Download specialty : cardiology clinical problem: heart failure

St. Richard’s Hospital
SPECIALTY : CARDIOLOGY
CLINICAL PROBLEM: HEART FAILURE
Summary
Heart failure has a worse prognosis than many cancers with an annual mortality of 40%
in the first year following diagnosis and 10% thereafter. Accurate and timely diagnosis
is therefore important and echocardiography is mandatory.
CAUSES OF HEART FAILURE
Common causes of heart failure are
• Coronary heart disease and myocardial infarction (most common cause).
• Hypertension.
• Valvular heart disease
These conditions generally cause left ventricular systolic dysfunction although
hypertension can cause “diastolic heart failure” while mitral stenosis is usually
associated with normal left ventricular function. Other causes of left ventricular systolic
dysfunction include alcoholic cardiomyopathy, dilated cardiomyopathy and myocarditis.
Heart failure can also be secondary to diseases that are not typically associated with
left ventricular systolic dysfunction and examples are pericardial disease, hypertrophic
cardiomyopathy and infilterative disorders such as amyloidosis and sarcoidosis.
The reason for making a distinction between heart failure due to left ventricular systolic
dysfunction and other types is that there are differences in treatment. The
pharmacological recommendations in the NICE guidelines are directed at patients with
left ventricular systolic dysfunction and patients with other types of heart failure should
be seen and assessed by cardiologists.
SYMPTOMS AND SIGNS OF HEART FAILURE
Symptoms
The most common symptoms are
• Breathlessness
• Fatigue
• Exercise intolerance
• Peripheral oedema
Unfortunately, these symptoms are not unique to heart failure and are frequently seen
in patients presenting to primary care. Other conditions which may present with some
or all of these symptoms include obesity, chest disease, venous insufficiency, drug
induced ankle swelling (e.g. calcium antagonists) or fluid retention (e.g. NSAIDs), hypoalbuminaemia and renal or hepatic disease. Other symptoms of heart failure include
nocturia, anorexia, abdominal bloating and discomfort, constipation, and cerebral
symptoms such as confusion, dizziness and memory impairment.
Signs
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Raised JVP (high predictive value but may not be present especially if patient on
diuretics)
Gallop rhythm
Displaced apex
Peripheral oedema
As with the symptoms, the signs are not unique to heart failure but generally, the more
symptoms and signs that are present, the more confident that a diagnosis of heart
failure can be made. However, investigations are required to confirm the diagnosis.
THE DIAGNOSIS OF HEART FAILURE
If a detailed history and clinical examination suggests a diagnosis of heart failure, then
confirmatory investigations are required (Figure 1). In one study, less than half the
patients treated for heart failure in general practice had the disease.
A normal ECG is very reassuring and we can be 98% sure that a patient does not have
heart failure.
Measurement of serum BNP (brain natriuretic peptide) has been introduced recently
and can also be used to help diagnose heart failure. A negative result is useful in
excluding heart failure.
It can be seen that a normal ECG and a negative BNP result can be used to exclude
heart failure this means referral for echocardiography maybe more selective and
should be taken into consideration when investigating the patient. However, BNP
assays are expensive and factors such as the ready availability of echocardiography
should be considered. Locally, the waiting time for open access echocardiography is 2
–3 weeks, therefore at present we are not advocating BNP.
Echocardiography is extremely useful for the assessment of the structure and function
of the heart and its valves. Sometimes, the quality of the images is suboptimal and
alternative imaging techniques are required.
HEART FAILURE ?
History and Examination
Request Investigations
ECG, Chest X-Ray,
Blood Tests
Start Diuretics if clinically
indicated
If investigations abnormal/indicative of heart failure REQUEST ECHO.
Direct Referral to Echo
Service
For Routine Investigation
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Refer to Cardiology clinic for specialist opinion and echo if:
Severe symptoms
Heart Murmur
The diagnosis is still unclear
There is complex concomitant disease
There is severe left ventricular dysfunction
The patient may be considered a suitable candidate for
transplant
THE TREATMENT OF HEART FAILURE
This section deals with the treatment of patients with left ventricular systolic
dysfunction.
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Diuretics. These are used for the relief of congestive symptoms and fluid retention
(figure1) Loop diuretics such as frusemide are commonly used while thiazides such
as bendrofluazide and metolazone can be added (often temporarily) to increase
diuresis. Dosage is titrated against symptoms and body weight and serum
electrolytes need to be monitored. Combination or high dose diuretics increase the
risk of hypokalaemia and renal impairment.
ACE inhibitors. All patients should be considered for treatment with ACE inhibitors,
which should be started before beta-blockers. Treatment should be initiated at the
relevant low dose and the dose increased at 2 weekly intervals so long as
biochemistry, blood pressure and side effects allow. In hospital, where there is close
monitoring, dosages can be increased daily. Examples of target dosages that have
been used in clinical trials are Captopril 50 mg tds, Enalapril 20mg bd, Lisinopril
30mg od and Ramipril 10mg od. For other ACE inhibitors, the target doses are
based on manufacturers’ recommendations rather than from outcome studies. Care
and close supervision are required before initiating ACE inhibitors in patients with a
serum creatinine > 200µmol/l or a potassium > 5.0mmol/l or a systolic blood
pressure < 80mmHg. An increase in creatinine of up to 50% above baseline, or to
200 µmol/l, whichever is the smaller, is acceptable as is an increase in potassium to
5.9 mmol/l.
Beta Blockers. The beta blockers licensed for heart failure are bisoprolol and
carvedilol and these should be initiated after ACE inhibitors regardless of whether
the patient is symptomatic or not. The rule is “start low, go slow” and heart rate,
blood pressure and clinical status should be checked before each dose increase. If
patients were already on a beta-blocker prior to developing heart failure, it is
acceptable to continue with the existing beta-blocker.(Nurse led Heart Failure Clinic)
Spironolactone. Patients who remain moderately symptomatic and who are
already on diuretics, ACE inhibitors and beta blockers can be commenced on
Spironolactone at a dose of 25mg od. It is important to closely monitor the serum
potassium and creatinine levels.
Digoxin. This should be considered in anyone with atrial fibrillation or in those with
severe heart failure despite the above treatment. (usualy introduced by specialist)
Other drugs. The majority of patients will have coronary heart disease and may
require other drugs such as aspirin and statins. Warfarin should be considered in
those with atrial fibrillation and those assessed as being at risk for left ventricular
thrombus formation. Calcium antagonists that are negatively inotropic should be
avoided but amlodipine can be used. Angiotensin II receptor antagonists are not
licensed for heart failure but can be used if patients are intolerant of ACE inhibitors.
Heart Failure Nurse Specialist. Patients with heart failure are often on sub-optimal
treatment. For instance, it is estimated that as few as 10% of patients are on betablockers. Two hospital heart failure nurse specialists are based on Charlton Ward,
St. Richard’s Hospital. Heart failure nurse specialists have been shown to reduce
hospital admission rates by educating patients about their condition and by giving
timely management advice when their clinic status is deteriorating.
Lifestyle. Patients should be advised to give up smoking and patients with alcoholic
cardiomyopathy should abstain from drinking. Regular aerobic and resistive
exercise can improve symptoms and exercise tolerance. Overweight patients should
lose weight aiming for a BMI of 25 to 30.
Vaccination. Annual vaccination against influenza is recommended as is
vaccination against pneumococcal disease (required once).
Cardiac Resynchronisation Therapy. Biventricular pacemakers have been shown
in some studies to improve symptoms and to reduce hospitalisations for heart
failure. Pending studies investigating their effect on long-term survival, NICE has
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made no firm recommendations about their prescription. Current indications are
those patients with left ventricular ejection fraction 35%, drug refractory symptoms
and a QRS duration > 120ms.
Implantable cardioverter-defibrillators (ICDs). Up to 50% of heart failure patients
die suddenly from cardiac arrest rather than from “pump failure”. ICDs are
recommended for those who have survived a cardiac arrest due to VT or VF or who
have had sustained VT that was haemodynamically significant5.
Figure 1. Algorithm for the pharmacological treatment of symptomatic heart
failure due to left ventricular systolic dysfunction (from NICE guidelines for the
management of chronic heart failure).
Generalist
New diagnosis
Add Diuretic
Diurectic therapy is
likely to be required
to control congestive
symptoms and fluid
retention
Specialist input
Add Digoxin
If a patient in sinus
rhythm remains
symptomatic despite
therapy with a
diurectic, ACE
inhibitor (or
angiotensin in ||
receptor antagonist)
and beta blocker.
OR if a patient is in
atrial fibrillation
then use as first line
therapy
Start ACE
inhibitor and
titrate upwards
Or if ACE inhibitor not
tolerated (eg due to
severe cough)
Consider angiotensin-ll
receptor antagonist
Add beta-blocker
and titrate
upwards
Add spironolactone
If patient remains
moderately to
severely
symptomatic despite
optimal drug therapy
listed above
Seek specialist
advice for further
options
Specialist
REFERRAL TO A CARDIOLOGIST
Referral to a cardiologist should be considered in the following circumstances
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When there is a cardiac murmur indicating valvular heart disease or other lesion.
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For assessment of any underlying coronary heart disease especially if angina is
poorly controlled.
When heart failure is difficult to manage e.g. requiring high dose diuretics or patient
is intolerant of medication.
When the cause of heart failure is other than left ventricular systolic dysfunction e.g.
diastolic heart failure, restrictive cardiomyopathy and pericardial disease.
If patients are suitable candidates for cardiac transplantation, cardiac
resynchronisation therapy or implantable cardioverter-defibrillators.
If patients have significant co-morbidity.
PALLIATIVE CARE
Palliative care has been a relatively neglected part of the management of patients with
heart failure. The main areas of need include
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Symptom control.
Psychological and social support.
o Intensive Care at Home
o Recently established Heart Support Group
Planning for the future
End of life care
General palliative care can be delivered by the usual professional carers but specialist
advice may be required from professionals with palliative care skills.
REFERENCES
Davie AP et al. Value of the electrocardiogram in identifying heart failure due to left
ventricular systolic dysfunction. BMJ 1996;312:222
Hobbs FDR et al. Reliability of N-terminal pro-brain natriuretic peptide assay in
diagnosis of heart failure:cohort study in representative and high risk community
populations. BMJ 2002;324:1-5
Developing services for heart failure. Department of Health Publications.
www.doh.gov.uk/heart/heartfailure/developingservices.
Chronic heart failure. Management of chronic heart failure in adults in primary and
secondary care. Clinical Guideline 5. National Institute for Clinical Excellence.
Guidance on the use of implantable cardioverter defibrillators for arrhythmias. NICE
Technology Appraisal Guidance No. 11. www.nice.org.uk/Docref.asp?d=10239.
AUTHOR: Dr Yuk-ki Wong, Consultant Cardiologist, St Richard’s Hospital, Chichester.
OTHERS INVOLVED: Consensus reached by Consultant Physician Colleagues – Dr
Colin Reid and Dr Conrad Murphy , Dietetics Department, & CCU at St Richard's
Hospital, The Royal West Sussex Trust, Chichester. All LRMG Committee.
PUBLISHED: 7/97
REVIEWED & UPDATED: 04/00, 06/04, 12/07
NEXT REVIEW: 12/09