Heart Disease

1. Does the patient have symptoms and signs of congestive heart failure at rest?

SYMPTOMS

SIGNS

____ dyspnea at rest: 'short-winded,' 'can't breathe'

____ dyspnea on exertion: 'can't breathe with exercise'

____ orthopnea: 'can't breathe lying down'

____ paroxysmal nocturnal dyspnea (PND):
'waking up at night, short of breath'

____ edema: 'swollen ankles, legs'

____ syncope

____ weakness

____ chest pain

____ diaphoresis: sweating

____ cachexia: profound weight loss

____ jugulovenous distension (JVD)

____ neck veins distended above clavicle

____ rales: wet crackles in lungs heard on inspiration

____ gallop rhythm: S3, S4

____ liver enlargement

____ edema, pitting edema

2. Has the physician verified that the patient is on optimal diuretic and vasodilator therapy?

Diuretics (patient should be on optimal dose of one of the following)

_____ Furosemide (Lasix)
_____ Ethacrynic Acid (Edecrin)
_____ Bumetanide (Bumex)
_____ Torsemide (Demedex)
_____ Metolazone (Zarloxlyn, Mykrox)

(may be combined with the above, but not used alone)

Vasodilators (patient should be on optimal dose of one of the following)

A. Nitrates (e.g. Nitro patch, Isosorbide) plus Hydralazine _____
B. Apresoline Anglotensin Converting Enzyme (ACE) Inhibitor:

_____ Benazepril
_____ Lisinopril (Prinvil, Zestril)
_____ Captopril (Capoten)
_____ Quinapril (Accupril)
_____ Enalapril (Vasotec)
_____ Ramipril (Altace)
_____ Fosinopril (Monopril)

3. Does the patient have ejection fraction of < 20% (only if test results available)?

4. The following factors are further indications of decreased survival time.

_____ symptomatic supraventricular or ventricular arrhythmias resistant to antiarrhythmic therapy
_____ history of cardiac arrest and resuscitation in any setting
_____ history of syncope of any cause, cardiac or otherwise
_____ cardiogenic brain embolism, i.e. embolic CVA of cardiac origin
_____ concomitant HIV disease

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