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Guideline: Chronic Heart Failure
SIGN Guideline (Feb 2007)
Presented by
Dr Tom Gamble
Heart Failure – Some Facts
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Heart failure is a syndrome and not a
single pathological process.
The syndrome of heart failure is
common and readily recognised:
the patient complains of symptoms of breathlessness and
exhaustion at rest or with less than the normal degree of exertion
the functional reserve of the heart is grossly reduced
there are associated changes in many organ systems
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The incidence of heart failure is 20-30 per
thousand per year with an overall prevalence
of 1%. The prevalence in the over 80 age
group is about 30%.
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Mild- 90% annual survival rate
Severe – 50% annual survival
BNP predictive of prognosis
Diagnosis
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History and examination: consider
common alternative diagnoses:
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obesity
hypoalbuminaemia
chest disease (lung/diaphragm/chest wall/)
renal or hepatic disease
venous insufficiency in lower limbs
PE
drug induced ankle swelling (Ca channel blockers)
drug induced fluid retention (NSAIDs)
depression/anxiety disorders
severe anaemia/thyroid disease
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Diagnosis 2
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Investigations: FBC; fasting blood glucose;
U&Es; urinalysis; TFTs; CXR.
ECG and/or natriuretic peptide
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Both normal? Heart failure unlikely
1 or more abnormal: echocardiography.
Management-Behavioral
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Reduce alcohol consumption
Smoking cessation advice
Regular low intesity physical activity when
stable
Diet (salt intake <6g/day)
Daily weight (report increase of >1.5kg)
Management- Drugs
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ACE inhibitor
Beta blocker when condition stable unless
contra-indicated
ARB if not tolerant of ACEi
Consider diuretics for patients with dyspnoea
or oedema
If symptomatic consider addition of candesartan to ACEi and Bblocker
For moderate to severe heart failure consider spironolactone
(eplerenone alternative)
Consider digoxin if still symptomatic after optimum therapy
Palliative Care
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Focus on symptom relief and discontinuation
of non-essential treaments
Opportunity to discuss issues of sudden
death and living with uncertainty
After optimisation of diet/fluid intake and
drugs, consider opiods if dyspnoeic
NICE (2003)
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Broach sexual activity
Vaccinations (influenza/pneumococcus)
Titrate up ACEi and beta-blocker
ARBs not licensed for heart failure at time of
NICE
Specialist consideration of isosorbide and
hydralazine if ACEi not tolerated