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DERBY HOSPITALS NHS FOUNDATION TRUST
ADULT HEART FAILURE GUIDELINES
(Primary and Secondary Care)
Ref. No: CG/T/2008/019
Contents
Introduction
1
References & Document Control
2
Assessment of New patients presenting with Suspected Heart Failure in
Primary Care.
3
Echocardiography In Suspected Heart Failure-Primary Care Guidelines.
4
First Line management of Heart Failure due to Left Ventricular Systolic
Dysfunction (LVSD).
Guidelines for Primary and Secondary Care.
5
Second –Line Therapy for Heart Failure due to left ventricular Systolic
Dysfunction (LVSD).
Guidelines for Primary and Secondary Care.
6
Protocol for Initiation of Beta-blockers in Heart Failure Patients.
7&8
Spironolactone in Heart Failure due to LV Systolic
Dysfunction (LVSD)
9
Purpose
This policy is to ensure that all adult patients with chronic heart failure are treated
appropriately, based on research and/or best practice evidence
Aim and Scope:
These guidelines apply to all staff involved in the management of chronic heart failure
patients in both Primary and Secondary care settings. It will support clinical decision making
so as to improve the standards and outcomes for these patients.
Implementing the policy:
The successful implementation of this guideline relies on dynamic education and awareness
training programme for all staff (Primary and Secondary Care).
It will be distributed throughout Primary and Secondary Care.
CG-T/2008/019
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References:
Baig,M., Mahon, N., McKenna, W., Cafario, A., Bonow, R., Francis, G.and Gherioade,M. (1999) The
pathophysiology of advanced heart failure. Heart and Lung Vol.28 No. 2 pp87-101.
Cotter, G., MetzKor, E., Faigenberg, Z., Miller, R., Simovitz, A., Shaham, O., Marghitay, D,.Lpren, M., Blatt, A.,
Moshkovitz, Y., Zaidenstein, R., Golik, A. (1998) Randomised trial of high-dose isosorbide dinitrate plus
low-dose furosemide versus high dose furosemise plus low-dose isosorbide dinitrate in severe
pulmonary oedema. The Lancet 351. 9100 pp389-93
Davies, M., Gibbs, G.and Lip (2000)(3) ABC of heart failure: diuretics, ACE inhibitors and nitrates. British
Medical Journal Vol. 320 pp.428-431
Jackson,G., Gibbs,C., Davies,M., Lip,G. (2000) ABC of heart failure: pathophysiology of heart failure. British
Medical Journal Vol. 320 pp.167-170.
Millane, T., Jackson, G., Gibbs, C.R., Lip, G.Y.H. (2000) Acute and chronic management strategies IN Gibbs,
C.R., Davies, M. and Lip(Eds) (2000) ABC of heart failure pp.33-39. BMJ Books. London
th
Opie, L.H. (1997) Drugs for the Heart 4 Edition. W.B.Saunders. Philadelphia.
Stewart, S., Blue, L. (2001) Improving outcomes in chronic heart failure. BMJ Books. London
Documentation Control:
Shared Care Guidelines
Development of Guideline:
Dr Burn. Consultant Cardiologist
Consultation with:
Medical Services Directorate
Clinical Governance Steering Group, Clinical
Guidelines Group, D&T, NMAC,MAC, DPAG
And Clinical Services development Group
Acute Trust
Signature:
Date:
Print name and position:
July 2008
Chair of Clinical Guidelines Group, Derby
Hospitals NHS Foundation Trust
Date of approval
September 2004
Primary Care Trust
Signature:
Print name and position:
Date of approval
19th October 2005
Dr Paul Nathan PEC Chair (Chair CSDGroup)
Central & Greater Derby PCTs
October 2005
Review date:
August 2010
Distribution and Location of
Guideline:
All Acute wards and departments
and
The 5 Southern Derbyshire PCT’s
Cardio thoracic Consultant
Date:
Key Contact:
CG-T/2008/019
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DERBY HOSPITALS NHS FOUNDATION TRUST
ASSESSMENT OF NEW PATIENTS PRESENTING WITH SUSPECTED HEART FAILURE
IN PRIMARY CARE
Symptoms and/or signs suggestive of heart failure i.e. breathlessness, fatigue,
oedema
N.B. BNP = B-Type
Natriuretic Peptide
(NT – proBNP assay)
Perform CXR and ECG: send blood
sample for BNP assay.
Check FBC, Biochem, LFT, TFT,
urinalysis and blood glucose
Exclude anaemia,
renal disease &
thyroid disease
If ECG, CXR and
BNP normal, with no
past history of heart
disease or MI
If ECG and BNP are normal
but a new CXR abnormality is
present (except for definite
pulmonary congestion or
cardiomegaly)
If abnormal ECG,
or raised BNP, or
cardiomegaly on
CXR or pulmonary
congestion on CXR
Consider referral to the
Respiratory Medicine
Department
HEART FAILURE
IS A LIKELY
DIAGNOSIS
Consider other
causes for
symptoms and
investigate as
appropriate
Any of the following:
valvular heart disease,
undiagnosed murmur,
angina, uncontrolled
arrhythmia?
YES
Refer to Secondary Care (Cardiology,
Medicine or DME as appropriate).
Start diuretics if symptomatic
NO
Refer for Open Access
Echocardiography or to
Secondary Care (if preferred)
Start diuretics if symptomatic
CG-T/2008/019
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DERBY HOSPITALS NHS FOUNDATION TRUST
ECHOCARDIOGRAPHY IN SUSPECTED HEART FAILURE – PRIMARY CARE
GUIDELINES
Patient with suspected Heart Failure – Referred for Echocardiogram
Echocardiogram result returned to referring GP
Echocardiogram
reported as normal LV
systolic function and no
significant valve disease
Echocardiogram reports
significant valve disease –
any degree of aortic stenosis,
aortic regurgitation or mitral
stenosis; mitral regurgitation
which is more than mild in
degree
Refer to the
Cardiology
Service
Reconsider the diagnosis
of Heart failure – consider
any other causes for the
symptoms
Echocardiogram has
confirmed LV
systolic dysfunction
(LVSD) (mild or
Moderate or severe)
Heart Failure due
to LVSD confirmed
REFER TO THE
GUIDELINES FOR
LVSD THERAPY
If still doubt about the
diagnosis, discuss with
Consultant Cardiologist
Management in Primary or Secondary
Care (according to preference) with HF
Specialist Nurse Service Input
CG-T/2008/019
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DERBY HOSPITALS NHS FOUNDATION TRUST
First-Line Management of Heart Failure due to Left Ventricular
Systolic Dysfunction (LVSD)
(Guidelines for Primary and Secondary Care)
Echocardiogram has confirmed LVSD (mild, moderate or severe; or measured LV ejection fraction less
than or equal to 40%)
•
•
•
•
•
•
General Measures in all cases:
Discontinue aggravating drugs if possible: NSAID, calcium antagonists
Specific advice on fluid intake and salt in diet
Address risk factors: smoking, alcohol, obesity, hypertension, diabetes
Follow local guidelines on primary/secondary prevention of CAD
Advice pneumococcal vaccination and influenza vaccination
Start patient-held record – for therapy, weight, risk factors etc.
Initial Treatment for all patients
If signs of fluid retention (oedema, lung crackles, raised JVP, pulmonary congestion on chest Xray) – start oral loop diuretic
• If patient in AF – refer to second-line therapy guidelines for digoxin/warfarin/aspirin use
Start ACE–inhibitor in all patients, unless contraindication (aortic stenosis or suspected renal artery
stenosis) or specialist advice needed (see below)
If contraindication to ACE-inhibitor
Refer to Secondary Care as appropriate
•
•
•
•
•
•
Stop potassium supplements or potassium sparing diuretics (risk of hyperkalaemia)
Start ACE-inhibitor at low dosage - warn patient about hypotensive symptoms
Check renal biochemistry after 1 week of therapy
If biochemistry stable, slowly titrate ACE-inhibitor to target dosage or maximally tolerated dose
(suggest at intervals of two weeks). Check biochemistry at each titration stage.
An increase in creatinine > 30% from baseline – halve dose or stop ACE-inhibitor
Target Doses of selected ACE-inhibitor: Lisinopril 30-40 mg od; Enalapril 20 mg bd; Ramipril
10 mg od; Captopril 50 mg tds.
Once on Target or Maximal tolerated dose of ACE-inhibitor
•
•
Repeat renal biochemistry after one month. If stable, check every 6 months or more frequently
if patient status changes (particularly intercurrent illness).
Check for adverse effects – symptomatic hypotension; rise in creatinine to >200umol/l or >
30% from baseline; hyperkalaemia (Potassium>5.5 mmol/l); intolerable cough
If truly intolerant of ACE-inhibitor (except renal dysfunction or hyperkalaemia)
•
•
•
Start angiotensin receptor antagonist i.e. Valsartan 40 mg bd: target dose 160 mg bd; or
Candesartan 4 mg od : target dose 32 mg od. (Titrate doses at intervals of two weeks).
Note: these drugs not currently licensed for heart failure, but good trial evidence exists.
Check renal biochemistry according to guidelines given above for ACE-inhibitors.
Once Established on ACE-inhibitor
or Angiotensin Receptor Blocker +/diuretic
Consider Second-Line Therapy for Heart
failure due to LVSD – see second-line Rx
guidelines
CG-T/2008/019
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1.
2.
3.
4.
5.
Seek Specialist advice before ACE-inhibitor
therapy in following groups:
Creatinine > 150 umol/l
Sodium < 130 mmol/l
Systolic BP < 100 mmHg
Diuretic Dose > 80 mg frusemide per day
(or equivalent)
Known or suspected renal artery stenosis
(eg severe peripheral vascular disease)
Review Date: August 2010
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DERBY HOSPITALS NHS FOUNDATION TRUST
Second-Line Therapy for Heart Failure due to Left Ventricular Systolic Dysfunction
(LVSD)
(Guidelines for Primary and Secondary Care)
Patient with Chronic Heart Failure: Now established on target or maximal tolerated dose of
ACE-inhibitor (or Angiotensin Receptor Blocker if truly intolerant) with or without diuretic
therapy in addition (if evidence of fluid retention)
Patient not in Atrial fibrillation
Patient in Atrial Fibrillation
and has heart failure
•
•
•
Start digoxin if resting heart
rate > 70 bpm
Consider Warfarin if no
contraindication
Aspirin if contraindicated
Then consider:
•
•
•
Beta-blocker therapy
(see guidelines shown)
Spironolactone therapy
(see guidelines shown)
Referral to Cardiology if the AF
rate control is poor or if DC
cardioversion is considered an
option
1.
2.
3.
4.
5.
Is patient suitable for a
Beta-blocker?
Is the patient suitable
for the addition of
Spironolactone?
Indications for Betablocker
Indications for Spironolactone
Stable CHF (NYHA I – III)
No signs of fluid retention
Heart rate > 50 bpm
Systolic BP > 90 mmHg
No contraindications - see
table below
If suitable for Beta-blocker refer
to Secondary Care (Cardiology,
Medicine or DME as appropriate)
or Heart Failure Specialist Nurse
service. A plan for initiation of
therapy will be drawn up.
1. Current or previous severe
heart failure
(NYHA class III– IV)
2. Already on ACE inhibitor
and diuretic
3. No current evidence of
hypovolaemia
If suitable, consult
Spironolactone
initiation guidelines
Contraindications to Beta-blocker therapy in Heart Failure
•
•
•
•
CG-T/2008/019
Asthma
Second or third degree heart block (refer to Cardiology if present)
Sick sinus syndrome (refer to Cardiology if present)
NYHA Class IV heart failure – unless initiated in hospital or supervised by
the Cardiology or Heart Failure Service
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DERBY HOSPITALS NHS FOUNDATION TRUST
PROTOCOL FOR INITIATION OF BETA-BLOCKERS IN HEART FAILURE PATIENTS
Most patients with heart failure due to LV systolic dysfunction should be initiated on
beta-blockers if there is no absolute contraindication. Though this can be done in the
community, some patients will need initiation of beta-blocker therapy under medical
supervision.
The golden rule with beta-blocker therapy in CHF is “start low and go slow” i.e. start at low
doses and slowly titrate dose upward to target, at no less than two week intervals.
Target doses for Therapy
Bisoprolol:
10 mg once daily if tolerated
Carvedilol:
25 mg twice daily if < 85 kg.
50 mg twice daily if > 85 kg.
Protocol for Beta-blocker Initiation
1. Patients observed in suitable area.
2. Baseline BP and observations taken, including baseline body weight.
3. Beta-blocker of choice should be indicated in the notes by the referring doctor; if not one
“rule of thumb” is to use bisoprolol if baseline BP < 110 systolic and carvedilol if systolic
BP ≥ 110.
4. Carvedilol – give 3.125 mg initially. Observe pulse and BP for 4 hours.
5. Bisoprolol – give 1.25 mg initially. Observe pulse and BP for 4 hours.
6. If patients stable – discharge on maintenance of Carvedilol 3.125 mg bd or bisoprolol
1.25 mg od. Continue this dose for 2 weeks.
7. Warn patients about side-effects and how to cope with them (see over).
8. Dose titration: Carvedilol – increase to 6.25 mg bd for 2 weeks if stable,
then to 12.5 mg bd for 2 weeks,
then to 25 mg bd for 4 weeks
then to 50 mg bd if body wt. > 85 kg.
Bisoprolol – increase to 2.5 mg od for 2 weeks if stable,
then to 3.75 mg od for 2 weeks
then to 5 mg od for 4 weeks,
then to 7.5 mg od for 4 weeks,
then to 10 mg od.
9. Before each dose titration, baseline observations are taken as before and body
weight checked. Patient observed for 4 hours after each new dose.
10. Supervised dose titration may take place in the GP’s surgery, patient’s home or under
hospital day-case supervision.
11. At each review, assess patients tolerance to the previously prescribed dose. Deal with
side-effects as detailed overleaf. If in doubt and patient having problems, reduce dosage
to previously tolerated dose and reassess at 4 weeks.
Problems with Beta-blockers in CHF
Patients need to be warned about the potential side effects of beta-blockers in CHF and how
to deal with them. The benefits of persevering with therapy in CHF (the prognostic and
CG-T/2008/019
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therapeutic effects) need to be explained. There are three main side-effects seen during
beta-blocker therapy:
1. Bradycardia
If excessive (heart rate < 50 bpm) or symptomatic bradycardia occurs during dose
titration – review other medication. Reduce dosages of drugs such as digoxin or ratelimiting calcium antagonists first. If necessary, reduce dose of beta-blocker to the
previous level. Review within 1 week and reduce dose further if heart rate still < 50 bpm.
If heart rate falls below 40 bpm, stop beta-blocker and perform ECG to check for AV
block.
2. Vasodilatation and Hypotension
More of a problem with carvedilol than bisoprolol. Symptoms (dizziness or lightheadedness) may occur within two hours of dose titration and usually decrease within a
few days. Separate the dose timing of beta-blocker from other vasodilators by around two
hours; consider temporarily reducing the dose of other vasodilators (including ACEinhibitors). Check for overdiuresis and consider reducing diuretic dosage. If necessary,
reduce dose of beta-blocker to previous range. If symptoms unresolved, stop betablocker. Wait 4 weeks before attempting further upward dose titration.
3. Worsening of heart failure
Symptoms of worsening heart failure include weight gain, increasing dyspnoea or
oedema. May occur within 3 to 5 days of dose titration. Patients should be reassured that
these are usually transient.
Patients should weigh themselves daily (first thing in the morning) and report any
sustained weight increase ( ≥ 1 kg over 3 days). Diuretic dose should be increased to
combat this effect or any increased dyspnoea. Normally, symptoms should improve
within 3 days of an increased diuretic dosage. More severe symptoms usually require
further optimisation of heart failure therapy or temporary reduction (or withdrawal) of
beta-blocker dose. A more prolonged period on the lower dose of beta-blocker may be
required before further upward dose titration (for at least 4 weeks).
The only indications to stop beta-blocker therapy abruptly in CHF are:
Severe symptomatic hypotension
Acute pulmonary oedema
Cardiogenic shock
Severe symptomatic bradycardia
Second or Third degree AV block
CG-T/2008/019
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DERBY HOSPITALS NHS FOUNDATION TRUST
Algorithm for the use of Spironolactone in Heart Failure due to LV
Systolic Dysfunction (LVSD)
(Guidelines for Primary and Secondary Care)
Confirmed LV Systolic Dysfunction – Moderate or Severe LVSD on echocardiography or
LV ejection fraction less than or equal to 35% (Note: LVSD more severe than in the other
guidelines for initiation of heart failure therapy).
Suitable for initiation of Spironolactone?
Spironolactone Contraindicated
•
•
•
Indications for Spironolactone
•
•
•
Serum potassium > 5 mmol/l
Serum creatinine > 150 umol/l
Known acute liver disease
Check biochemistry; stop potassium
supplements and other potassium-sparing
diuretics before starting spironolactone
• Caution if low body weight (<50 kg)
• Potassium must be < 5 mmol/l
• Continue ACE-inhibitor, loop diuretics,
beta-blocker and digoxin if already
prescribed
• Liase with Heart failure Nurse service
If spironolactone contraindicated or is
withdrawn and patient is still NYHA
class III – IV despite therapy with a loop
diuretic, ACE-inhibitor and betablocker
Refer to Secondary Care.
(Cardiology, Medicine,
Nephrology or DME as
•
•
•
Severe heart failure (NYHA III – IV)
Already on ACE-inhibitor and diuretic
No evidence of hypovolaemia
•
•
•
•
Commence spironolactone 25 mg od
Repeat biochemistry at day 5
If stable, monitor biochemistry weekly
After 8 weeks, increase to 50 mg once daily
only if still NYHA Class III and biochemistry
stable
Repeat biochemistry at 1 week after any dose
change and weekly for 4 weeks
Once biochemistry and dose stable, repeat
biochemistry every 3 months
Do not exceed 50 mg if patient is on an ACEi
•
Further Monitoring
Patient may become dehydrated
•
on spironolactone – if so reduce
other diuretic dosages or stop
•
spironolactone
If patient develops intercurrent
illness that causes salt and
If intolerant of spironolactone or potassium > 5.5 mmol/l or
water loss (e.g. D & V) -tell
creatinine > 150 umol/l
them to stop spironolactone
• Reduce dose to 25 mg alternate days
Repeat
biochemistry and
CG-T/2008/019
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• If still clinical/biochemical problems – stop spironolactone
monitor closely
• If potassium > 5.9 mmol/l – stop spironolactone