Download the Guideline Summary for Heart Failure

 Caring for Heart Failure Patients Accurate and timely diagnosis is vital to alter the natural history of the disease and to ensure that appropriate evidence based treatments are used in this high risk patient population. Guideline based care has been shown to improve symptoms and quality of life, reduce hospitalizations and prolong survival. Definition: Heart Failure is defined as “the inability of the heart to pump a sufficient amount of blood to meet the demands of the body at normal filling pressures” (Ross, Howlett, Malcolm et al, 2006 p.750). Broadly defined, there are two types of HF: Both may present in a similar manner  Systolic Heart Failure (SHF)‐ LVEF < 40%  Heart Failure with Preserved Systolic Function (HFPSF) ‐ LVEF  40% Making the diagnosis in a patient with suspected HF: Remember that HF is a clinical diagnosis and is based on the presence of signs and symptoms consistent with volume overload and/or low cardiac output. Assess for Symptoms  Breathlessness, Fatigue, swelling of the lower extremities, confusion, orthopnea, PND, abdominal bloating and distension, decreased exercise capacity Signs of volume overload  elevated JVP, peripheral edema, ascites, rales, extra heart sounds, displaced apex, low O2sat, weight gain Signs of low cardiac output  hypotension, tachycardia, pallor and cyanosis Identify Important Co‐morbid Conditions: 
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Chronic Kidney Diseases COPD Anemia Depression Created by: Sean Virani, Andrew Ignaszewski, and Bonnie Catlin, Adapted from: MoH Heart Failure guideline:
Reviewed by: Heart Failure Network Resource Working group
Identify Important Causes for HF: 
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Cardiovascular risk factors or established history of vascular disease Thyroid disease Alcohol or substance abuse Family History Atrial Fibrillation Toxic exposures including chemotherapy and radiation therapy Diagnostics: 
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Assessment of left ventricular function (eg. Echo, MIBI, MUGA) CXR 12 lead ECG Suggested laboratory investigations o Electrolytes o Renal function including eGFR o CBC o TSH o UACR, HbA1c and FBS in diabetics o Lipids If high index of suspicion of HF in the absence of S& S or if there is limited access to diagnostic imaging, consider  BNP or NTproBNP New York Heart Association Functional Class (NYHA) Functional Class I II III IV Severity No symptoms Can perform ordinary activities without any limitations No symptoms at rest Occasional swelling Somewhat limited in ability to exercise or do other strenuous activities Symptoms with less than ordinary activity Noticeable limitations in ability to exercise or participate in mildly strenuous activities Comfortable only at rest Symptoms at rest Unable to do any physical activity without discomfort Created by: Sean Virani, Andrew Ignaszewski, and Bonnie Catlin, Adapted from: MoH Heart Failure guideline:
Reviewed by: Heart Failure Network Resource Working group
Treatment: Non pharmacological  Multidisciplinary HF care including specialized HF clinics where available  Patient Education with focus on HF self management o Diet  Low sodium diet (less than 2000mg per day)  Fluid restriction ( to 1.5 L/day or 4‐6, 8oz glass per day) o Activity (if stable HF, attempt regular aerobic and anaerobic activity OR refer to cardiac rehabilitation program) o Smoking cessation counseling or referral to smoking cessation program where available o Daily weights  Weight gain (No more that 4 lbs (2 kg) in 2 days or > 5 lbs (2.5 kg) in one week)  Immunizations  Counseling for alcohol abstinence and substance abuse  Advanced care planning Discussion initiated early in the disease course and particularly when symptoms and/or functional status declines despite maximal medical therapy.  Discussion about natural history of the disease and prognosis in all cases  Address all precipitating factors: angina, hypertension, sodium and fluid restriction, adherence to medications, contributory conditions  Ensure all active therapeutic options have been appropriately considered (ICD, biventricular pacing, revascularization, transplant) Once the decision to initiate end‐of‐life care is made, the goal of therapy is to manage all symptoms (including those of comorbid conditions, e.g. chronic pain) and address function and quality of life issues. Subsequent care should be based on the following principles o Support of dying patients and their families o Control of pain and symptoms ( eg. overload)  Consider choice and dose of narcotic as renal function is likely impaired – i.e. Hydromorphone for narcotic naïve, Duragesic patch.  Consider narcotic use with uncontrolled angina, or as a first‐line for dyspnea  Consider home oxygen (See COPD Guideline for indications http://www.bcguidelines.ca/guideline_copd.html)  Adequate diuretic use (sometimes more than one agent) is important  ACE‐I dose may need to be reduced if limited by symptomatic hypotension and renal impairment (Cr > 250 μmol/L or > 30% from baseline) o Decisions on the use of life‐sustaining therapies Created by: Sean Virani, Andrew Ignaszewski, and Bonnie Catlin, Adapted from: MoH Heart Failure guideline:
Reviewed by: Heart Failure Network Resource Working group
Pharmacological Treat all cardiac risk factors If LVEF, <40% start ACE‐I +/‐ Beta Blocker S& S of volume overload Start Diuretic (Minimum dose to control overload)
Systolic HF (SHF) HF with Preserved Systolic Function (HFPSF) LVEF <40% LVEF >40% ACE‐I + Beta Blocker Treat underlying causes (HTN, atrial fib, ischemia) Consider ARB +/‐ Beta Blocker
Titrate to maximum does If not tolerating ACE switch to ARB Still symptomatic
Yes: NYHA III‐IV
Yes: NYHA II‐III No: NYHA Class I
Increase or combine diuretics, add Add: Aldosterone Blockade OR ARB Continue current therapy aldosterone blockade Consider: and wean diuretic to Consider: Referral (eg. Cardiologist, lowest possible dose Digoxin, specialist referral (eg. heart function clinic, admission to Internist, Cardiologist, Heart Function Clinic) Medications: acute care for class IV) Ensure the patient is started on HF medication appropriate for the type of HF (e.g. SHF versus HFPSF) and titrate medications to maximal tolerated target dose ACE Inhibitors Captopril Enalapril p) Perindopril Ramipril Trandolapril Starting dose 6.25 to 12.5 mg TID 1.25 to 2.5 mg BID 2 to 4 mg daily 1.25 to 2.5 mg BID 1 to 2 mg daily Target dose 25 to 50 mg TID 10 mg BID 4 to 8 mg daily 5 mg BID 4 mg daily Starting doses Target dose 4 mg daily 40 mg BID 32 mg daily 160 mg BID ARBS (if unable to tolerate ACE’s) (Special Authority required: call the below # 1-250-952-1216 (direct) or
1-877-657-1188) Candesartan Valsartan Created by: Sean Virani, Andrew Ignaszewski, and Bonnie Catlin, Adapted from: MoH Heart Failure guideline:
Reviewed by: Heart Failure Network Resource Working group
Beta Blockers (only initiated when patient is not in fluid overload) Bisoprolol Carvedilol (Special Authority required) : call the below # 1-250-952-1216 (direct) or
1-877-657-1188) Metoprolol CR/XL (not covered by MSP) Metoprolol Starting dose 1.25 mg daily 3.125 mg BID Target dose 10 mg daily 25 mg BID 50 mg BID( if weight is greater than 85 kg)50 mg r than 85 kg 12.5 to 25 mg daily 200 mg daily 12.5mg BID 100mg BID Starting dose Maximum total daily dose Furosemide 20 mg– 40 mg daily or BID 600 mg Bumetanide 0.5mg – 1 mg daily or BID 10 mg Ethacrynic acid 25mg –50 mg daily or BID 400 mg THIAZIDE Metolazone 2.5 mg daily 20 mg Starting dose 12.5 mg daily Target dose 25 mg daily 50 mg daily Diuretics LOOP Aldosterone Blocking Agent Spironolactone Eplerenone (not covered by MSP) 25 mg daily Should be considered early post MI Vasodilators Hydralazine Isorbide dinitrate Starting dose 37.5mg TID or QID 20mg TID Target dose 75 mg TID or QID 40mg TID Indication for referral to heart failure specialist: 
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New onset of heart failure Worsening heart failure Heart failure with suspicious murmur Titration of heart failure medications Heart failure with atrial fibrillation or other arrhythmias Patients with NYHA class II‐ IV o NYHA class I‐III should also be referred to a cardiac rehabilitation program  Patients with recent or repeated admissions to hospital experience long term benefits associated with referral to a Heart Function Clinic that offer inter‐professional collaborative HF care, evidenced based medical therapy, ongoing close monitoring and individualized interventions tailored to the specific patients needs Created by: Sean Virani, Andrew Ignaszewski, and Bonnie Catlin, Adapted from: MoH Heart Failure guideline:
Reviewed by: Heart Failure Network Resource Working group
Management of HF with co‐morbid conditions: Chronic Kidney disease  Stable renal function: standard therapy including ACE‐I, ARB or spironolactone (if eGFR <45); monitor K+ and creatinine often  Declining renal function/persistent volume overload (Assess for reversible causes, e.g., meds, infection, hypovolemia and hypotension)  Renal impairment (creatinine increase > 30%; eGFR < 30mL/min or <45 mL/min with unknown cause). Refer to nephrology Anemia (Hb < 110 g/L; generally symptomatic at Hgb < 90 g/L)  Investigate and treat underlying cause  Replace substrate deficiencies, e.g., iron, B12, folate  No evidence for use of erythropoetin (or darbepoetin)  If anemia and advanced symptoms persist, consider blood transfusion Management during intercurrent illness:  Pneumonia/COPD: Continue ß‐blockers, ACE‐I, ARBs at usual dose unless not tolerated; if concerned, briefly decrease beta‐blocker to 50% of patient’s regular dose; do not abruptly discontinue these medications  Acute dehydrating illness: Promptly evaluate renal function and electrolytes and adjust medications as needed  Surgery: Ensure evaluation by a physician experienced in peri‐operative HF management  Gout: Oral colchicine ± prednisone; avoid NSAIDs; prevent gout with allopurinol or reduced diuretic doses For further information on caring for your HF patient refer to the Provincial Heart Failure Network Website: www.bcheartfailure.ca Created by: Sean Virani, Andrew Ignaszewski, and Bonnie Catlin, Adapted from: MoH Heart Failure guideline:
Reviewed by: Heart Failure Network Resource Working group
References Arnold, J.M.O et al. (2006). Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: Diagnosis and Management. Canadian Journal of Cardiology, 22(1), 23‐45. Arnold, J.M.O et al. (2008). Canadian Cardiovascular Society consensus conference guidelines on heart failure‐2008 update: Best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies. Canadian Journal of Cardiology, 24(1), 21‐40. Howlett, J.G. et al. (2010). The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs. Canadian Journal of Cardiology, 26(4), 185‐202. Ross, H. et al. (2006). Treating the Right Patient At The Right Time: Access to heart failure care. Canadian Journal of Cardiology, 22(9), 749‐754. Howlett, J.G. et al. (2009). Canadian Cardiovascular Society consensus conference guidelines on heart failure, update 2009: Diagnosis and management of right‐ sided heart failure, myocarditis, device therapy and recent important clinical trials. Canadian Journal of Cardiology, 25(1), 85‐105. 2008, British Columbia Ministry of Health, Heart Failure Guideline. Retrieved: June 30, 2011. http://www.bcguidelines.ca/guideline_heart_failure_care.html Created by: Sean Virani, Andrew Ignaszewski, and Bonnie Catlin, Adapted from: MoH Heart Failure guideline:
Reviewed by: Heart Failure Network Resource Working group