Heart Failure Management In Primary Care

Sep 13

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Show notes:

Heart failure is, without a doubt, one of the more complex topics that you will encounter in primary care. Even some season practitioners stumble with this subject. Two types, four stages, four classes, evolving guidelines for treatment, and a host of medications – it’s a lot to wrap your head around. Especially in a 15-minute visit, and even more so when you are meeting a patient for the first time.

Where to start, and where to go once you get there?

Let’s talk about the core concepts of heart failure and increase your confidence. We’ll cover:

The two types of heart failure, and how the different types impact the approach to treatment
Diagnostics – which labs, which tests, and the crucial role of ejection fraction in heart failure
The questions you don’t want to forget to ask the patient
Medications used to treat heart failure
What to look for in the chart BEFORE the first visit

Don’t worry if you feel over your head with those first heart failure patients. Like so many other things with primary care, managing heart failure does get less stressful with time. But until then, having a strategy will increase your efficiency in the visit, your confidence on the subject, and give you clarity about co-managing with cardiology.

Resources mentioned in this episode:

Heart Failure Guidelines 2022

If you liked this post, also check out:

WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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So in this week's episode, I'm going to be talking about managing heart failure
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in primary care.
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It can feel really unnerving for new grads, and I remember feeling this way too, for
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being like the provider when it comes to heart failure, even despite having for myself
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personally having multiple years of inpatient adult experience as a nurse working with
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patients with heart failure, it just, it was a little different and it felt overwhelming
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sometimes as a new provider.
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So in this episode, I really want to focus on patients who have established heart
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failure already as a diagnosis and start with some background information.
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Next I'll talk about assessment, like assessing heart failure, the main things that we need
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to assess in that primary care provider role.
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I'll touch on management pieces and then as well as referral and co-management
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with cardiology.
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So a couple of pieces of really important background information.
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And whenever I do any of my teaching, I really start with these foundational pieces
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because it really informs every other step.
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These are the things you must know to kind of pass go, continue, right?
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And so it may feel like, what is the point of this?
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But I promise you it's important.
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So a couple of background pieces of information.
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When it comes to heart failure, this is a complex clinical diagnosis that has no
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real gold standard of like, yes, you have heart failure.
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It's a combination of a variety of things, both patient symptoms, as well as some
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diagnostic testing.
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But the moral of the story, especially according to the ACC AHA guidelines with a new
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version in 2022 for heart failure, is that it's about a either functional or
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structural abnormality of the ventricles so that they're not as effective in
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pumping blood.
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That's like the main definition of it.
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And the way you diagnose it, again, is a variety of pieces.
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So there are symptoms which I'll talk about in a moment.
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But a couple of diagnostic tools, I just want to introduce in broad brush
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perspectives, right?
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So one is a serum blood test called BNP.
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I'm not going to attempt to pronounce it because I'm going to pronounce it
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wrong, but BNP, N as in Nancy, and NT-pro-BNP.
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So this is a hormone.
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BNP is a hormone that's reduced when the ventricles are overly stretched.
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And it can be a sign of heart failure.
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NT-pro-BNP is something that's broken off of that precursor for that hormone.
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And so that has also been measured for diagnosis of heart failure.
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That's a test that has a lot of caveats.
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It is not routinely used for monitoring patients in heart failure.
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It has some data of correlation of prognosis with higher levels can lead
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to worse prognosis.
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However, there's no recommendations for continuously monitoring it.
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And there are so many caveats in there.
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If you're going to order that test, please get comfortable with that test
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before you do so.
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Please don't just order BNP on somebody and be like, oh, great.
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It's blah, blah, blah, right?
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There's a lot of caveats.
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And the other test that is used in consideration of the diagnosis initially
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is echocardiogram, which is important when it comes to the different types
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of heart failure.
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And what they're looking for in that echocardiogram is the actual
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structure of the heart and how it's functioning.
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We're looking at the ejection fraction of how much blood
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is leaving the heart.
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So hold that thought for a moment.
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So that's some important diagnostic criteria.
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The next piece of important background information
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is the two broad types of heart failure.
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When I was in school and undergrad, that was over 10 years ago,
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and we used to talk about systolic and diastolic heart failure.
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It's sort of still a thing, sort of.
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But heart failure is just, I think, the moral of the story
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is heart failure is a lot more complicated.
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And the newer terminology is heart failure with reduced ejection fraction
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versus heart failure with preserved ejection fraction,
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meaning the ejection fraction measured on an echocardiogram, right?
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So there are actually many shades of this,
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but reduced ejection fraction is effectively less than 50%
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on an echocardiogram.
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Versus preserved is 50% or greater ejection fraction.
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Again, there are shades in between and nuances,
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but I'm going to leave it at that for simplicity.
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But the main moral of the story with that
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is that we need to know, when we're seeing a patient,
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is this reduced ejection fraction or preserved ejection fraction
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because management is different, right?
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It's kind of like two different entities.
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They're similar, but they're very different, right?
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And in this episode, I'm really talking about reduced ejection fraction.
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Two last pieces about background information.
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And again, this all ties together when
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it comes to assessment and management and collaboration
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with cardiology.
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So the next piece is about stages and classes.
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And so probably this is a review for you,
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but the stages are in the ACC AHA guidelines.
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And what it's talking about is the levels of severity
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of structural impairment and symptoms.
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And there's levels A through D.
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So A is, and these are broad, right?
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And definitely look at the guidelines
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if you want to learn more.
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But the broad overview is that A is for people
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who are at risk for heart failure.
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So they have diagnoses like diabetes, hypertension.
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Patients with obesity fall into this category.
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There are some cardiac abnormalities
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that predispose somebody's risk for heart failure.
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Those patients are considered stage A.
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Stage B is still considered, quote, pre-heart failure.
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However, it's patients who have signs
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of structural cardiac impairment, structural disease,
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cardiac disease, but they do not have symptoms.
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Stage C is patients who have both signs
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of structural cardiac disease and now have symptoms.
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And stage D is called advanced heart failure.
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And those are patients that both structural changes
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and symptoms so severe that they're interfering
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with their daily lives or leading
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to recurrent hospitalizations.
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So like, why does that matter?
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That sounds very tedious, Liz, right?
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No, it's really not, I promise.
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The rationale for that is that
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because inside the guidelines,
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the treatments correlate with what stage
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we're talking about.
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And so just to orient you,
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when you have a patient coming in to your clinic,
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that's one of the questions you need to think about.
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What stage are we talking about here?
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The last pieces of background
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that's really important, again,
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it's all ties together with the management pieces,
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is that there are classes.
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It's NYHSA, I believe.
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I always get the acronym messed up,
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so I'm not gonna say it,
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but it talks about the classes of heart failure.
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And this one, whereas the stages are really static,
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the classes are a bit mobile,
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meaning it's really describing the state
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of their symptoms as they are currently.
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So somebody can go from stage one to stage four
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and back to stage one again.
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And it's really, it just depends
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on what their, it's helpful to determine
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what their quote unquote baseline is to shoot for.
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And also if we're having like a worsening state
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of their symptoms, how do we classify that, right?
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So the four stages, there are four stages.
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So the first one is that there's no symptoms
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with both physical activity or rest.
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The second one is that you're starting
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to get some symptoms with activity,
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but you're still feeling okay when you're resting.
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The third stage is that you're having
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pretty significant symptoms
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when you're doing physical activity,
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but still when you're resting, you're doing okay.
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Stage four unfortunately is when patients
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have both symptoms, severe symptoms with physical activity
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and they also have symptoms at rest.
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Like I said, it's not a fixed state
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to be in those classes of symptoms.
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Those can change,
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but those are just things to watch out for.
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So again, just to kind of recap,
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you wanna think about,
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are we talking about reduced ejection heart failure,
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HEF-REF versus HEF-PEF, which are just the cutest names.
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So you're talking about HEF-REF versus HEF-PEF.
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What stage of heart failure are we talking about
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and what class of heart failure are we talking about
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in this visit, right?
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Cause that one changes.
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Last piece is what are the goals
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of care for heart failure?
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Just to orient you or reorient you about that,
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the goals are to prevent complications,
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reduce morbidity, meaning hospitalizations,
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reduce quality of life, et cetera,
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and reduce mortality and prevent progression.
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We're really trying to keep it like,
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can we optimize what we have,
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prevent it from getting worse
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and prevent patients from dying?
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Like those are really important crucial parts
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of the management of heart failure.
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So next I wanna talk about the assessment
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and just really kind of put it in context.
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So the typical context is that you're a new grad
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or maybe you're returning to primary care
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or you just want a refresher, beautiful, right?
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So you have a person who's in front of you
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or on your schedule and you're like,
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oh gosh, they're coming in for a follow-up of heart failure.
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What do I do?
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It's like, okay, take a new breath first of all.
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Second of all, let's think about some assessment pieces.
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So things you can start
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before the patient even comes in the room.
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So looking at their chart,
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when were they last seen in your clinic?
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By who, right?
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Was it one of the other primary care providers?
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Was it a chronic care follow-up three months ago
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or were they last seen two years ago?
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Another question, have they seen cardiology before?
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Ever, hopefully, right?
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If somebody has a diagnosis of heart failure,
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the hope is that they at least have seen cardiology
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on that initial diagnosis, right?
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Spoiler alert for referrals.
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But have they seen cardiology before?
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When was that last appointment?
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Was it a year ago because they're stable?
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Was it six years ago
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because they're just not really interested
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in their care right now
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and now they're like really short of breath, right?
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Other pieces, what tests have been done before?
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Have they have an echocardiogram done before?
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Have they had a BNP done before or NT ProBNP?
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Again, that's kind of for reference.
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We don't really continually monitor that BNP test.
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We do continually monitor those echocardiograms though.
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Typically, it's annually.
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And then also,
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while you're looking at that cardiology note,
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likely they're gonna say those things
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that I just talked about.
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Hef-ref, hef-pef,
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what's the rejection fraction percentage?
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Is it less than 50, greater than 50?
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What number is it?
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Do they talk about their baseline?
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Do they talk about how they're feeling at that visit?
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What the expectations are?
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What is their care regimen
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and what is their recommended plan of care?
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Follow up in three months,
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follow up in six months,
249
00:11:22.330 --> 00:11:23.450
follow up in a year, right?
250
00:11:23.590 --> 00:11:25.730
So that's all before the patient walks in the door,
251
00:11:25.870 --> 00:11:27.170
before you're in front of them.
252
00:11:27.650 --> 00:11:29.490
So when it gets to being in front of the patient,
253
00:11:29.490 --> 00:11:31.270
you wanna do a couple of assessment questions.
254
00:11:31.630 --> 00:11:33.630
You wanna assess how their symptoms are.
255
00:11:34.030 --> 00:11:35.910
There's a whole bunch of symptoms for heart failure
256
00:11:35.910 --> 00:11:38.270
with a variety of sensitivity and specificities.
257
00:11:38.510 --> 00:11:40.310
However, let's touch on some of the main ones.
258
00:11:40.310 --> 00:11:43.530
So we wanna ask questions about dyspnea,
259
00:11:43.970 --> 00:11:44.730
chest pain.
260
00:11:45.890 --> 00:11:48.970
Are we having it with either dyspnea or chest pain
261
00:11:48.970 --> 00:11:50.650
with activity at rest?
262
00:11:50.650 --> 00:11:52.310
Again, talking about the classes, right?
263
00:11:52.890 --> 00:11:54.550
Activity, are they fine at rest?
264
00:11:54.690 --> 00:11:56.150
Are they not well when they're resting?
265
00:11:56.430 --> 00:11:57.310
Those are important.
266
00:11:57.630 --> 00:12:00.030
Do they have edema, lower extremity swelling?
267
00:12:00.110 --> 00:12:00.930
Do they have a cough?
268
00:12:01.410 --> 00:12:03.670
Do they have paroxysmal nocturnal dyspnea?
269
00:12:03.730 --> 00:12:05.330
Meaning waking up in the middle of the night,
270
00:12:05.830 --> 00:12:07.410
suddenly waking up because they're short of breath.
271
00:12:07.910 --> 00:12:09.370
Do they have orthopnea?
272
00:12:09.370 --> 00:12:11.270
Meaning they can't lay flat, right?
273
00:12:11.350 --> 00:12:13.610
All of those things have various sensitivity
274
00:12:13.610 --> 00:12:15.570
and specificity for heart failure,
275
00:12:16.670 --> 00:12:17.830
including weight gain,
276
00:12:18.250 --> 00:12:19.610
which hold that thought for one second.
277
00:12:19.670 --> 00:12:20.850
I'm gonna touch on that.
278
00:12:21.090 --> 00:12:23.730
But last kind of like physical assessment piece,
279
00:12:23.730 --> 00:12:24.890
if you're looking at a person
280
00:12:24.890 --> 00:12:27.350
aside from assessing their subjective symptoms,
281
00:12:27.990 --> 00:12:30.610
are listening to their lungs for rails
282
00:12:30.610 --> 00:12:33.250
that can be associated with heart failure,
283
00:12:33.570 --> 00:12:34.970
worsening or maybe their baseline,
284
00:12:35.330 --> 00:12:36.170
hopefully not their baseline.
285
00:12:36.730 --> 00:12:39.190
But anyway, listening to their lungs,
286
00:12:39.650 --> 00:12:41.710
looking for edema in their lower extremities.
287
00:12:41.910 --> 00:12:44.010
How far up does it go on their legs
288
00:12:44.010 --> 00:12:45.350
if they do have it in their feet?
289
00:12:45.650 --> 00:12:47.230
Is it pitting, is it not pitting?
290
00:12:47.550 --> 00:12:50.170
Is it pitting, three plus pitting up to the shins?
291
00:12:50.550 --> 00:12:52.410
Do they have generalized anisarca?
292
00:12:52.470 --> 00:12:54.230
Like hopefully not, very terrifying.
293
00:12:54.970 --> 00:12:57.010
And then the last really tricky assessment piece
294
00:12:57.010 --> 00:12:58.910
for physical exam is that JVD,
295
00:12:58.990 --> 00:13:00.210
the jugular vein distension.
296
00:13:00.590 --> 00:13:01.810
I know it's really tricky.
297
00:13:01.950 --> 00:13:02.810
You can Google it.
298
00:13:02.810 --> 00:13:04.870
You can take a look and see what the steps are.
299
00:13:04.870 --> 00:13:06.930
From a cardiologist's mouth,
300
00:13:07.910 --> 00:13:10.810
the most important piece is assessing for it.
301
00:13:10.970 --> 00:13:13.850
Less so like how many centimeters or inches
302
00:13:13.850 --> 00:13:16.090
or however you measure it above.
303
00:13:16.490 --> 00:13:17.570
So moral of the story,
304
00:13:17.570 --> 00:13:19.910
that's the one where you lean back about 45 degrees.
305
00:13:20.290 --> 00:13:23.170
You can press on the patients around their liver
306
00:13:23.170 --> 00:13:25.090
and it can lead to some reflex back up
307
00:13:25.090 --> 00:13:26.170
into their jugular veins.
308
00:13:26.190 --> 00:13:28.770
And then you measure how tall it is above that line.
309
00:13:29.390 --> 00:13:30.510
Anyway, the moral of the story
310
00:13:30.510 --> 00:13:32.170
is that you're trying your best to assess it.
311
00:13:32.170 --> 00:13:33.190
It doesn't have to be perfect.
312
00:13:33.230 --> 00:13:34.750
You don't have to get those exact measurements.
313
00:13:34.750 --> 00:13:36.790
You're just trying to get a picture of what's going on.
314
00:13:37.370 --> 00:13:39.270
Cardiologists do this all day, every day.
315
00:13:39.310 --> 00:13:40.490
So they're very good at it.
316
00:13:41.010 --> 00:13:42.710
All you gotta do is practice, right?
317
00:13:43.610 --> 00:13:45.090
So I do wanna touch on weight
318
00:13:45.090 --> 00:13:47.090
because this leads into the patient assessment,
319
00:13:47.090 --> 00:13:48.550
like assessment slash counseling.
320
00:13:49.150 --> 00:13:51.330
So one of the pieces you wanna assess is weight gain.
321
00:13:51.470 --> 00:13:53.530
I felt really uncomfortable with this as a new grad.
322
00:13:54.030 --> 00:13:56.630
And I think it's really dependent on the patient
323
00:13:56.630 --> 00:13:59.130
as well as the cardiologist that you're collaborating
324
00:13:59.130 --> 00:14:00.990
with and the co-management of this patient.
325
00:14:01.450 --> 00:14:03.230
But typically patients who have heart failure
326
00:14:03.230 --> 00:14:04.650
with reduced ejection fraction,
327
00:14:05.390 --> 00:14:08.310
they wanna check their weights at home every day.
328
00:14:08.850 --> 00:14:09.590
And ideally, right?
329
00:14:09.710 --> 00:14:11.430
Ideal world, they check it every day.
330
00:14:11.510 --> 00:14:13.150
And there's various parameters,
331
00:14:13.570 --> 00:14:15.330
whether they have worsening symptoms
332
00:14:15.330 --> 00:14:17.870
or they have a certain amount of weight gain
333
00:14:18.470 --> 00:14:21.970
in the course of overnight versus in the course of a week.
334
00:14:22.110 --> 00:14:23.650
So for an example, I had a patient
335
00:14:23.650 --> 00:14:25.630
who if they had worsening dyspnea
336
00:14:26.110 --> 00:14:27.370
or shortness of breath and dyspnea,
337
00:14:27.470 --> 00:14:28.790
the same thing, but like coughing,
338
00:14:29.650 --> 00:14:30.570
worsening of their edema,
339
00:14:30.690 --> 00:14:33.050
they had more than three pounds of weight gain
340
00:14:33.050 --> 00:14:34.850
within one day to the next.
341
00:14:35.630 --> 00:14:37.950
Or five pounds over the course of a week,
342
00:14:38.150 --> 00:14:39.730
they were directed to call the office,
343
00:14:39.890 --> 00:14:42.150
either the cardiology office or our office
344
00:14:42.150 --> 00:14:44.670
to get guidance about their medication management,
345
00:14:45.070 --> 00:14:49.070
any education, any diuresis that they might need,
346
00:14:49.310 --> 00:14:51.190
things like that, or guidance to go
347
00:14:51.190 --> 00:14:53.390
for hospitalization, for example, to the ER.
348
00:14:54.510 --> 00:14:56.490
So weight measurement is really important
349
00:14:56.490 --> 00:14:58.070
to having those conversations,
350
00:14:58.290 --> 00:14:59.910
seeing what cardiology recommends,
351
00:15:00.010 --> 00:15:01.670
coming up with a plan for that patient,
352
00:15:01.670 --> 00:15:03.430
reinforcing it at that visit,
353
00:15:04.930 --> 00:15:07.410
and also talking about lifestyle management.
354
00:15:07.870 --> 00:15:11.870
So reducing sodium intake rate, the 1,500 to 2,000,
355
00:15:12.030 --> 00:15:13.910
they may need fluid restriction as well,
356
00:15:13.990 --> 00:15:15.890
depending on their staging, their symptoms.
357
00:15:16.370 --> 00:15:18.490
We definitely wanna talk about alcohol use
358
00:15:18.490 --> 00:15:21.850
and tobacco use, reducing those as best we can,
359
00:15:22.230 --> 00:15:24.490
and just overall kind of healthy diet
360
00:15:24.490 --> 00:15:25.990
as well as preventative measures.
361
00:15:26.490 --> 00:15:28.110
So when it comes to management,
362
00:15:28.110 --> 00:15:32.230
most of our role in primary care is assessment,
363
00:15:32.990 --> 00:15:34.390
like where are we at?
364
00:15:34.590 --> 00:15:35.790
When do they see cardiology?
365
00:15:35.990 --> 00:15:37.430
What is the regimen supposed to be?
366
00:15:37.550 --> 00:15:39.110
What's their baseline, right?
367
00:15:39.270 --> 00:15:41.150
Baseline weight, baseline symptoms,
368
00:15:41.430 --> 00:15:43.910
so that we can establish if there's been a deviation.
369
00:15:44.970 --> 00:15:46.690
And on that note, I actually wanna add
370
00:15:46.690 --> 00:15:50.730
about the symptom variety is that a lot of times
371
00:15:50.730 --> 00:15:52.590
patients will get diuresis
372
00:15:52.590 --> 00:15:54.670
when they are having signs of fluid overload,
373
00:15:54.910 --> 00:15:56.810
and that is an art more than a science.
374
00:15:56.810 --> 00:15:59.610
And it is normal if you feel very uncomfortable with that.
375
00:15:59.630 --> 00:16:01.670
And what I would do, and I still do,
376
00:16:02.290 --> 00:16:05.150
is call the cardiologist themselves and say,
377
00:16:05.210 --> 00:16:07.530
hey, I have our mutual patient, blah, blah, blah, blah.
378
00:16:07.770 --> 00:16:09.350
Here's all the information.
379
00:16:09.430 --> 00:16:11.110
They're taking all of these meds.
380
00:16:11.110 --> 00:16:12.790
Here's what is going on.
381
00:16:13.050 --> 00:16:15.750
Do you have guidance about adjusting
382
00:16:15.750 --> 00:16:17.630
their furosemide, for example, right?
383
00:16:17.630 --> 00:16:20.070
And it was a very collaborative conversation,
384
00:16:20.070 --> 00:16:21.590
but I digress.
385
00:16:22.050 --> 00:16:23.390
Okay, so when we talk about management,
386
00:16:23.750 --> 00:16:24.390
we'll get back to that.
387
00:16:24.390 --> 00:16:26.750
So management is effectively assessing the patient,
388
00:16:27.410 --> 00:16:28.650
doing patient education.
389
00:16:29.130 --> 00:16:30.150
Are they at their baseline,
390
00:16:30.290 --> 00:16:31.410
or are they not at their baseline?
391
00:16:31.590 --> 00:16:33.710
Are they worse, better, are they the same?
392
00:16:34.310 --> 00:16:36.910
And then what is their medication regimen, right?
393
00:16:36.970 --> 00:16:38.390
Because just because we prescribe something
394
00:16:38.390 --> 00:16:39.850
doesn't mean somebody's taking it.
395
00:16:40.070 --> 00:16:41.410
And then the other piece is that
396
00:16:41.410 --> 00:16:42.810
even if we prescribe a medicine,
397
00:16:42.970 --> 00:16:44.490
it doesn't mean that they tolerate it.
398
00:16:44.810 --> 00:16:48.130
So this is a little too much to get into for one episode.
399
00:16:49.010 --> 00:16:52.010
I do feel like this would be helpful course content,
400
00:16:52.010 --> 00:16:54.410
but I make no promises, but to be continued,
401
00:16:54.930 --> 00:16:58.830
talking about guideline-directed medical therapy, GDMT.
402
00:16:58.910 --> 00:17:00.050
You may see this in the guidelines
403
00:17:00.050 --> 00:17:02.050
or in heart failure conversations in general.
404
00:17:02.590 --> 00:17:04.450
Effectively, when we talk about those stages,
405
00:17:04.589 --> 00:17:07.990
the ABCD, in the guidelines, it takes the stages
406
00:17:07.990 --> 00:17:10.130
and it gives you exactly what those people
407
00:17:10.130 --> 00:17:11.210
are supposed to be taking
408
00:17:11.210 --> 00:17:14.170
for guideline-directed medical therapy, right?
409
00:17:14.390 --> 00:17:18.270
So if you're at risk, there's recommendations.
410
00:17:18.609 --> 00:17:20.550
If you have pre-heart failure,
411
00:17:20.569 --> 00:17:21.569
but you have structural changes,
412
00:17:21.569 --> 00:17:22.710
there's other recommendations.
413
00:17:22.990 --> 00:17:24.470
And if you're at that stage C
414
00:17:24.470 --> 00:17:26.569
of you know what, you have both structural changes
415
00:17:26.569 --> 00:17:29.610
and symptoms, you get a whole cocktail of medications.
416
00:17:30.330 --> 00:17:32.070
Without getting too much into it,
417
00:17:32.530 --> 00:17:34.670
the moral of the story is that there are medicines
418
00:17:34.670 --> 00:17:38.830
that are life-preserving, mortality-preserving,
419
00:17:39.230 --> 00:17:42.490
meaning these medicines are demonstrated over time
420
00:17:42.490 --> 00:17:45.310
to reduce a patient's mortality with heart failure.
421
00:17:45.610 --> 00:17:47.730
And then other ones that are symptom reduction
422
00:17:47.730 --> 00:17:49.070
and quality of life improvement
423
00:17:49.070 --> 00:17:50.710
and reducing hospitalizations,
424
00:17:50.710 --> 00:17:54.550
however, have no effect on their long-term mortality.
425
00:17:55.290 --> 00:17:56.630
So what's really important to take away
426
00:17:56.630 --> 00:17:58.850
is that take a peek at those guidelines,
427
00:17:59.090 --> 00:18:00.870
take a look at that kind of medicine cocktail
428
00:18:00.870 --> 00:18:03.930
that goes with each of the classes.
429
00:18:04.010 --> 00:18:06.730
I really wanna focus on just a snapshot
430
00:18:06.730 --> 00:18:08.970
of those patients who are at stage C,
431
00:18:09.150 --> 00:18:11.690
the ones who have both structural changes and symptoms
432
00:18:11.690 --> 00:18:13.810
because the majority of patients
433
00:18:13.810 --> 00:18:15.970
that I'm seeing in primary care are having that.
434
00:18:16.370 --> 00:18:18.530
So just as a broad overview,
435
00:18:18.530 --> 00:18:21.950
there's a cocktail of medications for those patients
436
00:18:21.950 --> 00:18:23.530
that they should be on.
437
00:18:23.970 --> 00:18:26.490
And I wanna be clear that there are medications
438
00:18:26.490 --> 00:18:28.690
that we choose for heart failure
439
00:18:28.690 --> 00:18:29.910
because they, number one,
440
00:18:30.130 --> 00:18:33.650
can improve their ejection fraction or reduce mortality.
441
00:18:33.970 --> 00:18:35.750
And then there are other medicines that we choose
442
00:18:35.750 --> 00:18:38.090
because it's important for their symptom management
443
00:18:38.090 --> 00:18:41.130
and to do things like reduce hospitalizations.
444
00:18:41.650 --> 00:18:45.330
However, those do not have that mortality benefit.
445
00:18:45.610 --> 00:18:47.110
And the reason I'm stressing that
446
00:18:47.110 --> 00:18:49.130
is because sometimes in the real world,
447
00:18:49.650 --> 00:18:51.610
just because we prescribe a medication for somebody
448
00:18:51.610 --> 00:18:53.250
doesn't mean that they tolerate it.
449
00:18:53.570 --> 00:18:55.090
And so sometimes we have to do things
450
00:18:55.090 --> 00:18:56.410
that are not exactly the way
451
00:18:56.410 --> 00:18:57.930
that they quote unquote should be
452
00:18:57.930 --> 00:19:01.070
because a variety of reasons, right?
453
00:19:01.210 --> 00:19:02.970
So just as a brief overview snapshot,
454
00:19:03.010 --> 00:19:04.390
it gets a lot more detailed than this,
455
00:19:04.410 --> 00:19:07.030
but you wanna think about what medicines classes
456
00:19:07.030 --> 00:19:08.290
is this person taking.
457
00:19:08.930 --> 00:19:12.770
Beta blockers, ACE inhibitors, and diuretics
458
00:19:12.770 --> 00:19:14.590
are the main three.
459
00:19:14.590 --> 00:19:18.990
Those first two ACEs, ARBs, and beta blockers actually,
460
00:19:19.170 --> 00:19:21.170
those ones are mortality reducing,
461
00:19:21.770 --> 00:19:22.890
mortality improving rather.
462
00:19:24.150 --> 00:19:26.350
Diuretics are important for symptom management
463
00:19:26.350 --> 00:19:27.830
and preventing hospitalization.
464
00:19:28.090 --> 00:19:29.970
However, those are not necessarily linked
465
00:19:29.970 --> 00:19:32.350
to reduction in mortality.
466
00:19:32.850 --> 00:19:34.950
After that, there's actually been some updates too,
467
00:19:34.950 --> 00:19:36.670
whether it's reduced ejection fraction
468
00:19:36.670 --> 00:19:38.390
or preserved ejection fraction.
469
00:19:38.710 --> 00:19:40.810
And definitely check out the details of the guidelines
470
00:19:41.150 --> 00:19:43.390
as it applies to your practice and your patients.
471
00:19:43.390 --> 00:19:47.750
But there's more included now about those SGLT2 inhibitors.
472
00:19:47.830 --> 00:19:50.510
Regardless of patients who have diabetes or not,
473
00:19:51.190 --> 00:19:55.170
there are recommendations about using Dapagliflozin.
474
00:19:55.170 --> 00:19:56.330
I'm probably not saying that right.
475
00:19:56.450 --> 00:19:57.930
I'm gonna include it down below,
476
00:19:58.010 --> 00:19:59.650
some links in the guidelines as well.
477
00:19:59.930 --> 00:20:02.090
But that's definitely a consideration for patients
478
00:20:02.090 --> 00:20:04.750
who have heart failure both reduced and preserved.
479
00:20:05.350 --> 00:20:08.630
And then they also, we wanna think about
480
00:20:08.630 --> 00:20:11.270
a mineralicoid receptor antagonist.
481
00:20:11.270 --> 00:20:14.210
So spironolactone, aplanonone,
482
00:20:14.570 --> 00:20:17.090
those are also diuretics,
483
00:20:17.150 --> 00:20:19.610
but those are more linked to the reduction of,
484
00:20:19.930 --> 00:20:22.090
or like prolongation, reduction of mortality,
485
00:20:22.830 --> 00:20:23.830
prolongation of life.
486
00:20:24.370 --> 00:20:27.450
From there, there's like a whole other host of things.
487
00:20:27.790 --> 00:20:30.030
But really, that's just like a snapshot overview
488
00:20:30.030 --> 00:20:33.390
of like there is a cocktail of medications,
489
00:20:34.330 --> 00:20:38.670
guideline-directed medical therapy, GDMT,
490
00:20:39.230 --> 00:20:41.250
that patients should be on depending on their stage
491
00:20:41.250 --> 00:20:42.830
and their classes and all of that.
492
00:20:43.090 --> 00:20:44.610
So definitely take a peek at that
493
00:20:44.610 --> 00:20:47.310
in conjunction with the notes from cardiology.
494
00:20:47.690 --> 00:20:51.330
And then your next steps are really kind of
495
00:20:51.330 --> 00:20:53.190
seeing if they've ever seen cardiology, right?
496
00:20:53.230 --> 00:20:55.310
So if this is an established diagnosis,
497
00:20:55.450 --> 00:20:57.970
they should have seen somebody from cardiology before
498
00:20:57.970 --> 00:21:00.490
and they should have some guidance from them
499
00:21:00.490 --> 00:21:03.790
about when to follow up and further adjustments.
500
00:21:03.930 --> 00:21:06.550
I really work collaboratively with my cardiologists
501
00:21:06.550 --> 00:21:08.710
in that work with my patients
502
00:21:08.710 --> 00:21:13.170
because it's really high risk for patients.
503
00:21:14.130 --> 00:21:17.210
And I think the other bottom line for real world practice
504
00:21:17.210 --> 00:21:20.210
is that in primary care, we only get 15 minutes
505
00:21:20.210 --> 00:21:21.930
and there are a whole bunch of tests.
506
00:21:21.950 --> 00:21:23.330
There's a whole bunch of education.
507
00:21:23.550 --> 00:21:26.130
There are a whole bunch of all these different things
508
00:21:26.130 --> 00:21:28.890
to be thinking about, as well as guideline updates
509
00:21:28.890 --> 00:21:30.790
and new studies and new medications
510
00:21:30.790 --> 00:21:32.970
and all of this stuff that really should be
511
00:21:32.970 --> 00:21:34.310
in the hands of cardiology.
512
00:21:34.510 --> 00:21:36.890
Like we can absolutely continue them in primary care,
513
00:21:36.890 --> 00:21:39.430
but I'm definitely a stand for us to get the support
514
00:21:39.430 --> 00:21:41.590
that we need to give the best care to our patients.
515
00:21:43.250 --> 00:21:45.350
And there's so much to be offered
516
00:21:45.350 --> 00:21:47.230
when we can co-manage patients.
517
00:21:47.610 --> 00:21:49.490
And I didn't talk about all of the medicines
518
00:21:49.490 --> 00:21:50.410
and heart failure.
519
00:21:50.470 --> 00:21:52.090
Like I said, that's a huge topic,
520
00:21:52.330 --> 00:21:54.610
but hopefully this is a helpful primer for you
521
00:21:54.610 --> 00:21:56.050
to feel more comfortable
522
00:21:56.050 --> 00:21:58.130
walking into those heart failure visits.
523
00:21:58.650 --> 00:22:00.830
So thank you so much for watching.
524
00:22:01.190 --> 00:22:02.850
If you haven't grabbed the ultimate resource guide
525
00:22:02.850 --> 00:22:03.830
for the new NP,
526
00:22:03.990 --> 00:22:06.490
head over to realworldnp.com slash guide.
527
00:22:06.490 --> 00:22:08.830
You'll get these episodes sent straight to your inbox
528
00:22:08.830 --> 00:22:10.170
every week with notes from me,
529
00:22:10.410 --> 00:22:11.530
patients' stories and bonuses
530
00:22:11.530 --> 00:22:13.290
I really just don't share anywhere else.
531
00:22:13.590 --> 00:22:15.250
Thank you so much for tuning in.
532
00:22:15.370 --> 00:22:16.310
I'll talk to you soon.
533
00:22:18.610 --> 00:22:20.210
That's our episode for today.
534
00:22:20.370 --> 00:22:22.150
Thank you so much for listening.
535
00:22:22.450 --> 00:22:24.890
Make sure you subscribe, leave a review
536
00:22:24.890 --> 00:22:26.770
and tell all your NP friends
537
00:22:26.770 --> 00:22:29.730
so together we can help as many nurse practitioners
538
00:22:29.730 --> 00:22:32.490
as possible give the best care to their patients.
539
00:22:32.810 --> 00:22:34.390
If you haven't gotten your copy
540
00:22:34.390 --> 00:22:35.870
of the ultimate resource guide
541
00:22:35.870 --> 00:22:37.010
for the new NP,
542
00:22:37.390 --> 00:22:40.510
head over to realworldnp.com slash guide.
543
00:22:40.930 --> 00:22:43.410
You'll get these episodes sent straight to your inbox
544
00:22:43.410 --> 00:22:45.530
every week with notes from me,
545
00:22:45.910 --> 00:22:47.610
patients' stories and extra bonuses
546
00:22:47.610 --> 00:22:49.770
I really just don't share anywhere else.
547
00:22:50.150 --> 00:22:51.710
Thank you so much again for listening.
548
00:22:51.950 --> 00:22:53.110
Take care and talk soon.

Podcast

Liz Rohr