How to manage Congestive Heart Failure (CHF) in a long-term care setting?

Managing Congestive Heart Failure in Long-Term Care Settings

Heart failure management in skilled nursing facilities requires tailored pharmacological therapy based on patient goals (rehabilitation, uncertain prognosis, or long-term care), combined with multidisciplinary disease management programs that include intensive patient education, daily monitoring, and systematic medication optimization. 1

Initial Assessment and Goal Clarification

Determine the patient's admission category immediately upon SNF entry, as this fundamentally shapes the treatment approach: 1

• Rehabilitation group: Patients expected to recover and return home
• Uncertain prognosis group: Patients whose trajectory is unclear
• Long-term group: Patients expected to remain in the SNF until death

Assess left ventricular ejection fraction (LVEF) in all rehabilitation and uncertain prognosis patients; individualize this decision for long-term residents based on how results will change management. 1

Recognize that approximately 70% of SNF residents with heart failure have ≥3 non-cardiac comorbidities, and 40% have ≥5 comorbidities, which significantly impacts medication tolerance and prognosis. 1

Pharmacological Management by Patient Category

For Heart Failure with Reduced Ejection Fraction (HFrEF)

Diuretics to achieve euvolemia are indicated for ALL patient groups regardless of goals of care. 1

ACE inhibitors or ARBs: 1

• Rehabilitation group: Yes, with individualized titration while avoiding low systolic blood pressure
• Uncertain prognosis group: Yes, but low-dose preferable to avoid hypotension
• Long-term group: Yes, but low-dose preferable to avoid hypotension

Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol only): 1

• Use in all three groups for HFrEF as tolerated by blood pressure, heart rate, and fatigue
• Critical caveat: No data exist for patients ≥80 years or those living in SNFs, yet guidelines still recommend use 1
• Data support improved function and reduced symptoms long-term, but tolerance must be carefully monitored 1

Mineralocorticoid receptor antagonists (spironolactone/eplerenone): 1

• Indicated for HFrEF NYHA class II-IV in all three patient groups
• Absolute contraindication: eGFR <30 mL/min/1.73 m² 1
• Important limitation: Only 20% of real-world octogenarians would have been eligible for the landmark RALES trial; no patients ≥91 years or from SNFs were included 1

Digoxin: 1

• Use only if symptomatic despite ACEI/ARB, beta-blocker, and mineralocorticoid receptor antagonist
• Dose restriction critical: ≤0.125 mg/day in all patient groups 1

Hydralazine-nitrate combination: 1

• For self-identified Black patients with HFrEF already on ACEI/ARB, beta-blocker, and mineralocorticoid receptor antagonist
• Also use when ACEIs/ARBs are contraindicated or not tolerated in any patient 1

Sodium and Fluid Management

Sodium restriction should be individualized for all patient groups rather than universally applied. 1

Fluid restriction for hyponatremia has uncertain benefit and should not be routinely prescribed. 1 Evidence shows fluid restriction only modestly improves hyponatremia and has limited-to-no effect on clinical outcomes or diuretic use. 1

Device Therapy Considerations

Implantable cardioverter-defibrillators (ICDs): 1

• Rehabilitation group: Consider if stable on optimized medications for 3 months, LVEF ≤35%, NYHA class II-III, and expected survival ≥12 months
• Uncertain prognosis group: Observe until recovery seems likely
• Long-term group: Not indicated

Cardiac resynchronization therapy (CRT): 1

• Rehabilitation group: Consider if persistent symptoms despite 3 months optimized medications, LBBB with LVEF ≤35%, QRS ≥150 ms, and NYHA class II-IV
• Uncertain prognosis and long-term groups: Not indicated

Managing Decompensation in the SNF

Recognize decompensation through weight gain, worsened symptoms (fatigue, dyspnea), or functional decline—but understand that cognitive impairment and sedentary lifestyles complicate symptom detection. 1

For stable vital signs, initiate diuresis in the SNF with oral or intravenous diuretics rather than automatic hospitalization. 1

Hospitalization decisions should be guided by: 1

• Rehabilitation potential and overall status
• Goals of care discussions
• Response to initial SNF-based diuresis

Patients with moderate-to-severe dementia and HF decompensation may have life expectancy <1 year, which should inform treatment intensity. 1

Implementation Through Multidisciplinary Disease Management

Passive guideline dissemination and basic provider education alone are ineffective and should never be the sole implementation strategy. 1

Effective implementation requires multifactorial interventions: 1

• Intensive educational and behavioral interventions for staff, patients, and caregivers (Class I recommendation) 1
• Chart audit with feedback of results 1
• Reminder systems for specific medications or tests 1
• Clinical decision support tools 1
• Engagement of local HF experts 1

Disease management programs reduce hospitalization frequency and improve quality of life, particularly for high-risk patients. 1 These programs should include:

• Intensive patient education about self-care 1
• Daily monitoring of weight, symptoms, and volume status 1
• Systematic medication review for guideline adherence 1
• Nurse case management directed by a physician 1

End-of-Life and Palliative Care Integration

Discuss goals of care and end-of-life preferences at SNF admission and whenever health status changes (Class I recommendation). 1

Continue HFrEF medications and volume management until limited by decreased oral intake, inability to swallow, or hypotension (Class I recommendation). 1 Maintenance of euvolemia and continuation of neurohormonal therapies (ACEIs, beta-blockers) palliate HF symptoms even at end of life. 1

For device deactivation preferences, include this in advance care planning discussions, informing patients about the distinction between ICD shock therapy versus pacing. 1

Assess and manage symptoms (dyspnea, pain, fatigue, weakness) throughout the HF course using patient self-rating rather than observation alone. 1 Small studies show opioids are safe and effective for dyspnea in advanced HF. 1

Critical regulatory consideration: Medicare regulations prohibit simultaneous enrollment in Medicare hospice benefit while receiving Medicare SNF payment—patients must be in non-Medicare-reimbursed beds (private pay) to receive hospice in a SNF. 1

Common Pitfalls to Avoid

Do not convert patients on non-evidence-based beta-blockers to carvedilol, metoprolol succinate, or bisoprolol without careful monitoring, as these are the only guideline-recommended agents for systolic HF. 1

Avoid polypharmacy complications by systematically reviewing for drug-drug and drug-disease interactions, particularly important since SNFs bear medication costs on Medicare-reimbursed units. 1

Do not rely on absence of symptoms at rest to indicate stable HF status—cognitive impairment affects symptom reporting capacity and sedentary lifestyles mask functional limitations. 1

Never use long-term continuous or intermittent intravenous inotropic agents outside of bridge-to-transplant, bridge-to-MCS, or palliative care contexts—this is potentially harmful (Class III: Harm recommendation). 1

Recognize that frailty strongly correlates with HF and confounds both patient assessment and medication tolerance, requiring more cautious dosing strategies. 1