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Heart failure - chronic
Scenario: Suspected chronic heart failure due to left ventricular dysfunction
Clinical summary: Managing suspected chronic heart failure while waiting for echocardiography
to provide a definitive diagnosis
How should I manage a person with suspected heart failure while they are waiting for echocardiography?
For someone who is suspected of having heart failure and is awaiting echocardiography for a definitive diagnosis:
•
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Assess for and manage any underlying causes.
Assess the severity of symptoms, for example by using the New York Heart Association classification.
If symptoms are sufficiently severe to warrant treatment while waiting for echocardiography, start a loop
diuretic and titrate the dose to control the symptoms — for more information see Clinical summary:
Diuretics.
If treatment with a diuretic fails to relieve symptoms adequately, review the differential diagnosis.
Consider obtaining specialist advice in the following situations:
o
Severe symptoms — refer urgently if diuretic treatment is ineffective.
▪
The person may have an underlying condition such as valve disease, and this may require urgent
investigation.
▪
Specialists may advise starting an angiotensin-converting enzyme inhibitor whilst waiting for the
results of the echocardiograph.
o
The diagnosis is uncertain.
o
Angina, atrial fibrillation, or other symptomatic arrhythmia.
o
Women who are pregnant.
1
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: Self-care advice
What self-care advice should I give someone with chronic heart failure?
Provide the following self-care advice for people being treated for chronic heart failure. Whenever appropriate,
include family members or carers.
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How to recognize the symptoms of heart failure, and what to do if symptoms deteriorate
o
When symptoms suggest deteriorating heart failure they should promptly seek medical attention, or
adjust the doses of their drugs (as pre-agreed), or both.
When and how to monitor body weight, and what to do if there is a gain in weight
o
Because a rapid gain in weight in people with heart failure is often the result of fluid retention,
worsening of heart failure may be detected early if weight is measured daily.
o
Home monitoring of weight is not practical for all people, for example those who are unable to stand
unaided on a scale.
o
If body weight is to be monitored at home, normal fluctuations in body weight should be minimized:
weighing should be at the same time each day (for example, after waking and voiding, but before
before dressing or eating).
o
If there is a sudden and sustained gain in weight (for example more than 2 kg in 3 days), they should
(as pre-agreed) either seek medical advice, or increase the dose of their diuretic, or both.
o
Patients and their carers should understand that deterioration can occur without weight gain.
How to keep active and practice physical exercise
o
Explain that keeping as fit as possible is safe and beneficial if exercise does not exceed the person's
capacity.
o
Encourage regular aerobic exercise (such as walking) and/or resistive exercise (e.g. weight training).
This may be more effective when part of a supervised exercise or rehabilitation programme, and may
be available as 'an exercise referral scheme'.
How to stop smoking
o
Advise smokers to quit, and offer referral to a smoking-cessation service.
o
For detailed information on the harmful effects of smoking and for advice on smoking cessation, see the
CKS topic on Smoking cessation.
How to use alcohol prudently
o
People with alcohol-related heart failure should never drink alcohol.
o
People with heart failure not due to alcohol should keep their alcohol intake within recommended levels.
o
For detailed information on sensible drinking limits and how to help people reduce their drinking, see
the CKS topic on Alcohol - problem drinking.
How to lose excess weight and then maintain weight within recommended limits
o
For advice on the management of obesity, see the CKS topic on Obesity.
How to restrict salt consumption
o
Excessive intake of salt is to be avoided, but there are no specific guidelines on salt intake.
o
Patients should be informed about the salt content of common foods.
o
Websites that have useful information about salt in the diet are listed in Online resources.
When to restrict fluid intake
o
People with severe symptoms of heart failure should restrict fluid intake to between 1.5 and 2.0 litres a
day.
o
People with mild or moderate symptoms are unlikely to benefit from fluid restriction.
What immunizations to have
o
Annual immunization against influenza and immunization once against pneumococcus are
recommended.
2
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: What information should I provide for people with heart failure?
What information about online resources is available for people with chronic heart failure?
Online information resources that may be useful for people with heart failure (and their families) include:
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Living with heart failure
o
www.bhf.org.uk — the British Heart Foundation
o
www.heartfailurematters.org — the European Society of Cardiology
Salt in the diet
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www.bhf.org.uk — the British Heart Foundation
o
www.salt.gov.uk — the British Food Standards Agency
o
www.bda.uk.com — the British Dietetics Association
Coronary heart disease (a common cause of heart failure)
o
www.heartforum.org.uk — the National Heart Forum
Planning ahead, and end of life issues
o
www.endoflifecareforadults.nhs.uk — the NHS National End of Life Care Programme supports the
implementation of the UK Department of Health's End of Life Care Strategy by sharing good practice in
collaboration with local and national stakeholders.
o
www.endoflifecareforadults.nhs.uk — Preferred Priorities for Care — this document is a combined
information leaflet and form that can be used as by patients and carers to plan, and document their
preferred priorities for care.
o
www.westonhospicecare.org.uk — Planning Ahead — this document, developed by Weston Hospice with
patients and palliative care professionals, is a set of leaflets that can be used to facilitate discussions
and to document decisions about end of life life issues.
What information should I provide about driving and chronic heart failure?
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For
o
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For
o
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group-1 entitlement (cars, motorcycles)
Driving may continue, provided there are no symptoms that may distract the driver's attention.
The DVLA need not be notified.
group-2 entitlement (lorries, buses)
Disqualified from driving if symptomatic.
Re-licensing may be permitted, provided that the left ventricular ejection fraction is at least 40%, and
there is no other disqualifying condition.
What information should I provide about sexual activity?
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Sexual problems may be related to cardiovascular disease, medical treatments (such as beta-blockers),
fatigue, or depression.
People who can tolerate moderate exertion without cardiovascular symptoms such as dyspnoea, palpitations,
or angina, should be able to engage in sexual activity without provoking these symptoms.
People with New York Heart Association (NHYA) class III or IV symptoms may have a slightly increased risk
of worsening heart failure triggered by sexual activity.
Phosphodiesterase type-5 inhibitors (such as sildenafil) are not recommended for use in people with
advanced heart failure, and should never be used in combination with nitrates.
What information should I provide about travel?
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Air travel is usually preferable to other means of travel for long journeys.
Air travel is not suitable for people who require oxygen.
People with symptoms of heart failure should try to avoid travelling to high altitudes (for example, above
1500 m) and to hot and humid destinations.
For many people with heart failure the most difficult part of air travel will be the long walk within the airport,
and they may require assistance.
3
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: Managing drug treatments for heart failure with left ventricular dysfunction
What drug treatments should I consider in a person with heart failure and left ventricular systolic
dysfunction?
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To relieve symptoms of fluid retention, prescribe a diuretic.
o
Titrate the dose (up and down) according to symptoms; review the dose and adjust as necessary after
introducing other drug treatments for heart failure.
To improve morbidity and mortality:
o
Prescribe an ACE inhibitor unless contraindicated or not tolerated. If ACE inhibitors cause troublesome
cough, use an AIIRA.
▪
Do not start a diuretic and an ACE inhibitor at the same time because of the risk of hypotension.
▪
If the person is already using high doses of a loop diuretic (equivalent to 80 mg furosemide or
more), consider seeking specialist advice before starting an ACE inhibitor or AIIRA.
▪
Titrate the dose of ACE inhibitor or AIIRA upwards until the target dose or the highest tolerated
dose is reached.
▪
Monitor renal function and serum electrolytes before starting an ACE inhibitor or an AIIRA and
after each dose increase.
o
Once stable, add a beta-blocker unless contraindicated (for example, asthma, heart block, or
symptomatic hypotension) or not tolerated.
▪
Start at a low dose and titrate slowly upwards until the target dose or the highest tolerated dose is
reached.
If still symptomatic, seek specialist advice regarding the addition of an aldosterone or digoxin to current
treatment, or the combination of an AIIRA with existing ACE inhibitor treatment.
In all people, consider whether an antiplatelet and a statin is indicated.
o
An antiplatelet drug is indicated if the person has atherosclerotic arterial disease (such as coronary
heart disease, stroke/transient ischaemic attack, or peripheral vascular disease). See the CKS topic on
Antiplatelet treatment.
o
A statin is indicated if the person has atherosclerotic arterial disease or has a 10-year risk of a
cardiovascular event which is 20% or more. See the CKS topics on CVD risk assessment and
management and Lipid modification - CVD prevention for more information.
Consider morbidities which may influence the treatment of heart failure.
4
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: Follow up and monitoring; referral of people with chronic heart failure
How should I follow up someone with heart failure?
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All people with heart failure require regular follow-up, monitoring, and review of medications to
assess any need for changes and to detect possible adverse effects.
The frequency of follow up and detail of monitoring needs to be individualized according to the
severity of symptoms, stability of clinical status, intensity of treatment, and any comorbidities.
o
More frequent follow up and more detailed monitoring will be required if the person has significant
comorbidity or if their condition has deteriorated since the previous review. The follow-up interval
should be short (days to 2 weeks) if the clinical condition or medication has changed, and at least every
6 months if the person's condition is stable.
o
People who wish to be involved in monitoring their condition should be provided with sufficient
education and support to do this, and with clear advice on what to do if their condition deteriorates (see
Self-care advice).
Assess and monitor:
o
Functional capacity (chiefly from the history)
▪
The New York Heart Association (NHYA) classification is a useful tool
o
Fluid status (chiefly from the physical examination)
▪
Change in body weight
▪
Jugular venous distension
▪
Lung crackles (crepitations)
▪
Hepatomegaly
▪
Peripheral oedema (ankles, sacrum)
▪
Change in blood pressure on standing up from a lying position (a postural drop of more than
20 mmHg suggests hypovolaemia).
o
Cardiac rhythm (chiefly from the physical examination)
▪
If an arrhythmia is suspected from the physical examination, consider doing a 12-lead
electrocardiogram (ECG), or arranging 24-hour ECG monitoring.
o
Biochemistry — for information on the monitoring recommended for particular drugs, see the
Prescribing information sections on:
▪
Monitoring (diuretics)
▪
Monitoring (ACE inhibitor/AIIRA)
▪
Monitoring (beta-blocker)
▪
Monitoring (aldosterone antagonist)
▪
Monitoring (digoxin)
When should I refer someone with chronic heart heart failure?
Consider obtaining specialist advice in the following situations:
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Heart failure due to valve disease, diastolic dysfunction, or any cause other than left ventricular systolic
dysfunction.
Angina, atrial fibrillation, or other symptomatic arrhythmia.
Women who are planning a pregnancy or who are pregnant.
Severe heart failure.
Heart failure that does not respond to treatment.
Heart failure that can no longer be managed effectively in the home setting.
Specialist advice may be appropriate when managing people with heart failure and a comorbidity such as:
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Renal dysfunction (for example serum creatinine greater than 200 micromols per litre).
Anaemia.
Thyroid disease.
Severe eripheral vascular disease.
Asthma, chronic obstructive pulmonary disease.
Gout.
5
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: Diuretics — prescribing information
Which diuretic should I use?
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Loop diuretics are the preferred diuretics in heart failure.
A thiazide diuretic may be sufficient for someone with mild symptoms.
In people with resistant oedema, consider adding a thiazide to a loop diuretic.
o
Metolazone is particularly effective when combined with a loop diuretic.
o
Consider seeking specialist advice when combining a thiazide and a loop diuretic, because this can
cause dramatic diuresis and disturbances in fluid balance and electrolytes.
What dose of diuretic should I prescribe and how should the dose be titrated?
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Start with a low dose of diuretic and titrate up (or down) according to symptoms and signs of congestion. A
duration of 2 weeks is suggested between titrations.
o
For recommended starting doses of diuretics inhibitors see What dose of diuretic should I prescribe and
how should the dose be titrated? in Prescribing information.
o
The dose is usually given once a day, in the morning, but they can be given twice a day (morning and
lunchtime) for additional diuresis.
Review the dose and adjust as necessary after restoration of dry body weight and after subsequent
treatment for heart failure has been introduced.
Provide patient education regarding self-adjustment of the dose based on regular weight measurements and
other signs and symptoms of fluid retention (see Clinical summary: Self-care advice).
How should I monitor someone taking a diuretic?
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Measure renal function and serum electrolytes before starting treatment.
Check renal function and serum electrolytes 1–2 weeks after starting treatment, and 1–2 weeks after each
dose increase.
o
Earlier monitoring (after 5–7 days) may be required for people with existing renal impairment, or those
taking a combination of a diuretic plus an ACE inhibitor, an AIIRA, or an aldosterone antagonist.
For people on a combination of a loop diuretic and a thiazide:
o
Check renal function 5–7 days after starting combination treatment, and recheck every 5–14 days,
depending on the person's stability.
o
Monitor weight and hydration status — if diuresis is extensive, consider earlier testing of renal function.
If serum creatinine increases by more than 20% of baseline, or eGFR falls by more than 15% baseline,
remeasure renal function within 2 weeks.
If potassium falls below 3 mmol/L (or 4 mmol/L in 'high risk' people) review diuretic treatment.
Once treatment is stable, measure renal function and serum electrolytes every 3–6 months in people at
'higher risk' and once a year in people at 'lower risk'.
What are the adverse effects of diuretics and how can they be managed?
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Excessive diuresis may cause orthostatic hypotension, dehydration, renal dysfunction, and electrolyte
imbalances.
o
If there is evidence of symptomatic hypotension, consider steps to counteract this (reduce the dose of
diuretic, or reduce the dose of any concomitant drugs known to reduce blood pressure) or seek expert
advice.
o
Titrate the dose of diuretic (up and down) according to the person's symptoms; use the lowest possible
dose to control symptoms.
o
Monitor renal function and serum electrolytes regularly, especially after increasing the dose of diuretic
or adding another drug for heart failure.
Diuretics can cause hyperuricaemia and may precipitate or aggravate gout.
o
Consider prophylaxis with allopurinol to reduce the risk of recurrence of gout.
What advice to I give to someone taking diuretics for heart failure?
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Where appropriate provide education and advice regarding self-adjustment of the diuretic dose based on
regular weight measurements and other symptoms of fluid retention.
o
Ensure that the person or their carer knows how to adjust the dose in response to symptoms, and when
to seek help if their symptoms deteriorate or do not respond to dosage adjustment.
6
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: Angiotensin-converting enzyme inhibitors — prescribing information
Who should avoid taking ACE inhibitors?
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Contraindications to angiotensin-converting enzyme (ACE) inhibitors include:
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History of angioedema associated with previous exposure to an ACE inhibitor.
o
Hereditary or idiopathic angioedema.
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Renal artery stenosis.
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Pregnancy.
o
Breastfeeding.
▪
Which angiotensin-converting enzyme inhibitor is recommended?
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CKS recommends enalapril, lisinopril, ramipril, and trandolapril for the treatment of heart failure in primary
care.
What dose of ACE inhibitor should I prescribe and how should the dose be titrated?
•
•
•
•
•
ACE inhibitors can usually be initiated in primary care. However, consider seeking specialist advice before
starting if the person is receiving high-dose loop diuretics (equivalent to 80 mg furosemide or more).
Start with a low dose of ACE inhibitor and titrate upwards by doubling the dose in short intervals (usually 2week intervals are suitable). After each upward titration, monitor the person's renal function and blood
pressure.
Aim for the target dose, or failing that the highest tolerated dose — a low dose of an ACE inhibitor is better
than no ACE inhibitor at all.
Maintain the ACE inhibitor at the target dose (or highest tolerated dose) indefinitely unless complications
occur.
For recommended starting and target doses of ACE inhibitors see What dose of ACE inhibitor should I
prescribe and how should the dose be titrated? in Prescribing information.
What monitoring is required for someone taking an ACE inhibitor or an AIIRA?
•
•
•
Measure renal function and serum electrolytes before starting treatment.
Check renal function and serum electrolytes 1–2 weeks after starting treatment, and 1–2 weeks after each
increase in dose.
o
Earlier monitoring (after 5–7 days) may be required for people with existing renal impairment, or those
taking a combination of an ACE inhibitor or an AIIRA plus a diuretic or an aldosterone antagonist.
Once treatment is stable, measure renal function and serum electrolytes every 3–6 months in people at
higher risk (this includes people with existing renal dysfunction; age over 60 years; taking a combination of
a diuretic, an ACE inhibitor/AIIRA, or an aldosterone antagonist; or with relevant concomitant disease) and
once a year in people at 'lower risk'.
What adverse effects are associated with ACE inhibitors and how can they be managed?
The risks of worsening renal function and hyperkalaemia are increased if an ACE inhibitor is combined with an
AIIRA or an aldosterone antagonist and monitoring is essential.
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Deterioration in renal function: monitor renal function after starting an ACE inhibitor, after each increase in
dose, and regularly throughout treatment.
Hyperkalaemia: monitor serum electrolytes after starting an ACE inhibitor, after each increase in dose, and
regularly throughout treatment.
Orthostatic hypotension:
o
If hypotension is asymptomatic, there is no need to change treatment.
o
If hypotension is symptomatic (causing dizziness, light-headedness, or confusion):
▪
If there are no signs or symptoms of congestion, consider reducing the dose of any concomitant
diuretic.
▪
Consider seeking specialist advice.
Cough is common in people with heart failure and can be due to smoking-related lung disease or pulmonary
oedema.
o
If the cough is troublesome (for example it prevents the person from sleeping) and other causes have
been ruled out, consider switching to an AIIRA.
What advice should I give to someone taking an ACE inhibitor?
•
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Explain the expected benefits of treatment and the importance of taking the treatment as prescribed.
o
Treatment improves symptoms, prevents worsening of symptoms, and increases survival.
o
Symptoms improve within a few weeks to a few months.
Advise the person that they may experience adverse effects, but that these rarely necessitate stopping
treatment.
7
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
•
o
Advise people to report symptoms of hypotension to their healthcare professional.
Advise the person to avoid nonsteroidal anti-inflammatory drugs (these may be present in over-the-counter
products) and salt substitutes that are high in potassium.
8
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: Angiotensin-II receptor antagonists — prescribing information
Which angiotensin-II receptor antagonist is recommended?
•
CKS recommends candesartan, losartan, and valsartan for the treatment of heart failure in primary care.
o
Candesartan is the only AIIRA licensed for the treatment of people with heart failure and impaired left
ventricle systolic function as add-on therapy to an ACE inhibitor.
Who should avoid taking angiotensin-II receptor antagonists?
•
Contraindications to angiotensin-II receptor antagonists include:
o
Renal artery stenosis.
o
Severe hepatic impairment.
o
Pregnancy.
o
Breastfeeding
What dose of AIIRA should I prescribe and how should the dose be titrated?
•
•
•
•
•
AIIRAs can usually be initiated in primary care. However, consider seeking specialist advice before starting if
the person is receiving high-dose loop diuretics (equivalent to 80 mg furosemide or more).
Start with a low dose of AIIRA and titrate upwards by doubling the dose in short intervals (usually 2-week
intervals are suitable). After each upward titration, monitor the person's renal function and blood pressure.
Aim for the target dose, or failing that the highest tolerated dose.
Maintain the AIIRA at the target dose (or highest tolerated dose) indefinitely unless complications occur.
For recommended starting and target doses of AIIRAs see What dose of AIIRA should I prescribe and how
should the dose be titrated? in Prescribing information.
What monitoring is required for someone taking an ACE inhibitor or an AIIRA?
•
•
•
Measure renal function and serum electrolytes before starting treatment.
Check renal function and serum electrolytes 1–2 weeks after starting treatment, and 1–2 weeks after each
increase in dose.
o
Earlier monitoring (after 5–7 days) may be required for people with existing renal impairment, or those
taking a combination of an ACE inhibitor or an AIIRA plus a diuretic or an aldosterone antagonist.
Once treatment is stable, measure renal function and serum electrolytes every 3–6 months in people at
higher risk (this includes people with existing renal dysfunction; age over 60 years; taking a combination of
a diuretic, an ACE inhibitor/AIIRA, or an aldosterone antagonist; or with relevant concomitant disease) and
once a year in people at 'lower risk'.
What adverse effects are associated with AIIRAs and how can they be managed?
The risks of worsening renal function and hyperkalaemia are increased if an AIIRA is combined with an
angiotensin-converting enzyme (ACE) inhibitor or an aldosterone antagonist and monitoring is essential.
•
•
Adverse effects with AIIRAs are similar to those seen with ACE inhibitors, although they tend to be milder.
These include:
o
Hypotension
o
Hyperkalemia
o
Renal dysfunction
AIIRAs do not cause cough.
What advice should I give to someone taking an AIIRA?
•
•
•
Explain the expected benefits of treatment and the importance of taking the treatment as prescribed.
o
Treatment improves symptoms, prevents worsening of symptoms, and increases survival.
o
Symptoms improve within a few weeks to a few months.
Advise the person that they may experience adverse effects, but that these rarely necessitate stopping
treatment.
o
Advise people to report symptoms of hypotension to their healthcare professional.
Advise the person to avoid nonsteroidal anti-inflammatory drugs (these may be present in over-the-counter
products) and salt substitutes that are high in potassium.
9
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: Beta-blockers — prescribing information
Who should avoid taking beta-blockers?
•
•
Beta-blockers are contraindicated in:
o
People with a history of asthma or bronchospasm. Note: beta-blockers can be used in people with
chronic obstructive pulmonary disease but caution should be used if severe.
o
Second- or third-degree heart block (in the absence of a permanent pacemaker)
o
Sick sinus syndrome
o
Sinus bradychardia (less than 50 beats per minute at the start of treatment)
o
Severe hypotension
Seek specialist advice before starting a beta-blocker in someone with a current or recent exacerbation of
heart failure.
Which beta-blocker is recommended?
•
•
CKS recommends bisoprolol, carvedilol, and nebivolol for the treatment of heart failure in primary care
People who develop heart failure due to left ventricular systolic dysfunction and who are already on
treatment with a beta-blocker for a concomitant condition (for example, angina or hypertension) should
continue with a beta-blocker — either their current beta-blocker or an alternative licensed for heart failure
treatment
What dose of beta-blocker should I prescribe and how should the dose be titrated?
•
•
•
•
A beta-blocker should only be started once the person is stable (without fluid overload or hypotension).
Beta-blockers should be started at a low dose and titrated up slowly to the target dose or failing that to the
highest tolerated dose.
o
Do not increase the dose if there are signs of worsening heart failure, symptomatic hypotension (e.g.
dizziness), or excessive bradycardia (< 50 beats per minute).
Continue treatment at the target dose (or highest tolerated dose) indefinitely unless complications occur.
For recommended starting doses and titration regimens of beta-blockers see What dose of beta-blocker
should I prescribe and how should the dose be titrated? in Prescribing information.
What monitoring is required for someone taking a beta-blocker
Beta-blockers should not be stopped suddenly unless absolutely necessary; there is a risk of rebound myocardial
ischaemia or infarction, or arrhythmias. Ideally, specialist advice should be sought before stopping a betablocker.
•
•
•
Monitor clinical status for symptoms and signs of heart failure, particularly after each dose-increase. If the
condition is worsening (e.g. increasing dyspnoea, fatigue, oedema, or weight gain), consider the following
actions:
o
Increasing congestion: double the dose of diuretic and, if this does not work, consider halving the dose
of beta-blocker.
o
Marked fatigue: halve the dose of beta-blocker (rarely necessary).
o
Serious deterioration: halve the dose or stop the beta-blocker (seek specialist advice).
o
Review the person in 1–2 weeks. If there is no improvement, seek specialist advice.
Check heart rate after each dose-increase; if heart rate drops to 50 beats per minute or less, consider the
following:
o
Halve the dose of beta-blocker, or, if deterioration is severe, stop the beta-blocker (seek specialist
advice).
o
Review the need for other drugs that slow heart rate (e.g. digoxin, amiodarone, diltiazem).
o
Arrange for an electrocardiograph to exclude heart block.
o
Seek specialist advice.
Check serum electrolytes, urea, and creatinine 1–2 weeks after initiation, and 1–2 weeks after reaching the
target dose.
What adverse effects are associated with beta-blockers and how can they be managed?
•
•
•
•
Adverse effects that should be checked for during monitoring include:
o
Deteriorating symptoms of heart failure (e.g. congestive symptoms and fatigue)
o
Hypotension
o
Abnormally low heart rate (bradycardia)
Cold extremities, paraesthesiae, and numbness can occur, and are more common in people with peripheral
vascular disease. If troublesome, beta-blockers might need to be stopped (seek specialist advice).
Sexual dysfunction (impotence and loss of libido) can occur; people should be directly questioned about
whether they are having sexual problems because this information is often not volunteered due to
embarrassment.
10
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
•
•
Warning signs of hypoglycaemia (e.g. tremor, tachycardia) can be masked by non-selective beta-blockers. A
selective beta-blocker is therefore preferred in people with diabetes. Avoid beta-blockers in someone who
experiences frequent hypoglycaemia.
What advice should I give to someone taking a beta-blocker?
•
•
•
Explain the expected benefits of beta-blockers:
o
Beta-blockers slow down the worsening of the disease (reducing hospital admissions) and prolong lifeexpectancy.
o
Beta-blockers improve symptoms of heart failure.
Explain that there may be an initial deterioration in symptoms before improvement:
o
Temporary deterioration occurs in 20–30% of people during the titration stage.
o
Symptomatic improvement may develop slowly after starting treatment (over the course of 3–6
months).
Advise people to:
o
Seek medical advice if there is a rapid deterioration in symptoms such as tiredness, fatigue, or
breathlessness. Worsening symptoms can usually be controlled by adjusting other medications, and
beta-blockers should never be stopped without consulting a healthcare professional.
o
Weigh themselves regularly and consult their healthcare professional if there is persistent weight gain
(an increase of more than 1.5 kg persisting over more than 2 days).
11
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: Aldosterone antagonists — prescribing information
Who should avoid taking an aldosterone antagonist?
•
•
Spironolactone (and eplerenone) is contraindicated in people:
o
With addison's disease.
o
Who are already taking a combination of an ACE inhibitor and an AIIRA.
Use caution or seek specialist advice when starting spironolactone in people with:
o
Anuria, acute renal insufficiency, rapidly deteriorating or severe impairment of renal function (serum
creatinine > 220 micromol/L).
o
Hyperkalaemia (potassium > 5 mmol/L).
Which aldosterone antagonist is recommended?
•
•
Spironolactone is the aldosterone antagonist of choice.
Eplerenone may be considered as an alternative to spironolactone in men who develop gynaecomastia with
spironolactone.
What dose of aldosterone antagonist should I prescribe and how should the dose be titrated?
•
•
Start with a low dose of aldosterone antagonist and consider titrating up after 4–8 weeks if tolerated.
o
On each upward titration, monitor the person's renal function and blood pressure.
o
Do not increase the dose if there is worsening renal function of hyperkalaemia.
For recommended starting and target doses of aldosterone antagonists see What dose of aldosterone
antagonist should I prescribe and how should the dose be titrated? in Prescribing information.
What monitoring is required for someone taking an aldosterone antagonist?
•
Check blood chemistry (electrolytes, urea, and creatinine) before starting treatment with spironolactone and
after 1, 4, 8, and 12 weeks. Check again after 6, 9, and 12 months, and every 6 months thereafter:
o
If potassium rises to between 5.5 and 5.9 mmol/L, or creatinine rises above 220 micromol/L, reduce
the dose to 25 mg taken on alternate days, and monitor blood chemistry frequently to ensure that renal
function is not worsening.
o
If potassium rises to 6.0 mmol/L or above, or creatinine rises above 310 micromol/L, stop
spironolactone immediately and seek specialist advice.
What adverse effects are associated with aldosterone antagonists and how can they be managed?
•
•
•
Spironolactone (and eplerenone) may cause elevated levels of serum potassium (hyperkalaemia):
o
Potassium levels require careful monitoring to ensure that renal function is not deteriorating.
o
Potassium levels at the higher end of the normal range may be desirable in people with heart failure,
particularly if they are taking digoxin.
Spironolactone may cause hormonal disturbances, especially in men, resulting in gynaecomastia and breast
tenderness in about 10% of men receiving low-dose spironolactone.
o
Consider eplerenone as an alternative in men who develop gynaecomastia whilst taking spironolactone.
Other adverse effects include fatigue, gastrointestinal disturbances, menstrual disruption, skin complaints,
and blood disorders.
What advice should I give to someone taking an aldosterone antagonist?
•
•
•
Explain the potential benefits of spironolactone:
o
Spironolactone slows down the worsening of the disease and prolongs life expectancy.
o
Spironolactone improves symptoms of heart failure.
Explain that symptom improvement may not occur for a few weeks or months after starting treatment.
Advise people to:
o
Temporarily stop spironolactone and seek specialist advice if they develop diarrhoea or vomiting
suspected to be associated with spironolactone use.
o
Avoid using nonsteroidal anti-inflammatory drugs, unless specifically prescribed by a physician.
o
Avoid using salt substitutes that are high in potassium.
12
Heart failure - chronic
Scenario: Chronic heart failure with left ventricular systolic dysfunction on
echocardiography
Clinical summary: Digoxin — prescribing information
Who should avoid taking digoxin?
•
Digoxin is contraindicated in people with:
o
Some supraventricular arrhythmias, such as Wolff-Parkinson-White syndrome.
o
Heart conduction problems, such as intermittent complete heart block or atrioventricular heart block.
o
Ventricular tachycardia.
o
Hypertrophic obstructive myopathy.
What dose of digoxin should I prescribe and how should the dose be titrated?
•
•
Loading doses of digoxin are not needed in people who are stable with sinus rhythm.
The usual dose of digoxin is 125–250 micrograms in people with normal renal function.
o
Higher doses (above 250 micrograms) are rarely needed to treat heart failure.
o
Lower doses (62.5–125 micrograms) are usually used in the elderly or people with impaired renal
function.
What monitoring is required for someone taking digoxin
•
•
•
•
Routine monitoring of serum digoxin is not recommended.
Consider checking serum digoxin levels:
o
When there are adverse effects suggestive of toxicity (e.g. confusion, nausea, disturbance of colour
vision).
o
When other factors may affect the serum digoxin level, such as the use of a concomitant drug that may
affect levels (e.g. amiodarone, diltiazem, verapamil), or deteriorating renal function.
o
When poor compliance is suspected.
The likelihood of toxicity is dependent on the serum concentration of digoxin, the presence or absence of
signs and symptoms of toxicity, and the serum potassium level:
o
Levels less than 1.5 nanograms per millilitre, in the absence of hypokalaemia, indicate that digoxin
toxicity is unlikely.
o
Levels greater than 3.0 nanograms per millilitre indicate that digoxin toxicity is likely.
o
With levels between 1.5 and 3.0 nanograms per millilitre, digoxin toxicity should be considered a
possibility.
In addition, blood chemistry measurements should be taken (electrolytes, urea, and creatinine), as this can
affect digoxin toxicity.
What adverse effects are associated with digoxin and how can they be managed?
•
•
•
Digoxin has a narrow therapeutic window — adverse effects usually occur at serum concentrations above the
upper limit of the therapeutic window, and are dose-dependent. If significant adverse effects occur, serum
levels of digoxin should be measured.
Non-cardiac adverse effects are usually associated with overdosage and include:
o
Nausea, vomiting and, less commonly, diarrhoea (nausea in particular is indicative of overdosage).
o
Visual abnormalities (blurred or yellow vision).
o
Central nervous system effects such as weakness, dizziness, confusion, apathy, malaise, headache,
depression, and psychosis.
Cardiac adverse effects are usually associated with overdosage, although electrolyte imbalances may
predispose the person to cardiac adverse effects so that they occur even at therapeutic concentrations. They
include various conduction and rhythm disturbances.
13
Heart failure - chronic
Scenario: Heart failure symptoms with normal left ventricular ejection fraction
on echocardiogram
Clinical summary: Heart failure symptoms with normal left ventricular ejection fraction on
echocardiography
How should I manage unconfirmed heart failure with preserved left ventricular ejection fraction?
For someone who has symptoms of heart failure, and echocardiography shows preserved (normal) left ventricular
ejection fraction:
•
•
Reconsider the diagnosis of heart failure.
If heart failure is still thought to be likely:
o
Continue any current treatment that seems to have helped — this will often be a diuretic.
o
Refer for specialist assessment.
How should I manage confirmed heart failure with preserved left ventricular ejection fraction?
For someone who has been diagnosed by a specialist to have heart failure but whose echocardiography shows a
preserved (normal) left ventricular ejection fraction:
•
•
•
The
o
o
o
o
non-drug management is similar to that for heart failure with left ventricular systolic dysfunction:
Include family members or carers in education and decision-making when appropriate.
Provide self-care advice.
Provide information about online resources, driving, sexual activity, and travel.
Ensure that any comorbidities and precipitating factors such as hypertension, myocardial ischaemia and
atrial fibrillation are optimally managed.
Continue drug treatment as recommended by a specialist.
Monitor regularly; tailor the detail and frequency of monitoring to the individual's needs.
14
Heart failure - chronic
Scenario: End-stage chronic heart failure
Clinical summary: Managing end-stage chronic heart failure
How should I ensure appropriate advance planning for people with end-stage heart failure?
•
•
•
•
•
People with end-stage heart failure and their carers, should have an advance care plan that takes accounts
of their needs, priorities and preferences for end of life care. The plan should address symptom control and
comfort measures, anticipatory prescribing of medication to manage exacerbations, discontinuing
inappropriate interventions, needs for psychological and spiritual care, and care of the family (before and
after death of the patient). The plan should also include the person’s preferences regarding the setting or
location in which they wish to be cared for.
Carers and families should know when, who, and how to call for help when there is a crisis or acute
exacerbation, and what the options are for management. (The benefits of hospital admission can be difficult
to predict, as response to treatment is often unpredictable and deterioration in symptoms may be due to
causes other than heart failure.) The advance care plan should include the person's preferences regarding
resuscitation should they have an acute deterioration or arrest, and this information should be made
available to the out of hours and ambulance services.
Opportunities to discuss end of life issues and review the advance care plan can arise when there is a clinical
event or deterioration, or when there is a change in social circumstances such as a move into a care home.
Patients and carers may find the following online resources useful when planning the management of end of
life issues:
o
www.endoflifecareforadults.nhs.uk — the NHS National End of Life Care Programme.
o
www.endoflifecareforadults.nhs.uk — Preferred Priorities for Care — information leaflet and planning
guide.
o
www.westonhospicecare.org.uk — Planning Ahead — information leaflet and planning guide.
Carers and their families should know how to dispose of the person's medicines after their death.
For more information see the CKS topic on Palliative cancer care - general issues.
How should I manage someone with end-stage heart failure?
Because palliative care for people with heart failure is similar to that for people with cancer, this overview
provides links to more detailed CKS topics on the management of specific aspects of palliative care in people with
cancer — their recommendations can usually be easily modified for people with end-stage heart failure.
Coordination of care services
•
People with end-stage heart failure may require co-ordination of a diverse range of health and social care
services to enable them to continue living at home and to die there if that is their wish.
Managing symptoms
•
•
•
•
•
Breathlessness
o
Optimize standard treatment with diuretics, fluid restriction (to between 1.5 and 2 litres a day) and
avoiding excessive consumption of salt. If this is ineffective, consider prescribing an opioid, a
benzodiazepine, or oxygen.
o
For information on when and how to prescribe opioids, benzodiazepines, and oxygen see Palliative
cancer care - dyspnoea.
Pain
o
Pain is often due to cardiac ischaemia, and this can be relieved by morphine and nitrates. Other pain
can be relieved by opioids.
o
For prescribing information see the CKS topics on Angina and Palliative cancer care - pain.
Anxiety, insomnia, and depression can be managed with sedatives and hypnotics.
o
For prescribing information see the CKS topics on Depression and Insomnia.
Constipation, nausea and loss of appetite can be managed with dietary changes, and laxatives.
o
For prescribing information see the CKS topics on Palliative cancer care - constipation, and Palliative
cancer care - nausea & vomiting.
Urinary incontinence is often related to weakness and the use of diuretics. It can be managed by careful
timing of diuretic doses, incontinence pads, for males a urisheath or a urethral catheter.
Managing an acute exacerbation
•
•
Ensure that medications commonly required to treat distressing symptoms are available in the house (for
example, cyclizine, diamorphine, and midazolam).
Admission is an option that should (ideally) be preplanned and re-evaluated as the person's condition
develops.
Managing the terminal phase
•
•
•
•
•
•
•
Explore understanding; provide appropriate explanation of the situation to the patient, family, and carers.
Set realistic goals.
Ensure that religious and spiritual care is offered if wanted.
Ensure that the environment and care setting is appropriate. Consider involving palliative care services.
Stop unnecessary drugs and continue with other drugs by an appropriate route.
Ensure that physical symptoms are well controlled.
For more information, see the CKS topic on Palliative cancer care - general issues.
15
Heart failure - chronic
Scenario: End-stage chronic heart failure
16