. GUIDELINE MEDICATIONS FOR HFrEF AND HFpEF Queens 5 &'()*#+),'$% !,'+-#)'()*#+),'$% !"#$$% Acute Heart Failure Management Guidelines Card ./-0/%%1230/%4%5678% ./90/%%1230/%:;678% ! 1. DECONGEST WITH LOOP IV DIURETIC "##!$%&!'()*!+,-!./0!**!1234156! "M+!/0!&;0<=?!+@!><;08&<&A!".%80!+@!><;08&<&-! M!I!OAJ! ! HEF!I!14J!:.%80!8;K/#8L<9!'()*!+,! a c. e. %8&%308%8&%!#/B!>/&8!C!D8?<=!;$%<%0:%8L:!'"(R+,! . Use 2x home dose IV bid with Target 2-3L daily urine output IF weight not decreasing /0!(0!"-!G/#>308>;98!><;08%<9!C!08%8&%! P/#>!./0!:=8&%G8&<:!C!>S8!&%;><8&! rapid escalation if not responding or 2-5 lbs daily weight loss as by 2lbs/day, add thiazide "M+!/0!&!(#:&&!U34!$%&! d. <=?&% "(R+!B<%G<=!4V!G0&! d!aily-> 40mg IV furosemide BID) Use standing daily weights ; or loop diuretics BID/TID/drip '()*!+,!./0!:>><%8L:! (/=&<>80!G/#>308>;98!><;08%<9!./0!%8&%!>/&8! A!"##$%&'(()&*+,'#&-.+/*&01+2&34564-%&7847&&dmission labs, BN P, Q8 -12 lytes; accurate ins and outs P/#>!./0!:=8&%G8&<:!C!>S8!&%;><8&! k&eep K> 4.0 (add aldo blocker early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a3_!:#>/!D#/9W80!'()*!+,!./0!!!!!! +=%/#80:=98! =>B!@/<0$%1.!F'+>@.B<>'1!0/%$-2!56!$HI! .H(-#"#I)'EF')+-#+E$! **!X434456!8&$A!<=!E#:9W&A! 7=W=/B=! 7&8!9:;%AA1.DB!'/!H-./012$%1L!'/.012$%1L!#-21'><$%1!/.! "#%80=:%@.B<$@!>@$%G! '+$>M$%1!N$J1J!><>O+BA>?$0L!.>0+L!$'@+$.$>PQ!RSK!>!0-AH>! 9/=%0:<=><9:%8>-!@.B<>'1!0/%$-2!! >AA1.DB!+$-! ()*!b!"((3"P"!(#:&&!/.!*89/LL8=>:%80:%8-!!++D!b!d8:W!!'BBBA:99A/0?,! )J!R7SL!@/<'.>$<%!'/!1<'1.>A!>@@100!/.!T5!2>A>#0/.O'$/;9%!%/!%:0?8%!>/&8!'L8><;L!%/!G/&8-!8Q98$%!:#>/! D#/9W80&!:%!#/B!>/&8,A!(:;%!:&!/;%_$:%<8=%-!L/08!&#/B#S!./0!D8%:_D#/9W80&-!:=>!:&!%/#80:%8>A! ;J!U+>$.!/H!=1%$@$<1!>OO./:>A!.1(-$.1%!O.$/.!'/!$<$'$>'$/&-!L/&%!:=%<_:00GS%GL<9&!'/%G80!%G:=!:L:0/=8,-!$<#%<:T8L!C!K80:$:L<#! F(-$:>A1<'!%/0$<$%1!42D!N56G7SP!V!K/.012$%1!)32D!V!F'+>@.B<$@!>@$%!E32D! . DISCHARGE PLANNING: (Provider & Care Coordination) *M;CN;O>P&Q9=&@9HF;EC?;9E&O;<=>?;@&.R&GHIJ& 6 T$:1!;3!2$<-'10!#1H/.1!56!A//O!%$-.1'$@! a. Hospital day 1-2: =1'/A>M/<1! ! )JE&43! =>?!.1@/221<%1%!%>$AB!%/01!)3!2D!! =/<$'/.!H/.!+BO/W>A12$>! • Identify Outpatient Follow-up Providers XB%./@+A/./'+$>M$%1! ! )E! =/<$'/.!H/.!+BO/W>A12$>!N2>?$2-2!%/01!4332D!%>$ABP! • Mobilize OOB early; order PT/OT ! • Identify high risk patients at interdisciplinary rounds 2. WORK UP DECOMPENSATION - Identify High Risk Care Team (Outpatient MD, Care Transition Provider, Care Manager) Identify Special Needs: a. d. f. - b. Review recent TTE or perform e. Ischemia evaluation, myocarditis workup Other (diet, alcohol, • home care services • home meals • home IV infusion • outpt IV therapies c. Telemetry for arrhythmia r/o co-morbidity ie ,infection, PE, TFTs, NSAIDS, meds, b. Patient Education on Heart Failure: Consider pace r/ICD interrogation HIV and OSA Utox, etc.) . CONSIDER CARDIOLOGY CONSULT AND/OR HEART FAILURE OUTPATIENT REFERRAL NYP CHF education booklet available on infonet Low Na diet and special combo diets 3 • • a. e. j. https://infonet.nyp.org/PatientED/Pages/Resources.aspx • Fluid restriction CHF readmission Persistent elevated troponin Intolerance or down titration b. f. Daily AM weights & call MD for gain of 2 lbs in 2d Medications SBP <100 or syncope g. No weight change 48 hours k. neurohormonal blockade • • c. or 5 lbs in a wk Hypope rfusion: Cr >1.8 h. EF <35% Pre-discharge pro-BNP >4,000, or or increase bLy 25%, Difficult to manage or l. B NP >700, trigger HF outpatient referral c. Discharge Ready rising LFTs, MS, cool i. atypical HFpEF m. HFr EF w/LBBB, QRS >150, or RV paced Age <50 Appropriate ICD shock d. extremities or inotrope • Off inotropes for 24h (or d/c on inotropes) • Repeat BNP 24 hours prior to d/c Na <130 • Out of bed, ambulating if able • 7-10 days follow-up appt scheduled Cardiology Consult: 718-661-8154 d. Discharge Summary must include: Advanced Heart Failure Outpatient: Weill Cornell 212-746-2381 • Admission and Discharge Data: • Target weight . CONSIDER HEART FAILURE CONSULT OR TRANSFER 4 wt, exam, Cr, BNP, diuretic doses • Med titration instructions a. d. f. Follow-up appointment with transition provider in 7-10 days. Include specific date, time, b. ≥2 of above criteria listed in #3 EF <20% or recent inotrope >2 admissions in 6mo • Persistent shock: SBP <90, Cardiac e. (outpatient, if stable) g. for medical reasons location and phone number. c. Index <2, or cold extremities or inotropes Mod PH: PASP >50 (or if Complicated valvular or Challenging atrial/ventricular SBP <90 then >40mmhg) congenital heart disease arrhythmias or mPAP >35 Heart Failure Consult: 929-362-9987 (NP/Fellow) Outpatient Referral Line for Advanced Heart Failure Clinic: Inpatient Heart Failure Transfer via Cardiology Fellow: 718-661-8154 (M-F, 9am– 5pm) Weill Cornell: 212-746-2381 Transfer Center: 1-800-NYP-STAT

V1 10/2017 DRIP MEDICATIONS

Concentration Line Bolus Typical Starting Rate Maximum Infusion Rate Special Comments

Diuretics 25 mg/100 mL NS Doses 0.5-2 mg IVP over 2-3 min Soft: 1 mg/h Bumetanide (0.25 mg/mL) Peripheral 0.1 mg/h None Doses > 2 mg via IVPB Hard: 2 mg/h

чϭϬϬŵŐ IVP over 2-5 min 100 mg/100 mL NS Soft: 20 mg/h Furosemide Peripheral (no faster than 20 mg/min) 1-5 mg/h None (1 mg/mL) Hard: 40 mg/h Doses > 100 mg via IVPB

Other drip medications 250 mg/250 mL Non-Intensive Areas: (1 mg/mL) Monitor BP, HR at initiation or dosage change: every Dobutamine Peripheral (large vein) None 2.5-5 microgram/kg/min Soft: 10 mcg/kg/min 500 mg/250 mL 15 min x 1 h, every 30 min x 2 h, then every 4 h

(2 mg/mL)

Non-Intensive Areas: 200 mg/250 mL Soft: 5 mcg/kg/min (0.8 mg/mL) Central Line Only Intensive Areas: Dopamine 400 mg/ 250 mL Peripheral None 0.5-5 microgram/kg/min Monitor BP, HR at initiation or dosage change: every Soft: 20 mcg/kg/min 15 min x 1 h, every 30 min x 2 h, then every 4 h Titrate available: 1-3 (1.6 mg/mL) mcg/kg/min q 5 min

NYP/Q: ICU only 20 mg/100 mL 12.5-50 microgram/kg IVP over 0.125 Soft: 0.5 mcg/kg/min Milrinone (200 microgram/mL) Peripheral 10 min (generally avoid) microgram/kg/min Hard: 0.75 mcg/kg/min Caution with renal dysfunction Monitor BP, HR at initiation or dosage change: q 15 min x 1 h, q 30 min x 2 h, then q 6h NYP/Q: ICU only

Monitor BP every 15 min x 4 upon initiation & after 1500 mcg/250 mL NS 2 microgram/kg IVP over 60 sec 0.005 - 0.01 Nesiritide Peripheral Hard: 0.03 mcg/kg/min every dose change. (6 microgram/mL) (generally avoid) microgram/kg/min An MD, NP, or PA must be present the first hour after initiation and during every dosage change; then monitor per nursing unit protocol.

Non-Intensive Areas: 100 mg/250 mL Soft: 100 mcg/min Nitroglycerin Peripheral 5-50 microgram/min None (0.4 mg/mL) Intensive Areas: Soft: 200 mcg/min

*Use concentrations listed above, Allscripts ordering system has multiple options that are not available at NYP/Queens.