add-on therapy to standard treatment within
rehabilitation. However, currently NPs are unable to 5 days of hospital discharge would improve outcomes
order cardiac rehabilitation to be eligible for reim- in patients with EF < 40% who had been recently
bursement. Despite this system barrier, NPs can hospitalized. However, the trial found no additional
advocate for their patients with HF to obtain referrals benefit in reducing hospitalization or cardiovascular
and encourage enrollment. death at 6 months and 1 year after starting this
medication as compared to placebo.14 Implications
NEW RESEARCH for NP practice are that addition of a direct renin
In addition to the 2013 guideline update, NPs should inhibitor to standard therapy to decrease
be aware of new research that may impact current rehospitalization or cardiovascular death is
and future practice. Three areas that warrant atten- not warranted.
tion include the best ways to administer diuretic Self-care is a vital component to engaging patients
therapy for patients who are decompensating, with chronic HF and is included in the 2013 guide-
whether direct renin inhibitors should be used as add- line.4 However, sustaining this level of engagement
on therapy to current GDMT, and how NPs might over an extended period can be manpower inten-
empower patients with HF to participate in self-care. sive and costly to an NP practice. Three focused
Administration through continuous infusion or options for outpatient HF care that have demon-
bolus therapy has been the primary treatment for strated to be effective in reducing readmissions

640 The Journal for Nurse Practitioners - JNP Volume 9, Issue 10, November/December 2013
include telemonitoring, structured telephone gather data and communicate directly with patients
support, and disease management. Telemonitoring outside a routine office visit. Through the use of
consists of a digital transmission of physiologic data innovative ways to improve quality of life and reduce
and symptom reporting to remote providers.15 hospitalizations, they can make a difference in the lives
However, improvement in short-term outcomes of their patients.
(eg, rates of decompensation or readmission for
patients with HF) from studies investigating tele- References

monitoring has been mixed; thus, more research 1. Heidenreich PA, Albert NM, Allen LA, et al, on behalf of the American Heart
Association Advocacy Coordinating Committee, Council on Arteriosclerosis,
is needed. Thrombosis and Vascular Biology, Council on Cardiovascaular Radiology and
Intervention, Council on Clinical Cardiology, Council on Epidemiology and
Structured telephone supports through auto- Prevention and Stroke Council. Forecasting the impact of heart failure in the
mated phone calls provide a second alternative to United States: a policy statement from the American Heart Association. Circ
Heart Fail. 2013;6(3):606-619.
providing patient follow-up communication and 2. Lindenfeld J, Albert NM, Boehmer JP, et al. Executive Summary: HFSA
2010 Comprehensive Heart Failure Practice Guideline. J Card Fail.
support for patients with chronic HF. In a study by 2010;16:475-539.
Piette and colleagues16 that included over 1,000 3. De Keulenaer G, Brutsaert D. Systolic and diastolic heart failure are
overlapping phenotypes within the heart failure spectrum. Circulation.
patients suffering from multiple medical conditions, 2011;123:1996-2005.
4. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the
researchers found that an interactive voice response management of heart failure: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines.
system had higher rates of participation in patients J Am Coll Cardiol. 2013;128. Published ahead of print.
with HF (90%) compared with diabetes (81%). 5. Jessup M, Abraham W, Casey D, et al. 2009 Focused Update: ACCF/AHA
Guidelines for the Diagnosis and Management of Heart Failure in Adults: A
Disease management programs, a third approach Report of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines: Developed in Collaboration
to empower patients to engage in self-care, are with the International Society of Heart and Lung Transplantation. Circulation.
designed to provide focused interventions over a 2009;119:1977-2016.
6. Smith DH, Johnson ES, Blough DK, et al. Predicting cost of care in heart
defined period using a multidisciplinary approach.17 failure patients. BMC Health Services Research. 2012;12:434.
7. Peterson P, Rumsfeld J, Liang L, et al. A validated risk score for in-hospital
When integrated into a comprehensive system, this mortality in patients with heart failure from the American Heart Association
option promotes self-care and provides substantive get with the guidelines program. Circulation. 2010;3(1):25-32.
8. Lindenfeld J, Albert NM, Boehmer JP, et al. Executive Summary: HFSA
patient surveillance in an effort to reduce HF hos- 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail.

pitalizations.17 Concurrent management of 2010;16:475-539.

9. Aliti GB, Rabelo ER, Clausell N, et al. Aggressive fluid and sodium restriction
comorbid, noncardiac conditions is paramount to in acute decompensated heart failure: a randomized clinical trial. JAMA Intern
Med. 2013;173:1058-1064.
achieve beneficial HF outcomes.17 While emerging 10. O’Riordan M. Coenzyme Q10 supplementation reduces HF admissions and
improves survival: Q-SYMBIO. http://www.theheart.org/article/1545585.do.
outpatient care strategies (eg, early follow-up visits Accessed June 29, 2013.
after discharge and early follow-up phone calls) are 11. O’Connor CM, Whellan DJ, Lee KL, et al, for the HF-ACTION Investigators.
Efficacy and safety of exercise training in patients with chronic heart failure
seen as promising strategies to reduce readmissions, HF-ACTION randomized controlled trial. JAMA. 2009;301:1439-1450.
12. Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute
more evidence is needed to support their integration decompensated heart failure. N Engl J Med. 2011;364:797-805.
13. Campbell PT, Ryan J. Diuretic dosing in acute decompensated heart failure:
into standard of care practice across the health care lessons from DOSE. Curr Heart Fail Rep. 2012;9(3):260-265.
continuum.4,15,18 14. Gheorghiade M, Bohm M, Greene SJ, et al, on behalf of the ASTRONAUT
Investigators and coordinators. Effect of aliskiren on postdischarge
mortality and heart failure readmissions among patients hospitalized for
heart failure: the ASTRONAUT randomized trial. JAMA. 2013;309(11):
CONCLUSION 1125-1135.
NPs in primary care settings are in an ideal position to 15. Inglis SC, Clark RA, McAlister FA, Stewart S, Cleland JGF. Which
components of heart failure programmes are effective? A systematic review
implement GDMT for their patients with HF. Man- and meta-analysis of the outcomes of structured telephone support or
telemonitoring as the primary component of a chronic heart failure
aging patients with chronic HF, however, is time management in 8323 patients: Abridged Cochrane Review. Eur J Heart Fail.
intensive and requires new strategies for implementing 2011;13:1028-1040.
16. Piette JD, Rosland AM, Marinec NS, et al. Engagement with automated
the most recent clinical guideline. Care coordination patient monitoring and self-management support calls experience with a
thousand chronically ill patients. Med Care. 2013;51:216-223.
with this patient population requires collaboration 17. Angermann C, Stork S, Gelbrich G, et al. Mode of action and effects of
among diverse groups across the spectrum of care. The standardized collaborative disease management on mortality and morbidity
in patients with systolic heart failure: the Interdisciplinary Network for Heart
time to explore different options for patient engage- Failure (INH) study. Circ Heart Fail. 2012;5:25-35.
18. Kim S, Han H. Evidence-based strategies to reduce readmission in patients
ment is now. In an era of technological advances and a with heart failure. J Nurse Pract. 2013;9(4):224-232.
transition to electronic health records, NPs have an 19. Ragab A, Al-Mazroua M, Abdel-Rahman R. Clinical utility of serum digoxin
level in cardiac patients for diagnosis of chronic digitalis toxicity. J Clinic
opportunity to lead. NPs can be creative in how to Toxicol. 2012;2:150.

www.npjournal.org The Journal for Nurse Practitioners - JNP 641

Margaret T. Bowers, DNP, RN, FNP-BC, AACC, CHFN, guidelines, the author reports no relationships with business or
is an assistant professor of nursing and coordinator of the adult/ industry that would pose a conflict of interest.
gerontology nurse practitioner program at Duke University in
Durham, NC. She also practices in the Duke Heart Failure
Same Day Access Clinic and can be reached at Margaret. 1555-4155/13/$ see front matter
© 2013 Elsevier, Inc. All rights reserved.
bowers@duke.edu. In compliance with national ethical http://dx.doi.org/10.1016/j.nurpra.2013.08.025

642 The Journal for Nurse Practitioners - JNP Volume 9, Issue 10, November/December 2013