Management of Heart Failure Guidance by asafwewe


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									     Management of Heart Failure Guidance

                                                                                BNSSG Health Community

     Heart failure is often misdiagnosed. The cause of heart failure should always be
     established, and objective evidence of left ventricular dysfunction obtained.

               Suspected heart failure
         Because of history, symptoms and signs

     Seek to exclude heart failure through:                        Other recommended tests:
 •     12-lead ECG                                               (mostly to exclude other conditions)
 •     and/or natriuretic peptides (BNP or                 •   Chest X-ray
       NTproBNP) – where available                         •   Blood tests: U&E’s, creatinine, FBC,
                                                               TFTs, LFTs, glucose and lipids.
                                                           •   Urinalysis, peak flow or spirometry

                    Both normal -                                      One or more abnormal
            Heart failure unlikely consider
               alternative diagnosis.
                                                                   Imaging by echocardiography

          No abnormality detected                                              Abnormal
     Heart failure unlikely, but if diagnostic                 Assess heart failure severity, aetiology,
       doubt persists consider diastolic                        precipitating and exacerbating factors
     dysfunction and consider referral for                         and type of cardiac dysfunction.
             specialist assessment                             Correctable causes must be identified
                                                                            Consider referral

Treatment of heart failure:
Core Treatment
Diuretic       Usually loop diuretic (e.g. Frusemide 40-80mg). Add thiazide if unresponsive
               oedema (e.g. Bendrofluazide 2.5-5 mg)
ACE inhibitor* Indicated in all cases where LV dysfunction confirmed and in all post MI
               patients. Consider Angiotensin II blocker if intolerant
Beta Blocker   Bisoprolol or Carvedilol ensure dose titration

Additional recommended treatment
Digoxin         If in atrial fibrillation. Some with dilated hearts appear to benefit
                symptomatically in sinus rhythm
Aspirin         If in AF, consider cardioversion if new onset.
Spironolactone Routine use for Grade III/IV heart failure 25-50mg od
     •  Patients with HF should not be taking NSAIDS/Cox-2
     •  Patients with HF should be offered annual flu vaccination.
     *See algorithm for introduction of ACE inhibitor in CHD NSF Chapter 6; Heart Failure, Appendix A, p20
     NICE Guidance for HF 2003

     Page 1 of 2                                                                  Review date: November 2004
Management of Heart Failure Guidance

                                                                        BNSSG Health Community

Monitoring of clinical condition and U&Es frequently on initiation and titration of treatment and
at least six monthly when stable.

New York Heart Association Classification
  Class I:   No limitation. No fatigue dyspnoea or palpitations on physical exercise
  Class II: Slight limitation in physical activity. Comfortable at rest, but fatigue, palpitations
             or dyspnoea on exertion
  Class III: Marked limitation in physical activity, but comfortable at rest
   Class IV: Symptoms present at rest

Causes of heart failure:
Heart failure is not a complete diagnosis. Cause should always be investigated.
Cause               Diagnosis                             Comment
IHD                 History of MI or angina. ECG          Consider Exercise ECG value of
                    evidence of old MI. (Enter into       revascularisation to treat heart
                    secondary prevention pathway)         failure
                    Echo evidence of regional

Hypertension        History, evidence of LVH on ECG
                    or echo
Valve disease       Murmurs, echo evidence                Mild valvular regurgitation on echo
                                                          is common and often clinically
Cardiomyopathy      Diagnosis of exclusion, alcoholic     Alcoholic cardiomyopathy usually
                    heart failure usually included in     responds well to abstinence
                    this group
Viral myocarditis   Acute heart failure, may be           Can be fulminant, can reverse
                    prodromal illness                     completely
Metabolic           Thyroid disorder, acromegaly,         In theory, respond to treatment of
causes              phaeochromocytoma,                    underlying disorder
                    haemochromatosis, amyloid
Miscellaneous       Incessant tachycardia, post
                    radiation, tumour, infiltrative
                    conditions, pericardial disease
                    and restrictive cardiomyopathy
• Refer all cases who may benefit from surgery (significant valve or coronary artery disease) or
   biventricular pacemaker (HF, broad QRS, persistent symptoms)
•   Consider for admission cases with refractory oedema (require IV diuretics etc)

Page 2 of 2                                                               Review date: November 2004

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