Managing Heart Failure in Primary Care: A Case Study Approach

Foreword
Preface
Acknowledgments
Contents
Editors and Contributors
About the Editors
Contributors
Part I: What Is Heart Failure?
1: Pathophysiology of Heart Failure
1.1 Introduction
1.2 Definition of Heart Failure
1.3 Factors that Govern Systolic Function
1.4 Neurohormonal Mechanisms
1.5 Correlation of Pathophysiology and Symptomology
References
2: Heart Failure Across the Population
2.1 Epidemiology
2.2 Etiology
2.3 Classification and Stages of Heart Failure
References
Part II: Clinical Assessment of Heart Failure
3: Comprehensive Heart Failure History
3.1 Introduction
3.2 History: Etiology and Precipitating Factors of Heart Failure
3.2.1 Risk Factors
3.2.2 Coronary Artery Disease (CAD)
3.2.3 Valvular Heart Disease
3.2.4 Hypertension
3.2.5 Endocrine
3.2.6 Pregnancy
3.2.7 Family History/Genetics
3.2.8 Illicit Substances and Toxic Agents (Chemotherapy, Drugs, Alcohol)
3.2.9 Myocarditis
3.2.10 Connective Tissue and Systemic Disorders
3.2.11 Anemia
3.2.12 Nutritional Deficiencies
3.2.13 Arrhythmias
3.2.14 Idiopathic
3.3 History: Symptoms of Heart Failure
3.4 History Taking: Assessment of Symptom Severity
3.5 Sample History Taking: Etiology, Risk Factor Assessment, and Symptoms
3.6 Conclusions
References
4: Physical Exam for Presence and Severity of Heart Failure
4.1 Introduction
4.2 General Inspection
4.3 Heart Rate and Rhythm, Blood Pressure, and Arterial Pulse
4.3.1 Heart Rate and Rhythm
4.3.2 Blood Pressure
4.4 Venous Congestion: Jugular Venous Pulse, Hepatojugular Reflux, Peripheral Edema, Hepatic Congestion, and Ascites
4.4.1 Jugular Venous Pressure and Hepatojugular Reflex
4.4.2 Peripheral Edema
4.4.3 Hepatic Congestion and Ascites
4.5 Pulmonary Congestion: Lung Examination
4.5.1 Respiratory Rate, Pattern, and Quality
4.5.2 Lung Sounds
4.6 Cardiac Examination: Examination of the Precordium, Heart Sounds, Heart Murmurs, Extra Sounds, and Rubs
4.6.1 Inspection and Palpation of the Precordium
4.6.2 Heart Sounds [39–41]
4.6.3 Heart Murmurs [39–41]
4.6.4 Pericardial Friction Rub and Other Extra Sounds
4.7 Putting It All Together: Assessment of Congestion and Perfusion
References
5: The Cardiology Referral for Heart Failure: Work-up and Expectations
5.1 Initial Clinic Evaluation
5.1.1 General Approach
5.1.2 Physical Exam
5.1.3 Diagnostic Testing
5.2 Case Scenario: Diagnostic Testing
5.2.1 Assessment for the Etiology of Heart Failure
5.2.2 Assessment for Coronary Artery Disease
5.3 Case Scenario: Invasive Testing
5.3.1 Work-up for Nonischemic Cardiomyopathy
5.4 Case Scenario: Diagnosis
5.4.1 Putting It All Together
References
Part III: Heart Failure Management
6: Heart Failure with Reduced Ejection Fraction
6.1 Introduction
6.2 Epidemiology
6.3 Etiology
6.4 Prevention
6.5 Outpatient Management
6.5.1 Diagnosis and Evaluation
6.5.2 Patient History
6.5.3 Physical Exam
6.5.4 Diagnostic Evaluation
6.5.5 Clinical Presentation
6.5.6 Guideline-Directed Medical Therapy
6.5.7 Initiation, Titration, and Optimization
6.5.8 Adjunctive Therapies
6.5.9 Nonpharmacological Interventions
6.5.10 Device Therapy
6.6 Putting It All Together
6.6.1 Case Study
6.6.1.1 Subjective HPI
6.6.1.2 Past Medical History
6.6.1.3 Current Medical Regimen
6.6.1.4 Review of Systems
6.6.2 Objective
6.6.3 Assessment
6.6.4 Plan
6.6.5 Heart Failure with Reduced Ejection Fraction: Clinical Considerations
6.7 Conclusion
References
7: Heart Failure with Preserved Ejection Fraction
7.1 Introduction
7.2 Definition
7.3 Epidemiology
7.4 Etiology
7.5 Prevention
7.6 Diagnosis of HFpEF
7.6.1 Natriuretic Peptides
7.6.2 Echocardiography
7.6.3 Invasive Diagnostics
7.6.4 Cardiac Magnetic Resonance
7.6.5 Diagnostic Algorithms
7.7 Clinical Mimics of HFpEF
7.7.1 Cardiac Amyloidosis
7.7.2 Hypertrophic Cardiomyopathy
7.7.3 Other Cardiomyopathies
7.7.4 Pericardial Disorders
7.7.5 Stiff Left Atrial Syndrome
7.8 Medical Management
7.8.1 Diuretics
7.8.2 Aldosterone Antagonists
7.8.3 Angiotensin Receptor-Neprilysin Inhibitor
7.8.4 Sodium-Glucose Co-transporter (SGLT) Inhibition
7.8.5 Pulmonary Artery Pressure Monitoring
7.8.6 Cardiac Rehabilitation
7.8.7 Coronary Revascularization
7.8.8 Hypertension Management
7.8.9 Atrial Fibrillation Management
7.8.10 Referral for Clinical Trials
7.9 Case Study
7.10 Conclusion
References
8: Transitions of Care and Self-Care Strategies for the Heart Failure Patient
8.1 Introduction
8.2 Transition from Hospital to Home
8.3 Community Resources
8.4 Initial Post-discharge Clinic Visit
8.4.1 History
8.4.2 Physical Examination
8.4.3 Assessment of Weights
8.4.4 Medication reconciliation
8.4.5 Diagnostics and Laboratory Testing
8.4.6 Optimization of Guideline-Directed Medical Therapy
8.5 Self-Care Strategies for the Heart Failure Patient
8.5.1 Definition of Self-Care and the Importance of Symptom Monitoring
8.5.2 Role of Family Caregiver with Promoting Self-Care
8.5.3 Cultural Influences of Self-Care
8.5.4 Health Literacy, Self-Care Education, and Self-Efficacy
8.5.5 Overall Self-Care Strategies for Managing a Patient with Heart Failure
8.6 Putting It All Together
References
9: Goals of Care for the Heart Failure Patient
9.1 Case Study: Setting the Stage
9.2 Palliative Care in Heart Failure
9.2.1 What Is Palliative Care?
9.2.2 Why Is Palliative Care in Heart Failure Important?
9.3 Current State of Palliative Care in Heart Failure
9.3.1 How and When to Refer to Palliative Care for the Primary Care Provider
9.4 Goals of Care Discussions in Heart Failure
9.4.1 Components of Goals of Care Conversations
9.4.2 Current State of Goals of Care Conversations
9.4.3 How to Initiate Goals of Care Conversations
9.5 Special Considerations for Goals of Care Conversations in Heart Failure
9.5.1 Difficulties in Discussing Goals of Care
9.5.2 Code Status Discussions
9.5.3 Defibrillator Device Deactivation
9.6 Hospice and End of Life Best Practices
9.6.1 Hospice Care
9.6.2 Barriers to Hospice Care Referral
9.7 Case Study: Putting It All Together
References
Part IV: Heart Failure and the Management of Co-morbidities in Primary Care
10: Atrial Fibrillation and Heart Failure
10.1 Introduction
10.2 Atrial Fibrillation-Induced Heart Failure
10.3 Heart Failure Induced Atrial Fibrillation
10.4 Other Causes of Atrial Fibrillation
10.5 Special Considerations
10.6 Treatment of Atrial Fibrillation and Heart Failure
10.7 Heart Failure and Rhythm Control
10.7.1 Antiarrhythmic Medications
10.7.2 Catheter Ablation
10.8 Heart Failure and Rate Control
10.9 Putting It All Together
10.9.1 Case Study
10.9.2 Objective
10.9.3 Assessment
10.9.4 Plan
10.9.5 Clinical Pearls
References
11: Cardiorenal Syndrome, Chronic Kidney Disease, Anemia, and Heart Failure
11.1 Cardiorenal Syndrome
11.1.1 Definition
11.1.2 Pathophysiology
11.1.3 Differential Diagnosis
11.2 Diagnostic Tools
11.2.1 Biomarkers
11.2.2 Imaging
11.3 Treatment
11.3.1 Diuretics
11.3.2 Diuretic Resistance
11.4 Chronic Kidney Disease and Heart Failure
11.4.1 Definitions and Staging of CKD
11.4.2 Prevalence with Heart Failure
11.4.3 Prevention of Heart Failure in a Patient with CKD
11.5 Medication Limitations with CKD and Heart Failure
11.5.1 Beta Blockers
11.5.2 RAAS-Altering Medications
11.5.3 Mineralocorticoid Receptor Antagonists (MRAs)
11.5.4 Sodium-Glucose Cotransporter 2 (SLGT2) Inhibitors
11.6 Ultrafiltration and Dialysis with Heart Failure
11.7 Renal Transplant Considerations for Heart Failure
11.8 Hyperkalemia in CKD and Heart Failure
11.9 Anemia, Heart Failure, and CKD Considerations
11.9.1 Incidence and Associations
11.9.2 Pathophysiology of Anemia in Heart Failure
11.9.3 Diagnosis
11.9.4 Iron Replacement
11.10 Conclusion
Case Study 1: Cardiorenal Syndrome Type II and Diuretic Resistance
Case Scenario
Objective
Labs
Diagnostics
Assessment
Plan
Clinical Pearls
Case Study 2: The Complex Interaction of CKD, HF, and Anemia
Case Scenario
Objective
Clinical Pearls
References
12: Diabetes and Heart Failure
12.1 The Bidirectional Link Between Diabetes and Heart Failure
12.2 Management of Type 2 Diabetes Mellitus
12.2.1 Evidence-Based Recommendations
12.2.2 Individualized Therapy
12.2.3 Cardiovascular Safety
12.2.4 T2DM and Kidney Disease
12.2.5 Special Considerations for Treatment of DM in Patients with HF
12.2.5.1 Individualized Glycemic Goals
12.3 Pharmacotherapy for T2DM
12.3.1 General Considerations
12.3.2 Metformin
12.3.3 SGLT-2 Inhibitors
12.3.4 GLP-1 Receptor Agonists
12.3.5 DPP-4 Inhibitors
12.3.6 Sulfonylureas
12.3.7 Thiazolidinediones
12.3.8 Insulin
12.3.9 Combination Therapy
12.4 Conclusion
12.5 Case Study
12.5.1 Subjective
12.5.2 Objective
12.5.3 Assessment
12.5.4 Plan
12.6 Clinical Pearls
References
13: Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, and Heart Failure
13.1 Introduction
13.2 Obstructive Sleep Apnea
13.2.1 Obstructive Sleep Apnea Definition and Prevalence
13.2.2 Obstructive Sleep Apnea Risk Factors and Pathophysiology
13.2.3 Obstructive Sleep Apnea Concerns
13.2.4 Obstructive Sleep Apnea Evaluation and Management in the Presence of Heart Failure
13.3 Chronic Obstructive Pulmonary Disease
13.3.1 COPD Definition and Prevalence
13.3.2 COPD Chronic Bronchitis
13.3.3 Pathophysiology of Chronic Bronchitis
13.3.4 COPD Emphysema
13.3.5 Pathophysiology of Emphysema
13.3.6 COPD Clinical Manifestations
13.3.7 Heart Failure and Chronic Obstructive Pulmonary Disease Clinical Manifestations
13.3.8 Approach to the Management of Chronic Obstructive Pulmonary Disease and Heart Failure
13.3.9 Pharmacological Management of Chronic Obstructive Pulmonary Disease and Heart Failure
13.3.10 Medications Used in Comorbid Chronic Obstructive Pulmonary Disease and Heart Failure
13.3.11 Nonpharmacological Management of Comorbid Chronic Obstructive Pulmonary Disease and Heart Failure
13.3.11.1 Smoking Cessation
13.3.11.2 Cardiopulmonary Rehabilitation
13.3.11.3 Dietary Considerations
13.3.11.4 Recommended Vaccinations
13.4 Case Study
References
14: Pulmonary Hypertension in Heart Failure
14.1 Introduction
14.2 Pathophysiology
14.3 Assessment of PH-LHD
14.4 Case Study
14.4.1 Interim Assessment and Plan
14.4.2 Follow-Up
14.5 Conclusions/Practice Pearls
References
15: Liver Disease and Heart Failure
15.1 Introduction
15.2 Liver Disease Related to Heart Failure
15.2.1 Liver Diseases and Conditions That Exacerbate Heart Failure
15.2.1.1 Cirrhotic Cardiomyopathy
15.2.1.2 Nonalcoholic Fatty Liver Disease
15.2.1.3 Heart Failure Following Liver Transplant
15.3 The Role of Heart Failure in Liver Disease
15.3.1 Congestive Hepatopathy
15.3.2 Cardiogenic Ischemic Hepatitis
15.4 Approach to the Management of Liver Disease and Heart Failure
15.4.1 Pharmacologic Management
15.4.1.1 Nonalcoholic Fatty Liver Disease (NAFLD)
15.4.1.2 Heart Failure
ACE Inhibitors
ARBs
ARNIs
Beta Blockers
Diuretics
SGLT2 Inhibitors
Aldosterone Antagonists
Lipid-Lowering Agents
Anticoagulant/Antiplatelet Therapy
15.4.1.3 Congestive Hepatopathy
15.4.1.4 Cardiogenic Ischemic Hepatitis
15.4.1.5 Post-Liver Transplant
15.4.2 Nonpharmacologic Management
15.4.2.1 Lifestyle Modifications
Diet
Exercise
Weight Loss
15.5 Laboratory Monitoring and Diagnostics for Hepatic Complications in Heart Failure
15.5.1 Liver Function Tests
15.5.2 Synthetic Function Tests
15.5.3 Metabolic Markers
15.5.4 EKG
15.5.5 Echocardiogram
15.5.6 Risk Scores
15.5.7 Fibrosis Score
15.5.8 Model for End-Stage Liver Disease (MELD)
15.5.9 Child-Pugh Score
15.6 Case Study: Putting It All Together
15.6.1 Subjective
15.6.1.1 History of Presenting Illness (HPI)
15.6.1.2 Chronic Conditions Changes Since Last Visit
15.6.1.3 Past Medical History/Problem List
15.6.1.4 Family History
15.6.1.5 Social History
15.6.1.6 Medications/Allergies
15.6.1.7 Review of Systems (ROS)
15.6.2 Objective
15.6.2.1 Physical Examination
15.6.2.2 Labs and Risk Scores
15.6.3 Assessment
15.6.3.1 Plan
15.6.3.2 Nonpharmacology
15.7 Clinical Pearls
15.8 Conclusion
References
16: Substance Abuse and Heart Failure
16.1 Alcoholic Cardiomyopathy
16.1.1 Overview of Alcoholic Cardiomyopathy
16.1.2 Prevalence of Alcoholic Cardiomyopathy
16.1.3 Pathophysiology of Alcoholic Cardiomyopathy
16.2 Clinical Presentation and Diagnostic Testing for Alcoholic Cardiomyopathy
16.2.1 History and Physical
16.2.2 Diagnostic Testing
16.3 Management of Alcoholic Cardiomyopathy
16.4 Prognosis of Alcoholic Cardiomyopathy
16.5 Additional Considerations for Alcoholic Cardiomyopathy
16.6 Case Study: Alcoholic Cardiomyopathy
16.7 Cocaine- and Methamphetamine- Induced Cardiomyopathy
16.7.1 Overview of Cocaine and Methamphetamine Use
16.8 Clinical Presentation and Diagnostic Testing in Setting of Cocaine and Methamphetamine Use
16.9 Methamphetamine-Induced Cardiomyopathy
16.9.1 Prevalence
16.9.2 Pathophysiology of Methamphetamine- Induced Cardiomyopathy
16.9.3 Clinical Presentation and Diagnostic Testing
16.10 Additional Considerations for the Primary Care Provider for Methamphetamine-Induced Cardiomyopathy
16.11 Case Study: Methamphetamine-Induced Cardiomyopathy
16.12 Clinical Pearls for Alcohol- and Cocaine-Induced Cardiomyopathy
References
17: Human Immunodeficiency Virus and Heart Failure
17.1 Case Study
17.2 Background
17.3 HIV and Heart Failure
17.4 Pathophysiology and Clinical Presentation
17.4.1 Pre-ART Era or Limited ART Access
17.4.2 Contemporary ART Era
17.4.3 Clinical Implications
17.5 Risk Factors
17.5.1 Traditional Risk Factors
17.5.2 Nontraditional Risk Factors
17.6 Antiretroviral Therapy and HF
17.7 Evaluation and Management of HIV and Heart Failure
17.7.1 Diagnostic Testing and Advanced Therapy
17.7.2 Prognosis
17.8 Disparities in Care
17.9 Heart Failure Prevention
17.10 Case Study Discussion
17.11 Conclusion
References
18: Medications to Avoid When Treating Heart Failure
18.1 Case Example
18.2 Case Discussion
18.3 Introduction
18.4 Potential for Medication-Induced Worsening HF
18.5 Evaluation of a Medication’s Potential for Harm
18.6 Prescription Medications That May Cause De Novo HF
18.6.1 Anticancer Medications
18.6.2 Alkylating Agents
18.6.3 Antimetabolites
18.6.4 Biologic Agents
18.6.5 TNF-α Inihibitors
18.6.6 Sympathomimetic Stimulants
18.6.7 Anagrelide and Cilostazol
18.6.8 Bromocriptine, Pramipexole, and Ergotamine
18.6.9 Hydroxychloroquine
18.7 Prescription Medications That May Exacerbate Chronic HF
18.7.1 Anti-Arrhythmic Medications
18.7.2 Antidepressants
18.7.3 Antidiabetes Medications
18.7.4 Calcium Channel Blockers
18.7.5 Mineralocorticoids
18.7.6 NSAIDs
18.7.7 Pulmonary Hypertension Medications
18.7.8 Carbamazepine
18.7.9 Itraconazole
18.7.10 Minoxidil
18.7.11 Pregabalin
18.7.12 Alpha-Adrenergic Antagonists
18.8 Conclusion
References
Part V: Heart Failure Case Studies
19: Heart Failure Case Studies
19.1 Case Study 1
19.1.1 Diuretic Resistance and Asymptomatic Hyperuricemia in HFpEF
19.2 Case Study 2
19.2.1 HFrEF Optimization Considerations in the Setting of Volume Depletion
19.3 Case Study 3
19.3.1 HFrEF Optimization Considerations in the Setting of Volume Overload
19.4 Case Study 4
19.4.1 Valvular Heart Failure
19.5 Case Study 5
19.5.1 Anemia in the Setting of HFrEF
19.6 Case Study 6
19.6.1 Heart Failure and Social Determinants of Health
19.7 Case Study 7
19.7.1 Heart Failure with Improved Ejection Fraction
19.7.1.1 HFimpEF
19.8 Case Study 8
19.8.1 Advanced Decompensated Heart Failure
References