Bedside Teaching

Teaching Heart Failure in the Clinical Setting

The following teaching pearls are used by SHM members to teach heart failure management to residents and students. Submit your own to: heartfailure@hospitalmedicine.org.

“It is crucial to emphasize the importance of a complete history and physical examination. For every patient who presents with signs or symptoms of heart failure, I make sure the trainee performs and reports a thorough evaluation to determine the underlying etiology of cardiac abnormality and to identify the precipitating factors of heart failure. The most specific symptoms and signs of heart failure are paroxysmal nocturnal dyspnea, orthopnea, increased JVP, and a third heart sound. However it is important to remember that some patients, especially the elderly, can present with nonspecific symptoms such as fatigue, decreased appetite, and edema.
On rounds I discuss the key elements of the management of the heart failure patient with my team. Then I guide them to identify and correct the precipitating causes for the decompensated heart failure such as:

Non-cardiac causes: excess salt intake, infection, COPD/asthma exacerbation, thromboembolism, high output states (anemia, hyperthyroidism), worsening renal failure, substance abuse (especially alcohol or cocaine), medication nonadherence, and NSAID use.

Cardiac causes: Myocardial ischemia or infarction, uncontrolled HTN, worsening valvular disease, or arrhythmia (rapid atrial fibrillation, ventricular tachycardia).

If aggravating factors cannot be identified, at the very least, pharmacological therapies should be optimized.

Patient education is the most important part of the management. Patients and their families should receive counseling to increase their understanding of heart failure and medication-related side effects. I encourage housestaff to consult with PT/OT, nutrition, pharmacy, social services not at the time of discharge, but early during the admission. We also attempt to communicate with the primary care provider to arrange close outpatient follow-up. This communication and groundwork encourages the patient to help detect and report early signs or symptoms of volume overload or clinical deterioration.”

-Nurcan Ilksoy, MD
Hospitalist, Grady Memorial Hospital
Emory University School of Medicine