MANAGEMENT OF HEART FAILURE

Pharmacological treatment designed to:

• Improve symptoms (diuretics, ACE inhibitors, digoxin)
  
• Improve prognosis (ACE inhibitors, ß-blockers, Spironolactone, Nitrates +hydrallazine)

STEPWISE MANAGEMENT OF HEART FAILURE

You need to follow these steps sequentially in all patients. Please note the use of spironalactone and beta-blockers varies according to NYHA classification. Please select appropriate option(s).

Other factors to consider include:

• In patients with atrial fibrillation, consider warfarin (or aspirin), referral for cardioversion and ensure adequate rate control.
  
• In patients with known or suspectedcoronary artery disease, start aspirin and a statin if indicated & referral for consideration of revascularisation (e.g. history of angina, ECG evidence of previous MI or echo evidence of regional wall motion abnormalities, or strong family history of ischaemic heart disease at young age) in patients without medical conditions which themselves would preclude revascularisation.
  
• NB If recent MI start ACEI while echo awaited (unless clear contraindication).
  
• In patients truly intolerant of ACE-inhibitor, or with significant renal impairment (>200mmol/l), start Hydrallazine (start with 25mg QDS and increase to max 75mg QDS) and high dose nitrates. Although evidence is beginning to suggest that Angiotensin II receptor blockers (ACE2 inhibitor) may be as effective as ACE-inhibitor (and may have additional benefits if added to ACE-inhibitors) ACE2 inhibitors remain unlicensed for use in heart failure.
  
• Control Hypertension (aim <140/85 in non-diabetics and <140/80 in diabetics - BHS guidelines).
  (British Hypertension Society: www.hyp.ac.uk/bhs).

Contraindications to ACE-inhibitor therapy

• Aortic stenosis or other LV outflow obstruction
  
• Renal artery stenosis
  
• Renal impairment with creatinine ³ 200mmol/l
  
• Genuine intolerance to ACEI

Starting ACE inhibitors in heart failure

• Measure BP and check renal function and electrolytes
  
• Stop K+ supplements and Amiloride (Spironolactone may be continued)
  
• Omit or reduce diuretic from 12 to 24 hours before first dose if possible
  
• Advise patient to sit or lie down for 2 to 4 hours after first dose or take first dose after going to bed
  
• Start with low dose
  
• Review after 1 week to reassess symptoms, BP and check renal function and electrolytes
  
• Increase dose unless there has been a significant rise in creatinine (­ more than 20%) or K+ (>5.5mmol/l)
  
• Titrate to maximum tolerated dose at 1 to 2 weekly intervals, reassessing BP and checking renal function and electrolytes after each dose titration
  
• When stable, monitor renal function and electrolytes 6 monthly unless clinical condition changes

High risk patients that need to be monitored at weekly intervals during ACEI titration include

• Severe heart failure (NYHA IV)
  
• High dose diuretic therapy that cannot be omitted for at least 12 hours
  
• Systolic blood pressure < 100mmHg
  
• Resting tachycardia (>100 beats/min)
  
• Serum Na+ < 130mmol/l or Serum K+ > 5mmol/l
  
• Severe peripheral vascular disease

If concerned re initiating therapy in any of these groups refer to secondary care

Recommended maintenance doses of ACE inhibitors:

Indications for b-blockers in heart failure (for NYHA 11-111)

• Already on treatment with diuretics and ACE-inhibitor (optimal dose ie maximum tolerated or target dose)
  
• Clinically stable (see below), mild to moderately symptomatic (NYHA II or III) heart failure
  
• Evidence of LV systolic dysfunction

Contraindications to b-blockers in heart failure

• Clinically unstable, i.e. treatment adjusted or an admission to hospital (cardiac) in the previous 2 months
  
• Severe symptoms (NYHA IV) - although emerging data may change this
  
• Asthma or other significant reversible airways obstruction
  
• Bradycardia <60 beats/min or heart block (2nd or 3rd degree unless paced)
  
• Systolic BP < 100mm Hg
  
• Known intolerance to b-blockers

Initiation of b-blockers in heart failure

• Only Carvedilol and Bisoprolol are licensed for use in heart failure in the UK.
  
• Start with low dose and increase slowly (see table). Patients may worsen initially, before subsequently improving, so check for symptoms of worsening heart failure or hypotension after each dose increase.
  
• Bisoprolol is currently cheaper and special packs are available with low dose tablets
  
• Transient worsening of heart failure, hypotension, and or sodium and water retention may be treated by adjusting dose of diuretics, reverting to previous dose of b-blocker or temporarily discontinuing b-blocker
  
• If therapy has to be discontinued for more than 2 weeks go back to starting dose again.

Bisoprolol dose schedule table:

This schedule may be modified to allow more gradual introduction and dose changes.

*** If you identify patients who you feel should be on a b blocker and are unhappy to start it yourself discuss with local cardiologist or refer to OPD ***

In patients with persistent salt and water retention on oral Frusemide and maximum tolerated doses of ACE-inhibitors and b-blockers, if indicated consider:

• Increased dose of Frusemide and review early: if no response adopt strategies below
  
• Combination of loop and Bendrofluazide (2.5 mg daily). Monitor response, renal function and electrolytes after 2 to 3 days.
  
• Combination of loop and Metolazone (start with 2.5 mg twice weekly). Monitor response, renal function and electrolytes after 2 to 3 days.
  
• Add Spironolactone 25mg or increase to 50mg if already on it, provided serum K+ < 5mmol/l. Monitor renal function and electrolytes after 1 week.
  
• Use intravenous Frusemide

If patients are not responding to these measures please refer to hospital

Non-pharmacological and lifestyle measures

Education and self-help strategies

• Reduce salt intake (avoid salt -rich foods and adding salt to food)
  
• Encourage exercise
  
• Alcohol in moderation is allowed but abstinence is essential in alcohol related heart failure
  
• Stop smoking
  
• Weight reduction if obese
  
• Nutritional advice if cachexic
  
• Vaccination (flu/pneumococcal)
  
• Contraceptive advice where appropriate
  
• Patients and their families need psychological support and optimal care will be time consuming

Suggested follow-up for patients with heart failure once stable on treatment:

• Mild (NYHA I and II): Review at 6 monthly intervals and monitor symptoms, weight, BP, renal function.
• Moderate to severe (NYHA III and IV): Review at 3 monthly intervals and monitor symptoms, weight, BP, renal function.
• Patients should be advised that if symptoms deteriorate then early review is essential (you will need to respond accordingly).