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2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 1

CHF: A Clinical and Coding Perspective

Carla A. Sueta, MD, PhD, FACCProfessor of MedicineMedical Director, UNC Heart Center at MeadowmontUNC Center for Heart & Vascular CareUniversity of North Carolina at Chapel Hill

Garry L. Huff, MD, CCS, CCDSPresident/CEOHuff DRG Review Services, Eads, Tenn.

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Learning Objectives

Define heart failure stages, etiologies, and related altered anatomy

Recognize heart failure and types through documented physical exam and symptomsdocumented physical exam and symptoms in the health record

Apply coding guidance to clinical scenarios Formulate compliant physician queries to

clarify types of severity of heart failure

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Heart Failure Overview

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2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 2

Conflicts

None

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Outline

Definition Stages Etiologies Anatomy Anatomy Symptoms, physical exam Types (systolic, diastolic) Diagnosing acute heart failure Treatment

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Heart Failure Definition

Heart failure is a clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill (preserved EF/diastolic HF) or eject (systolic HF) blood.

The cardinal manifestations are dyspnea and fatigue, which may limit exercise tolerance,and fluid retention, which may lead to pulmonary congestion and peripheral edema.

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Hunt SA, et al. Circulation 2005;112:18251852.

Structural heart dz

High riskHypertensionAtherosclerotic dzDiabetes. Obesity,

Stage B

Stage A

Heart Failure Stages

Structural heart dz(-) Symptoms

Hx MILV systolic dysfunctionAsx valvular dz

Structural dz(+) SymptomsSOB, fatigue

End-stageNYHA INYHA II-III

NYHA IV

metabolic syndromeFH cardiomyopathyUsing cardiotoxins

Stage C

Stage D

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Patients at Risk forDeveloping Heart Failure Stage A

Hypertension Atherosclerotic disease Diabetes mellitus Obesity, metabolic syndrome Family history of cardiomyopathy Using cardiotoxins

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Structural Heart DiseaseBut No Symptoms Stage B

Previous MI LV remodeling including LVH, low EF Asymptomatic valvular disease

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Development ofDevelopment ofDevelopment of Symptoms

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Development ofSymptoms Stage C End-Stage HF

Marked symptoms at rest despite maximal medical therapy

Stage D

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2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 4

75% have a history of hypertensiony yp

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Etiologies of HF

Nonischemic Causes (1/31/2) Hypertension Cardiomyopathies

- Dilated Idiopathic Chemotherapy

Coronary ArteryDisease (1/22/3) Hx of MI CAD

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Chemotherapy Alcohol Cocaine Myocarditis Postpartum

- Hypertrophic- Restrictive

Amyloid, sarcoid Hemochromatosis

Valvular disease Thyroid Congenital/shunts

Types of Cardiomyopathies

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http://www.daviddarling.info/encyclopedia/C/cardiomyopathy.html

Anatomic Definitions

Left (most common)Systolic and diastolicDiastolic only

Right due to left (combined)g ( ) Cor pulmonale (right-sided only)

Emphysema/COPD/obstructive sleep apneaPulmonary hypertension

Primary pulmonary hypertension Thromboembolic disease

Congenital heart disease with shunting16

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The Pathway of Blood Flow Through the Heart

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Symptoms and Physical Exam

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Symptoms and Physical Exam

Symptoms Dyspnea at rest or exertion Reduced exercise capacity Orthopnea PND, cough Edema

Less specific Sx Early satiety Nausea, vomiting, abdominal

discomfort Wheezing or cough FatigueEdema

Chest pain or equivalent

Signs BP, HR, dry wt, wt change Jugular venous pressure Rales, wheezes Displaced PMI, RV heave, murmurs, S3 Hepatomegaly, ascites, hepatojugular

reflux Peripheral edema, scrotal edema

g Confusion/delirium

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Define Heart Failure Type

Systolic (EF) and preserved EF heart failure can present with the same Sx and signs:

Dyspnea on exertion, orthopnea Paroxysmal nocturnal dyspnea Pulmonary edema Jugular venous distension Rales S3, S4 Peripheral edema CARDIOMEGALY

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2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 6

Types of Heart Failure

Diastolic Heart FailureHFPEF

Systolic Heart FailureHFREFNormal

Thecafetechno.com21

Systolic vs. HF With PreservedEF (HFPEF) Heart Failure

Acute Chronic Acute on chronic

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Diagnostic Criteria:HF With Reduced vs. HF With Preserved EF

Clinical evidence of HF: Clear clinical presentation of HFor Framingham or Boston criteria

If uncertain:Plasma BNP or chest x-ray or cardiopulmonary exercise testing

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or cardiopulmonary exercise testing

Supportive evidence:

Eccentric LVH or remodeling

Supportive evidence:

Concentric LVH or remodeling

Left atrial enlargement in absence of AF

Echo Doppler or catheter evidence of diastolic dysfunctionExclusions: Non-myocardial disease

Exclusions: Non-myocardial diseaseAdapted from Yturralde FR. Prog Cardiovasc Dis 2005;47:31419

Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194

LVEF < 50% LVEF 50%

Heart Failure With Normal LVEF

*Hypertension*CADRestrictive cardiomyopathyInfiltrative cardiomyopathyHypertrophic cardiomyopathy

Adapted from Oh JK, et al. J Am Coll Cardiol 2006; 47:500. 12

Noncompaction cardiomyopathy*Valvular disease (severe valvular stenosis or regurgitation)Right heart failure (severe pulmonary hypertension, ASD,

RV infarct, arrhythmogenic right ventricular dysplasia)Pericardial disease (cardiac tamponade, constrictive pericarditis)Intracardiac mass (atrial myxoma)Pulmonary vein stenosisCongenital heart disease

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Acute Heart Failure

Symptoms Signs CXR Echo Echo Labs Treatment (e.g., intravenous furosemide)

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Framingham Criteria: 2 major or 1 major + 2 minor

PND Orthopnea

Peripheral edema Dyspnea on exertion

Major Criteria Minor Criteria

JVP Rales S3 CXR cardiomegaly CXR pulmonary edema

Hematomegaly Pleural effusion HR > 120 Weight loss > 4.5 kg/5

days with diuretic

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Chest X-ray

Cardiomegaly Pulmonary congestion or redistribution Pleural effusions most often bilateral Interstitial edema Interstitial edema Pulmonary edema

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Echocardiography

Ejection fraction(reduced/systolic vs. preserved/diastolic)

Valvular diseaseValvular disease

Diastolic dysfunction Diastolic HF(symptoms and supportive evidence must be present)

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Labs

Elevated (pro) BNP Elevated troponin Hyponatremia

El t d li f ti t t (AST ALT Elevated liver function tests (AST, ALT, alkaline phosphatase, bilirubin)

Hypoxemia (low O2 saturation)

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Systolic Heart Failure Rx

Medication/Device Mortality

Diuretic (furosemide, metolazone) No

ACE-I (lisinopril, enalapril, ramipril, captopril) Yes

ARB (losartan, candesartan, valsaratan) Yes

Beta blocker (metoprolol, carvedilol, bisoprolol) YesAldosterone antagonist (spironolactone, eplerenone) Yes

Digoxin No

Nitrate (isordil) + hydralazine Yes

ICD (EF< 35%) YesCRT (biventricular pacemaker) Yes

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HFpEFRx Underlying Risk Factors, ComorbiditiesHTN, CAD, DM, Obesity, CKD

Congestion

Diuretics

BP

ACE-I

Tachycardia

B-blockers Salt diet ARB

CCB B-blockers Nitrates

Verapamil Diltiazem Control Afib

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ACE-I/ARB: CVD, DM BB: Hx MI, HTN, AfibCCB: angina, Afib, HTN

Congestive Heart Failure: Breaking the Code!

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2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 9

Heart