Download Diagnosing Heart Failure (HF)

Diagnosing Heart Failure (HF)1
Perform ECG and baseline bloods (FBC, LFTS and renal function as minimal set)
Heart Failure (HF) is a clinical syndrome typified by the following criteria:
 symptoms of HF (SOB at rest or on exercise, fatigue, tiredness, SOA) and
 signs of HF (tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised JVP, peripheral
oedema, hepatomegaly) and
 objective evidence of a structural or functional abnormality of the heart at rest (eg abnormality
on the echocardiogram)
Brain natriuretic peptide (BNP) and NT-Pro BNP
This is a polypeptide secreted by the ventricles of the heart in response to stretch. It is a
validated tool to aid in the diagnosis of HF. A normal BNP level suggests that HF is very
unlikely (<5%) and is a good rule-out test. A raised BNP level can be due to HF amongst other
causes. The BNP level does not differentiate between HF due to left ventricular systolic
dysfunction and HF with preserved ejection fraction (see below). Do not perform BNP in
patients with known HF or previous MI. Very useful in diagnosis of HFPEF or HFmREF
Serum NT Pro-BNP tested in Dorset
Expensive test: do not use as breathlessness screen!
High
> 2000 ng/l
Raised 400-2000 ng/l
Normal < 400 ng/l
(236pmol/l)
(47-36pmol/l)
(47pmol/l)
Other investigations:
CXR
TFT
Fasting sugar and lipids
Urinalysis
Peak flow or spirometry
Other causes of elevated BNP/NT-BNP include AF, ischaemia,
tachycardia, LVH and renal failure.
BNP may be normal in very well treated HF and also with
ischaemic heart disease leading to SOB
References: 1NICE Chronic Heart Failure; Management of chronic heart failure in adults in
primary and secondary care August 2010, NICE Cardiac Resynchronisation Therapy 2007;
Map of Medicine. http://www.nice.org.uk/nicemedia/live/13099/50526/50526.pdf
2Ponikowski P et al. ESC Guidelines for HF management. Eur Heart J 2016.
Created by Dr C Boos, Consultant Cardiologist Poole Hospital;
[email protected]; Version 4; 02-08-2016
Differential diagnoses to consider:
Aetiology of HF
Obesity and / or sleep apnoea
Chest disease including COPD
Venous insufficiency lower limbs
Drug induced ankle swelling eg Ca channel blockers
Drug induced fluid retention eg NSAIDs
Hypoalbuminaemia, Renal or hepatic disease
Pulmonary embolism
Depression and/or anxiety
Severe anaemia, and /or thyroid disease
Ischaemic heart disease
Hypertension
Valvular disease
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Pulmonary disease
Alcohol
Chemotherapy
Tachycardiomyopathy etc
NYHA Classification
I no limitations, no symptoms with ordinary physical activity
II slight limitation, symptoms with ordinary activity
III marked limitation, symptoms with less than ordinary activity
IV breathless at rest, any physical activity increases symptoms
Heart Failure with Preserved Ejection fraction (HFPEF) of so called Diastolic HF (EF>50%)
This is due to abnormal relaxation of the left ventricle in diastole. Hence normal LV systolic function and
ejection fraction could still be HF.! Only consider if BNP is elevated. Typical patient is elderly, hypertensive
(♀>♂). Difficult to diagnose, echocardiogram may show ‘diastolic markers’ and left ventricular hypertrophy ±
left atrial dilatation. Functional: Mean E/e′ ≥13 and a mean e’ septal+lateral wall <9 cm/s on echocardiogram2.
Heart Failure with mid-range ejection fraction HFmREF as above but EF 40-49%
New term (ESC 2016) to represent a subgroup of HF-PEF
Drug Treatment for Heart Failure Due to LVSD
Diuretics
 use loop diuretic if congestion eg frusemide 40mg and uptitrate
ACE inhibitors
 Start low and titrate upwards at intervals of every 2 weeks
 Measure urea, creatinine and electrolytes with each dosage increment
 Up-titration to be limited by symptomatic low blood pressure and renal function only if
creatinine increases by > 50% or to > 200mmol/l.
Beta-blockers
 ‘Start low and go slow’, dosage increments every 2-4 weeks
 Monitor HR, BP and clinical status after each titration
 Warn patients that they may experience transient mild symptomatic deterioration but should
improve with continued treatment
 Switch stable patients on B for co-morbidty to a B licensed for HF (eg bisoprolol),
 Up-titration to be limited by symptomatic low blood pressure or by bradycardia (if
symptomatic or HR < 50/minute)
 Most patients with COPD without reversibility will tolerate
 Effective and safe in elderly, PVD, DM, erectile dysfunction
Aldosterone antagonists (spironolactone 1st line; eplerenone second line)
 if symptomatic in spite of optimised treatment esp in NYHA II-IV and EF <35%
 Monitor renal profile at 1w, 1m and every 6m if on ACEI/ARB
ARBs
 Consider as alternative to ACEI if intolerant
 Not in addition to ACE-I
ARNI angiotensin receptor neprilysin inhibitor – Entresto* (HF Specialist use)
 Consider in NYHA II-IV HFREF instead of ACE-I o/ARB if deteriorating
 48h wash out on conversion from ACE-I; avoid if SBP <100mmHg (*contains valsartan)
If-channel blocker - Ivabradine (Pure HR lowering drug)
 Consider in patients with HR >75/minute, in sinus rhythm and BB intolerant or on max
tolerated BB dose if still symptomatic (aim HR 50-60/minute); contraindicated in AF
Digoxin

Usual dosage 125mcg; no need to monitor levels
Aspirin

use only if other indication eg CHD/PVD
Not improving
1. ECG (AF/LBBB)
2. Hb and Iron status and consider Iron
replacement (note can be iron deficient and
not anaemic) Transferrin sat <20% +/ferritin <100 mg/L.
3. TFTs
4. Drug compliance
5. Sleep disordered breathing?
Digoxin od if EF <45% or AF and Ivabradine bd
if EF<35% and HR >75/minute in sinus rhythm
Target doses Bisoprolol 10mg od
Ramipril 10mg/day
Candesartan 32 mg daily
Ivabradine 7.5mg/bd
Consider Entresto ARNI
Lifestyle advice
Exercise:
encourage regular exercise
within capabilities;
HF rehab NYHA I-III
Diet:
encourage low salt diet
Smoking: strongly advise not to smoke
Alcohol:
abstain in those with alcohol
related HF
Sexual activity: be prepared to discuss
Vaccination: offer annual vaccination
against influenza and one-off
vaccination against
pneumococcus
Driving:
consult DVLA guidelines
HF nurse Strongly consider referral to
help with HF dose titrations
and education etc
CRT (resynchronisation pacing +/- ICD)
* Broad QRS and low EF = HIGH risk*
It should be considered in pts with:

QRS > 130ms (>150ms without LBBB)

LVEF ≤35%

Symptomatic HF despite good treatment
Refer to a HF specialist for treatment
optimisation and consideration of device
therapy.
NB. CRT without ICD is relatively cheap and
has significant short term symptom benefit
as well as mortality benefit, often
appropriate in the elderly. Check QRS
duration. ICD generally not recommended
within 40/7 of MI
Palliative Care
 NYHA IV in spite of optimal Rx
 Clinician would not be surprised if patient
died within 12 months
 Discuss CPR
 Consider referral to palliative care team
 Consider advanced care
and treatment escalation plans
Drugs to avoid







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NSAIDs
CCBs except amlodipine
Erythromycin, Tricyclics
Other drugs that prolong QT
Steroids, Lithium
Class I antiarrhythmics
Glitazones
Some others!
Nebivolol 10mg daily
Enalapril 20mg bd
Spironolactone 50mg od
Digoxin 125-250mcg od
Carvedilol 25-50mg bd
Lisinopril 25-35mg od
Eplerenone 50mg od
Entresto 97/103mg bd
Monitoring
Monitor all patients. Include:

Clinical assessment of functional capacity, cardiac rhythm, cognitive, fluid and
nutritional status

Re-iterate lifestyle advice especially diet, exercise, smoking

Review of drug treatment include need to change and monitoring for side ffects

Minimum of urea, electrolytes, creatinine, eGFR
Monitor at short intervals (days to 2 weeks) if clinical condition or drug treatment has
changed, otherwise monitor at least 6 monthly.
HF-PEF and HFmREF
 Manage fluid retention with diuretics
 Treat the cause
 Currently no trial evidence for ACEIs or beta blockers but important to consider
their use particularly with HFmREF
 If AF, consider adding digoxin for rate control
 Treat co-morbidities esp. hypertension