Indications for cardiological referral
The causes of heart failure, with particular respect to destabilizing factors, can be determined from a standard workup in the outpatient clinic, day hospital, or during hospitalization. Echocardiography, ergometry, 24-hour Holter monitoring, and specific therapeutic options such as revascularization and valvuloplasty all require specialist referral (Table I).
Mild or moderate heart failure: identification of underlying disease
Coronary artery disease
Identification of destabilizing factors: new-onset atrial fibrillation, increased angina, mitral regurgitation
Treatment: poor response or complications:
Failure to improve NYHA class despite therapy
Systolic blood pressure $90 mm Hg
Failure to respond to furosemide $75 mg/day
Indications for cardiological referral.
Indications for hospitalization
A number of clinical conditions in unstable patients are generally accepted indications for hospital admission (Table II). They mainly involve rapidly worsening new-onset symptoms, or severe deterioration in an already documented patient. In the first case, admission is indicated not only for therapy, but also for investigation and diagnosis. Arrhythmias represent another indication: syncope or symptomatic sustained arrhythmia needs monitoring and careful analysis.
Rapid new-onset heart failure Congestion and/or new-onset hypoperfusion Unstable heart failure
Acute pulmonary edema or severe dyspnea
Heart rate >120 bpm (without atrial fibrillation)
Blood pressure $75 mm Hg
Confusion due to cerebral hypoperfusion
Destabilization due to acute deterioration of extracardiac disease (eg, pulmonary or renal disease)
Another category comprises those conditions such as severe (New York Heart Association [NYHA] class IV) heart failure for which drug treatment (angiotensin-converting enzyme [ACE] inhibition or (i-blockade) is best initiated in hospital (Table III).
Furosemide dose >80 mg/day or equivalent
Systolic blood pressure $90 mm Hg
Hyponatremia (Na+<130 mEq/L) Hyperkalemia Possible hypovolemia Kidney failure (creatinine >3 mg/mL or creatinine clearance <30 mL/min) Severe mellitus diabetes associated with kidney disease Table III. Conditions indicating the initiation of ACE inhibition in the hospital setting. Indications for discharge Heart failure patients are fit for discharge once they have gained dry weight, have no orthopnea or edema, and can cope with activities of daily living. Clinical stability is assessed after observation for at least 24 hours: it assumes a stable dose of oral diuretic, and other drugs (including potassium supplementation), inotrope withdrawal for at least 48 hours, acceptable blood pressure, and an anticoagulant therapy program (where indicated), with the dose for the first days after discharge already decided. Joint follow-up by primary care physician and cardiologist must be scheduled for appropriate continuity of care. Weekly visits are useful for the first 3 to 4 weeks, not only to monitor stability, but also to tailor therapy, assess compliance with medication and lifestyle measures, and continue the health education of the patient and family. Clinical severity determines the length of cardiologist follow-up. Hambrecht R, Niebauer J, Fiehn E, Kalberer B, Offner B, Hauer K, Riede U, Schlierf G, Kubler W, Schuler G. Physical training in patients with stable chronic heart failure: effects on cardiorespiratory fitness and ultra-structural abnormalities of leg muscles. J Am Coll Cardiol. 1995;25:1239-1249 Homing B, Maier V, Drexler H. Physical training improves endothelial function in patients with chronic heart failure. Circulation. 1996;93:210-214. Hambrecht R, Fiehn E, Yu JT, Niebauer C, Weigl C, Hilbrich L, Adams V, Riede U, Schuler G. Effects of endurance training on mitochondrial ultrastructure and fiber type distrible chronic heart failure. J Am Coll Cardiol. 1997;29:1067-1073. Dubach P, Myers J Dziekan G, et al. Effect of exercise training on myocardial remodeling in patients with reduced left ventricular function after myocardial infarction: Application of maqnetic resonance imaqinq. Circulation. 1997;95:2060-2067. Keywords management; cardiological referral; destabilizing factor; hospitalization; drug treatment [gallery ids=""]