• New/exacerbated cough (especially at night)
  • New/exacerbated dyspnea at rest or DOE or PND
  • New/increased fatigue
  • Abdominal distention or RUQ pain
  • New/increased peripheral edema
  • Mental and/or functional status change



Even if the resident is moribund symptom control is always appropriate. Further diagnostic work-up and frequent laboratory studies may not be necessary.
Ongoing communication with the health care agent by the MD or NP is appropriate to assure them of comfort care options.



  • CAD (previous MI)
  • Chronic/exacerbated HTN
  • Cardiomyopathy, valvular heart disease
  • Arrhythmia
  • Anemia
  • Volume overload
  • Thyroid disease (hyper or hypo)
  • Pulmonary embolism
  • Pericardial disease
  • High salt intake
  • Chronic renal failure
  • Infections - fever
  • When EF < 40% review drugs: NSAIDs, corticosteroids, Class 1A or 1C antiarrhythmics, beta-blockers, Lithium, some antihistamines & decongestants, Glucophage (Metformin)
  • Obesity
  • Thiamine deficiency



  • Third heart sound (S3)
  • JVD
  • Rales
  • Change in murmur
  • Peripheral edema (pitting), periorbital or sacral edema
  • Displaced or forceful apex beat
  • Weight gain



  • CXR, ECG (if new arrhythmia present or to R/O MI)
  • Echocardiogram (for initial episode or if never done) to evaluate ejection fraction (EF) – determining whether from systolic or diastolic dysfunction is critical to treatment plan
  • Consider MUGA scan if ECHO not diagnostic (gives more precise EF; kyphosis prevents adequate visualization of ECHO)
  • Blood work: electrolytes, creatinine, albumin (CMP), LFTs, TSH, CBC, U/A; magnesium and calcium if on diuretics
  • Consider B-type natriuretic peptide [BNP] level if unclear as to cause of acute dyspnea [CV VS respiratory]- elevated level [>100 pg per ML] indicative of HF- BNP increases also with pulmonary hypertension, pulmonary emboli and renal failure
  • Consider cardiac Troponin T level when concerned for acute cardiac state



    I.    No limitation on physical activity, no symptoms with ordinary activities

    II.   Slight limitations, symptoms with ordinary activities

    III.  Marked limitation, symptoms with less than or ordinary activities

    IV.  Severe limitations, symptoms of heart failure at rest


    Systolic  - Ejection fraction < 40%

    Diastolic - Ejection fraction > 40 %



OPTIONS - EF < 40 %


OPTIONS - EF > 40 %

Review and eliminate drugs that increase risk

Attempt to correct anemia if present

Start ACEI - Zestril 5 mg QD - avoid in bilateral renal artery stenosis, angioedema, hyperkalemia, symptomatic hypotension - consider ARBs (Cozaar) if ACEI not tolerated due to coughing

If ACEI or ARB not appropriate substitute Hydralazine 10-25 mg TID AND Isosorbide Dinitrate 10 mg TID

Control precipitating factors: hypertension, tachycardia, reduce myocardial ischemia

Goal to reduce whatever symptom persists: Diuretics and salt restriction for congestive symptoms or nitrates for angina or ß-blocker or calcium channel blocker for heart rate control antihypertensives for BP control

Diuretics - do not use as monotherapy, use in volume overload - start Lasix 40 mg BID - titrate to obtain weight loss of 1-2 lbs/day until overload resolves

- if renal function worsens decrease diuretic before ACEI


Digoxin - if still symptomatic start Digoxin 0.125 mg/day - should not be used as monotherapy or alone with diuretics

ß-blockers - if still symptomatic start immediate release Toprol XL 12.5 mg QD - contraindicated in bronchospastic disease, advanced heart block, diabetes with frequent hypoglycemia, bradycardia, hypotension (SBP < 100) OR

Alpha-1 blocker – Carvedilol  3.125 mg QD

Aldactone - if still symptomatic start at 25 mg QD - contraindicated if potassium > 5 mEg/L or creatinine > 2.5 mg/dl. Monitor K+ level closely.



Patients are more comfortable in a "dry" state rather than "wet”. If terminally ill, treat SOB aggressively with diuretics even if the BUN climbs.



  • Sodium restriction diet and fluid restriction
  • Weight Q day if aggressively diuresing then Q 3 days- report gain > 3 lbs
  • Oxygen for pulse oximetry < 91%
  • Monitor electrolytes, renal function, Digoxin level - especially after addition of Aldactone
  • Consider cardiology consultation


References for HF

  1. AAFP Home Study, Update in Heart Failure, March 2004.
  2. Abraham, WT, Scarpinato, L.: Higher Expectations for Management of Heart Failure: Current Recommendations in JABFP, Vol. 15, No. 1, January-February 2002, 39-50.
  3. American Medical Directors Association Clinical Practice Guideline for Heart Failure, 1998.
  4. AHCPR (Agency for Health Care Policy and Research), Heart Failure Screening Algorithm referenced in Konstan, M; Dracup, K.; Baker, D; et al. Heart Failure: evaluation and care of patients with left ventricular systolic dysfunction. US Department of Health and Human Services, June, 1994.
  5. Aronow, WS: Therapy of Older Persons With Congestive Heart Failure in Annals of Long-Term Care, Vol.9. No.1, January 2001, 23-29.
  6. Aurigemma, GP & Gaasch, WH: Diastolic Heart Failure in NEJM, September 9, 2004, 1097-1105.
  7. Berko, BA et al: Echocardiography The role of this noninvasive test in the geriatric population in Geriatrics, Vol. 58, No. 7, July 2003, 30-34.
  8. Bonet, S, Agusti, A, et al: b-Adrenergic Blocking Agents in Heart Failure in Arch Intern Med, Vol. 160, March 13, 2000, 621-627.
  9. Bottorff, M: Recent Advances in the Treatment of Congestive Heart Failure in  Annals of Long-Term Care, Vol. 9, No. 3, March 2001, 47-56.
  10. COMET: The Carvedilol Or Metoprolol European Trial in Lancet, July 2003.
  11. Feldman, AM: A step-by-step guide to the best heart failure care in Patient Care, June 15, 2000, 154-170.
  12. Feenstra, J. et al: Association of Nonsteroidal Anti-inflammatory Drugs With First Occurrence of Heart Failure and With Relapsing Heart Failure, The Rotterdam Study in Archives of Internal Medicine, Vol. 162, Feb 11, 2002, 265-270.
  13. Fonarow, GC: Medical Management of Heart Failure in the Elderly: Clinical Evidence and Practical Concerns in Supplement to Annals of Long-Term Care, June 2002.
  14. Francis, GS. et al: Beta-blockers and ACE inhibitors: new data, old myths in Patient Care For The Nurse Practitioner, July 2000, 36-38.
  15. Frantz, RP: Beta blockade in patients with congestive heart failure in Postgraduate Medicine, Vol. 108, No. 3, September 1, 2000, 103-118.
  16. Garg, RK, Sorrentino, MJ: Beta blockers for CHF in Post Graduate Medicine, Vol. 109, No. 3, March 2001, 49-56.
  17. Gelzer-Bell, R: Diastolic Heart Failure in the Older Patient in Clinical Geriatrics, Vol. 13, No. 1, January 2005, 18-21.
  18. Goodman, A: Special Report: Heart Failure in LTC in  Caring for the Ages, Vol, 3, No. 11, November 2003, 10-12.
  19. Graff, DW, Patterson JH: Loop Diuretics in the Management of Congestive Heart Failure in the Elderly in Annals of Long-Term Care, Vol. 7, No. 10, October, 1999, 369-374.
  20. Gross, SB: Heart Failure A Review of Current Strategies in Advance for Nurse Practitioners, June, 1999, 27-32.
  21. Hjalmarson, A, Goldstein, S, et al: Effects of Controlled-Release Metoprolol on Total Mortality, Hospitalizations, and Well-being in Patients With Heart Failure in JAMA, Vol. 283, No.10, March 8, 2000, 1295-1302.
  22. Horwich, TB, Fonarow, GC: Anemia and prognosis in advanced heart failure in Cardiology Review, Vol. 20, No. 1, January 2003, 32-39.
  23. Hutt, E., et al: Associations Among Process and Outcomes of Care for Medicare Nursing Home Residents with Acute Heart Failure in JAMDA July/August, 2003, 195-199.
  24. ICSI Health Care Guidelines: Congestive Heart Failure, 1998, 1-26.
  25. Katz, AM, Silverman, DI: Treatment of Heart Failure in Hospital Practice, December 15, 2000, 19-31.
  26. Spironolactone For Heart Failure in The Medical Letter, Vol. 41, Issue 1061, September 10, 1999.
  27. Mueller, C. et al: Use of B-Type Natiuretic Peptide in the Evaluation and Management of Acute Dyspnea in NEJM, Vol. 350, No. 7, February 12, 2004, 647-663.
  28. Nash, D. Treating heart failure: A primary care issue in Family Practice, April, 1999, 19-38.
  29. Nash, D. Heart Failure: Update on Therapeutic Options in Consultant, Vol. 43, N0.14, December 2003, 1649-1654.
  30. Pitt, B, Zannad, F. et al: The Effect of Spironolactone on Morbidity and Mortality in Patients with Severe Heart Failure in New England Journal of  Medicine, September 2, 1999, Vol. 341, No. 10, 709-717.
  31. Ramahi, TM: Expanded role for ARBs in cardiovascular and renal disease? in Postgraduate Medicine, Vol. 109, No. 4, April 2001, 115-122.
  32. Reuben, DB, Grossberg, GT et al: Cardiovascular Disease in Geriatrics At Your Fingertips, 56-58, 1998/99 Edition.
  33. Rittenhouse, SK: Spironolactone For heart Failure: A Worthy Addition to Therapy in Advance for Nurse Practitioners, January 2001, 34-40.
  34. Umana, E: The failing heart in the elderly: A systematic review in Family Practice Recertification Special Geriatric Issues, May 15, 2000, 29-38.
  35. Velazquez, EJ, DeWald, TA, et al: Digoxin and Heart Failure: Old Drug Reconsidered in Emergency Medicine, August 2000, 38-50.
  36. Vesely, DL: Congestive Heart failure Update: Cardiovascular Hormones in Diagnosis and Treatment in Consultant, September 1, 2004, 1390-1398.
  37. Ward, RP, Anderson, AS: Slowing the progression of CHF in Postgraduate Medicine, Vol. 109, No. 3, March 2001, 36-45.
  38. Young, J. Heart failure: Highlights from new consensus guidelines in Cleveland Clinic Journal of Medicine, Vol. 67, No. 1, January 2000, 13-16.

Revised 2.05

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