Download Clinical guidance for the Management of patients with confirmed

Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Clinical guidance for the management of
patients with confirmed Heart Failure in
primary care in Lincolnshire
Reference No:
Version:
2.0
Ratified by:
Date ratified:
Name of originator/author:
LCHS Heart Failure Complex Case Managers
Name of responsible
committee/individual:
Clinical Governance Committee
Date issued:
June 2010
Review date:
June 2012
Target audience:
LCHS
Distributed via:
myMail
Website
1
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Lincolnshire Community Health Services
Clinical guidance for the management of patients with confirmed
Heart Failure in primary care in Lincolnshire – June 2010
Version Control Sheet
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Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Lincolnshire Community Health Services
Clinical guidance for the management of patients with confirmed
Heart Failure in primary care in Lincolnshire – June 2010
Contents
i)
Version Control Sheet
ii) Policy Statement
SECTION
PAGE
1
Summary of the purpose of the guidance
5
2
Indications for the use of the guidance
5
3
Associated Policies/Guidance
5
4
Contents
6
5
Useful Weblinks/Contacts
39
6
Other useful information
39
7
Audit/Monitoring of policy implementation
43
8
Implementations Strategy
43
9
References
40-42
3
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Lincolnshire Community Health Services
Clinical guidance for the management of patients with confirmed
Heart Failure in primary care in Lincolnshire
Policy Statement
Background: This Clinical guidance outlines the diagnosis and clinical
management for patients with a diagnosis of chronic heart failure.
Statement:
The guidance outlines a series of algorithms to support the
management of patients with a diagnosis through end of life.
Responsibilities
Training
The heart failure Complex Case Managers plan to deliver education
regarding the management of patients with chronic heart failure
which is based on the guidance.
Dissemination: This guidance will be distributed via My mail and available on the
NHS Lincolnshire website
Resource implication: The clinical guidance will be further reviewed and amended
in light of the latest NICE guidance (2010) once services
have been commissioned to implement the guidance
4
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Summary of the purpose of the Guidance
The purpose of this document is to provide guidance and a pathway for the treatment of
patients with heart failure. The guidance is separated into two parts, the first addresses best
practice in the clinical management of heart failure itself and the second focuses on
management of symptoms commonly experienced in advanced heart failure and is concerned
with palliative and supportive care.
The guidance takes the form of a series of algorithms supporting the optimal pharmacological
and non pharmacological management including appropriate referral pathways to specialist
heart failure services.
The term Heart Failure Complex Case Manager will be used throughout the (HFCCM). The
role is a specialist nursing role incorporating complex case management, clinical assessment,
diagnosis, non-medical prescribing and management of patients with chronic heart failure.
The role meets the educational standards as set out by the British Heart Foundation. The
term GPsi will be used throughout indicating the role of a general Practitioner with a special
interest in heart failure
Indications for the use of the Clinical Guidance
The algorithms should be used in conjunction with the associated national standards and
NICE guidance in order to support the stabilisation of a patient‘s heart condition through
optimising treatment, providing support and where necessary palliative care.
Associated Policies/ Guidance
National Institute for Clinical Excellence (NICE), 2003, Management of chronic heart failure in
adults in primary and secondary care.
Department of Health (2000), Heart Failure, Chapter Six, National Services Framework for
Coronary Heart disease
Cheshire West Primary Care Trust (2004), Clinical Guidance for the Management of Patients
with suspected or confirmed Heart Failure.
British National Formulary
Greater Glasgow NHS Board (June 2001), Medical Therapy Guidelines
Heart Failure Protocol (February 2005), Gaynor Rickell, Swallowbeck Surgery, North
Hykeham
ULHT Heart Failure Nurse Services Protocols and PGD‘s, ULHT
National Instutute for Health and clinical Excellence (2010) Chronic Heart Failure,
Management of Chronic heart failure in adults in primary and secondary care.
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (2008)
5
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Review date: June 2012
Contents:
Diagnosis and Management of Chronic Heart Failure
ALGORITHM FOR THE MANAGEMENT OF „SUSPECTED‟ AND „CONFIRMED‟ HEART FAILURE (LEFT VENTRICULAR
SYSTOLIC DYSFUNCTION) IN PRIMARY CARE BASED ON NICE GUIDELINES JULY 2003 ........................................ 7
ALGORITHM FOR PHARMACOLOGICAL TREATMENT OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION ................. 8
ALGORITHM FOR THE USE OF AN ACE INHIBITOR FOR „CONFIRMED‟ HEART FAILURE IN PRIMARY CARE BASED
ON NICE GUIDELINES 2003. .................................................................................................................................. 9
ALGORITHM FOR USE OF BETA BLOCKERS FOR „CONFIRMED HEART FAILURE IN PRIMARY CARE BASED ON NICE
GUIDELINES 2003 ................................................................................................................................................. 10
ALGORITHM FOR THE USE OF ANGIOTENSION RECEPTOR ANTAGONISTS (ARB) FOR CONFIRMED HEART FAILURE IN
PRIMARY CARE BASED ON CHARM 2003 ........................................................................................................... 11
ALGORITHM FOR THE USE OF DIURETICS FOR CONFIRMED HEART FAILURE IN PRIMARY CARE........................... 12
ALGORITHM FOR THE USE OF SPIRONOLACTONE FOR „CONFIRMED‟ HEART FAILURE IN PRIMARY CARE BASED ON
NICE GUIDELINES 2003 ....................................................................................................................................... 13
ALGORITHM FOR THE USE OF METOLAZONE FOR „CONFIRMED‟ HEART FAILURE IN PRIMARY CARE .................. 14
ALGORITHM FOR THE USE OF CARDIAC SYNCHRONISATION (CRT) THERAPY &/OR INTERNAL CARDIOVERTER
DEFIBRILLATORS (ICD), OR BOTH (CRT-D) BASED ON TECHNOLOGY APPRAISAL GUIDANCE 120 & 95 .............. 15
ALGORITHM FOR NON PHARMACOLOGICAL MANAGEMENT FOR „CONFIRMED‟ HEART FAILURE IN PRIMARY
CARE ................................................................................................................................................................... 15
Management of Advanced Heart Failure
MANAGEMENT OF SYMPTOMS COMMONLY EXPERIENCED IN ADVANCED HEART FAILURE ................................... 17
WHEN DOES A HEART FAILURE PATIENT BECOME “PALLIATIVE”? ...................................................................... 18
ISSUES FOR CONSIDERATION WHEN ASSESSING PATIENT‟S NEEDS ........................................................................ 19
MANAGEMENT OF SUSPECTED ACUTE CONFUSION / DELIRIUM ........................................................................... 21
MANAGEMENT OF BREATHLESSNESS ................................................................................................................... 22
MANAGEMENT OF CONSTIPATION ........................................................................................................................ 23
MANAGEMENT OF COUGH ................................................................................................................................... 24
MANAGEMENT OF FATIGUE ................................................................................................................................. 25
MANAGEMENT OF ITCHING .................................................................................................................................. 26
SPECIAL ISSUES FOR CONSIDERATION WHEN MANAGING PAIN IN HEART FAILURE............................................. 27
MANAGEMENT OF NAUSEA AND VOMITING......................................................................................................... 28
MANAGEMENT OF PERIPHERAL OEDEMA.............................................................................................................. 29
MANAGEMENT OF POOR APPETITE AND WEIGHT LOSS/ CACHEXIA..................................................................... 30
PSYCHOLOGICAL CONCERNS ............................................................................................................................... 31
MANAGEMENT OF SLEEP DISTURBANCE AND INSOMNIA ..................................................................................... 32
MANAGEMENT OF STOMATITIS / SORE MOUTH ................................................................................................... 33
MEDICINES MANAGEMENT IN ADVANCED HEART FAILURE ................................................................................ 34
MANAGEMENT OF ANAEMIA/GOUT ..................................................................................................................... 34
PATHWAY FOR ADVANCE CARE PLANNING IN PATIENTS WITH CHRONIC HEART FAILURE .................................. 36
IATROGENIC PROBLEMS ....................................................................................................................................... 37
PATHWAY FOR DEACTIVATION OF IMPLANTABLE CARDIOVERTER DEFIBRILLATORS AT END OF LIFE ................ 38
USEFUL WEBLINKS/ CONTACTS ........................................................................................................................... 39
OTHER USEFUL INFORMATION ............................................................................................................................. 39
AUDIT/ MONITORING OF POLICY IMPLEMENTATION ............................................................................................ 43
IMPLEMENTATION STRATEGY .............................................................................................................................. 43
6
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for the management of „Suspected‟ and „Confirmed‟ Heart Failure (Left
Ventricular Systolic Dysfunction) in Primary Care based on NICE guidelines July 2003
If symptoms and/or signs suggestive of heart Failure/Left Ventricular Systolic Dysfunction (LVSD)
Bloods – U&E, FBC, Glucose, TFT‘s, LFT‘s, Lipids: if abnormal investigate and treat accordingly
ECG- IF ECG abnormal, or
}
GP refers for
Chest X-ray- cardiomegaly or congestion
}
Echocardiography
IF ECG and CXR normal, echocardiography usually not indicated (consider other cause of symptoms)
Echo negative
Consider other cause of symptoms
Echocardiography
Cardiologist confirms LVSD- 1
Patients discharged
from hospital with
diagnosis of LVSD
Determine cause of LSVD
-Ischaemic heart disease
-hypertension
-Valvular heart disease
-Cardiomypathy
-Myocarditis
-Arrhythmia
-Other
1.
2.
3.
4.
5.
6.
7.
8.
Primary Care Informed of Diagnosis
Add to Heart Failure Register
(read code G5yy9)
First Consultation-2
Patient informed of diagnosis by GP or Nurse
Practitioner competent in Heart Failure
Agree Clinical Management plan
Information booklet
Optimising pharmacological treatment
Blood tests
1. Assessment and management of
decompensated patient.
2. Optimisation of medication in collaboration
with primary team and cardiologist.
3. Palliative care input
Also available for telephone advice on
management issues for Multi-Disciplinary Team
Not all patients need referral to Community heart
Failure Service or Cardiologist
No
Is patient on optimum pharmacological treatment and stable?
Review as clinically indicated or as a minimum annually
Review Date June 2012
I - No limitation of physical
activity
II - Slight limitation
Ordinary activities cause
symptoms
III - Marked limitation. Less
than ordinary activity
causes symptoms, but
comfortable at rest.
IV - Unable to perform any
activity. May have
symptoms at rest
Consider referral to Heart Failure Complex
Case Manager/ GPsi
2/52 wk review by GP or Nurse Practitioner
competent in Heart Failure in Primary Care
Education and advise on chronic Heart Failure
Consider referral to Expert Patient Programme
Clinical Status
Optimising pharmacological treatment
Check renal function
Flu and pneumovax vaccines
NYH classification I-IV
Review as indicated for pharmacological
optimisation
Yes
New York Heart
Association (NYHA) Class
Consider Cardiology referral (if any of the
following)
1. Patients with heart failure age< 65 years
2. Ongoing symptoms despite optimal
medications
3. Failure to respond to treatment
4. Arrhythmia
5. Significant valvular heart disease
6. LSVD due to IHD and candidate for
revascularisation
7. Congenital heart disease
7
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for pharmacological treatment of Left Ventricular Systolic Dysfunction
New diagnostic
Step1 – Start ACE inhibitor
and titrate upwards
See Algorithm for ACE
Inhibitor (page 9)
Add diuretic. Diuretic therapy
is likely to control congestive
symptoms and fluid retention.
Add digoxin. If a patient in
sinus rhythm remains
symptomatic despite therapy
with a diuretic. ACE inhibitor
(or angiotensin II receptor
antagonist) and beta blocker if
a patient is in atrial fibrillation
then use first line therapy
Step 2- Add beta blocker
and titrate upwards
See Algorithm for beta
blocker (page 10)
Step 3- Add spironolactone
If patient remains moderately
to severely symptomatic
despite optimal therapy listed
above
See Algorithm for
spironolactone (page 13)
Or if ACE inhibitor not
tolerated e.g. due to severe
cough. Consider angiotensin
II receptor antagonist
For advice, refer to Heart
Failure Complex Case
Manager/ GPsi +/_ Cardiologist
Telephone or written advice
rather than an outpatient review
will often be sufficient
N/B
Consider adding Angiotensin II receptor antagonist to an ACE I when patients remain either
symptomatic/hypertension under cardiologist supervision/advice.
8
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for the use of an ACE inhibitor for „Confirmed‟ Heart Failure in Primary Care
based on NICE guidelines 2003.
Confirmed Left Ventricular systolic Dysfunction (LVSD)
Suitable for initiation of Angiotensin converting enzyme (ACE) inhibitor
Step 1- Initiation of ACE inhibitor
 Stop potassium supplements/ Potassium
sparing diuretics (because of risk of
hyperkalaemia) with the possible exception
of spironolactone or Explerenone.
 If possible stop NSAID (because of risk of
renal dysfunction)
 Before starting ACE inhibitor, educate
patient about purpose, benefits and
possible side effects of medications(ie
dizziness, light-headedness, cough).
 Start with low dose ACE inhibitor
Step 2- Review after 1-2 weeks
 Check U&Es at 10 days
 Check for adverse effects
Symptomatic hypotension
Renal dysfunction (rise in Creatinine to
200umol/l)
Hyperkalaemia (rise in potassium to
>5.5mmol/l)
Intolerable cough (NOT just dry cough)
 Titrate to an intermediate dose if lower dose
is tolerated and U&Es satisfactory
 If no adverse effects uptitrate to maximal
tolerated dose.
 Check U&Es at 10 days and 4 weeks
Step 2- Review patient once optimal dose
reached
Check U&Es
Check for adverse effects
Symptomatic hypotension
Renal dysfunction (rise in Creatinine to > 200
umol/l
Hyperkaleamia (rise in potassium to > 5.5
mmol/l
Intolerable cough (NOT just dry cough)
Review Date June 2012
Specialist advice required before
staring ACE inhibitor if any of the
following:
 Creatinine > 200 umol/I
 Urea > 12mmols
 Sodium< 130mmol/I
 Systolic arterial pressure < 100mm Hg
 Diuretic dose > Furosemide 80mg/ day
or equivalent
 Known or suspected renal artery
stenosis (eg peripheral vascular
disease) or aortic stenosis
 Frail, Elderly
Refer to Heart Failure
Complex Case Manager/
GPsi +/- Cardiologist
Telephone or written advice
rather than an out patient
review will often be sufficient
If clinically
unstable
If clinically unstable
If clinically
unstable
If TRULY intolerant of ACE inhibitor
 Consider angiotensin II receptor
antagonist – e.g. Candesartan 4mg
daily and uptitrate to 32mg daily as
tolerated. Uptitrate similar to ACE
inhibitor.
 Consider hydralazine 12.5mg qds and
isosorbide dinitrate (ISDN) 20mg qds
as and alternative. Increase to
maximum daily dose of hydralazine
300mg and ISDN 160mg
9
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for use of Beta blockers for „confirmed Heart Failure in Primary Care based
on NICE guidelines 2003
Confirmed Left Ventricular Systolic Dysfunction (LVSD)
Suitable for initiation of beta blocker?
Step 1- Assess whether suitable for treatment


Monitor for signs of sodium and water retention e.g.
oedema, lungs crackles, rise JVP or congestion on CXR.
Monitor heart rate and blood pressure, i.e. heart rate
>60bpm & no heart block on recent ECG and systolic blood
pressure > 100mmHg
 Already on ACE inhibitor ± diuretics ± Digoxin
Step 2- Assess where treatment should be initiated
 Nothecontraindications
Identify
most appropriate environment for the patient for beta
block initiation. The options include;
Initiation in primary care at GP surgery
Initiation in primary care at home
Primary care beta blocker mass initiation clinics
Step 3- Initiation
of Beta
Secondary
care blocker
initiation as a day case
Start with lowest recommended dose
Educate the patient re: purpose, benefits and signs of worsening
heart failure, e.g. patients should be taught how to weigh
themselves correctly
If taking other rate reducing medication, consider reduction in dose
Adverse effects
Marked fatigue- reassure patient of likely improvement in
symptoms. Review- 2 weeks
Worsening heart failure- Consider adding or increasing dose of
loop diuretic
Symptomatic hypotension- Consider reduction in dose of nitrates,
calcium channel blockers or other vasodilators. Consider reducing
diuretic if no congestion.
If heart rate <50 bpm, obtain ECG. If taking other rate reducing
medication, consider reduction in dose.
Consider having dose of Beta Blocker
If already taking a beta
blocker continue drug
unless patient becomes
more symptomatic
Beta blocker probably contraindicted
Asthma, Severe COPD, Heart block. Sick-sinus syndrome, BP<
100mm/hg, Bradycardia <60bpm
Primary Care Initiation either in GP surgery or in mass initiation
clinics
To be suitable for primary care initiation then the following should apply;
1.
Definite echo proven diagnosis of heart failure due to left
ventricular dysfunction.
2.
Patient already on a loop diuretic
3.
No beta blocker contraindications
4.
No ongoing fluid overload/oedema
Primary care initiation at home
1.
Many patients are suitable for initiation at home;
2.
Systolic BP. 120mm/Hg
3.
Able bodied partner at home with telephone during
initiation.
4.
Patient/carer educated to call for help in unlikely (<2%)
incidence of untoward symptoms.
Secondary Care Initiation
Refer to Heart Failure Complex Case Manager/ GPsi +/Cardiologist
For initiation of beta blockers either in a mass initiation
clinic in primary care or for initiation in secondary care as a
say case.
For other requests, telephone or written advice rather than
an out patient view will often be sufficient.
Step 4- Disease increase




Beta blocker dosing schedule
Please see BNF for recommended doses. Dose depending on patients
condition and clinical judgement, e.g. in frail, elderly standard up
Uptitration of dose following dose schedule (every 2-3 weeks)
titration may need longer.
Aim for target dose or, failing that, the highest tolerated dose
Carvedilol dose schedule- Indications- treatment of stable mild to
moderate chronic heart failure (NYHA I-III) in addition to standard
Check U&Es and creatinine 1-2 weeks after initiation and 1-2 weeks
therapy.
after final dose titration
Bisoprolol dose schedule- Indications- treatment of stable chronic
moderate to severe heart failure (NYHA II-IV) with reduced ventricular
function in addition to standard therapy.
Nebivololbe considered
in light
of the
seniors advice.
trail in patient
If intolerant of Beta Blocker- Consider reducing dose and review in
2 weeks. May
Consider
stopping or
seeking
specialist
Beta over
the age
of 70specialist
EFC 35%advise should be sought before treatment
blockers should not be stopped suddenly unless absolutely necessary;
ideally
discontinuation. This algorithm is intended as a guide to care only and does not replace clinical judgement
Revised HF guidance Nov. 2007
Prior to each uptitration check heart rate and blood pressure i.e.
heart rate >50 bpm & systolic blood pressure > 100mmHg
10
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for the use of angiotension receptor antagonists (ARB) for confirmed heart
failure in primary care based on CHARM 2003
Confirmed Left Ventricular Systolic Dysfunction (LVSD)
Suitable for ARB in
addition to ACE I?
If using instead of
ACE I see ACE I
Algorithm
Asses whether suitable for treatment
Patients who are still symptomatic
despite therapy with an ACE I and
Beta-blocker following specialist
advice
Specialist advice required before starting ARB if any of
the following:
 Creatinine > 200umol/l
 Urea > 12mmols/l
 Sodium <130mmol/i
 Systolic arterial pressure < 100mm Hg
 Diurectic dose > Furosemide 80mg/day or equivalent
 Known or suspected renal artery stenosis (eg peripheral
vascular disease) or aortic stenosis
 Frail, elderly
Step 1- Review patient after 1-2 weeks
 Check U&Es at 10 days
 Check for adverse effects
- symptomatic hypotension
- renal dysfunction (rise in Creatinine to >200
umol/l)
- hyperkalaemia (rise in potassium to >5.5 umol/l)
 Titrate to an intermediate dose if lower dose is
tolerated and U&Es satisfactory
 If no adverse effects uptitrate to maximal tolerated
dose
 Check U&Es at 10 days and 4 weeks
Step 2- Review patient once optimal dose reached


Refer to Heart Failure
Complex Case Manager/
Cardiologist
Telephone or written
advice rather than an out
patient review will often
be sufficient
Check U&Es
Check for adverse effects
-symptomatic hypotension
Renal dysfunction (rise in creatinine to >200 umol/l)
- hyperkalaemia (rise in potassium to > 5.5 mmol/l)
11
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for the use of Diuretics for confirmed Heart Failure in Primary Care
Confirmed Heart Failure
Step1- Assess for signs and symptoms of water and sodium Retention
Increased peripheral oedema- Raised JVP?
Symptoms of breathlessness – PND and orthophoea?
IF YES - Are they on a loop Diuretic?
Yes
No
Up titrate to MAX 80mg furosemide or
equivalent if clinically indicated
Signs symptoms still present?
Consider: latest U+Es/ CKD stage,
BP/Hypotension and allergies, taking into account
the risk/benefit ratio for the patient
Suitable for Initiation of loop Diuretic?
No
Yes
Yes
Seek Specialist Advice
No
Aim to maintain
on dry weight
minimal dose
required.
Monitor U+Es
Consider adverse effects/signs
of dehydration?
Dizziness
Constipation
Weight loss >1kg/day
Reduced skin turgor
Disproportionate rise in urea
Patient Self Management Education:
Weight, signs and symptom monitoring, medication
information, when to seek help.
Commence Loop diuretic
-Furosemide 40mg od
- Bumetanide 1mg od
- Torasemide 10mg od
Check U+Es 7-14 days after starting.
Review in 1-2 weeks post initiation to reassess
Symptoms still present
Ensure
titration and
optimisation
of other heart
failure
treatment.
Consider
referral to
cardiologist
and/or
nephrologist
Symptoms resolved
NB: Diuretics should administered in combination with ACE inhibitors ARBs and B- blockers if tolerated
12
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for the use of Spironolactone for „Confirmed‟ Heart Failure in Primary Care
based on NICE guidelines 2003
Confirmed Left Ventricular Systolic Dysfunction (LVSD)
Suitable for initiation of spironolactone?
Step 1- Assess whether suitable for treatment
 Current or previous symptomatic heart failure (NYHA
III-IV
 Already on optimal pharmacological treatment
 No evidence of hypovolaemia
 Inform patient of purpose, benefits & possible side
effects of spironolactone
Step 2- Check U&Es and review use of potassium
supplements and potassium sparing diuretics
 Potassium must be < 5mmol/l to continue
 Consider stopping potassium supplements and
potassium sparing diuretics
 Continue ACE inhibitor, loop diurectics, Digoxin and
Beta blocker if also prescribed.
Step 3 – Spironolactone initiation
 Commence at 25mg od
Step 4 – Monitoring
 Repeat U&E at 1, 4, 8 & 12 weeks and every 3
months thereafter.
Spironolactone contraindicted
 Serum potassium > 5mmol/l
 Serum Creatinine >220
 Caution if mild to moderate renal impairment
 Caution if using in the frail and elderly if they
are taking ACE inhibitors
Adverse Effects
 Potassium > 5.5mmol/l
- Stop spironolactone or reduce to 12.5
mg daily
- Repeat bloods5-7 days later
 Intolerant to spironolactone
- Consider reducing dose to 12.5mg daily
or if necessary stop
 Gastro-intestinal disturbance
- For diarrhoea, stop spironolactone and
repeat U&Es at earliest convenience
If clinically unstable
If tolerant of spironolactone
 Consider Eplerenone particularly if the
aetiology for heart failure is IHD and if post
Myocardial Infarction
Refer to Heart Failure Complex
Case Manager/ GPsi+/Cardiologist
Telephone of written advice
rather than an out patient review
will often be sufficient.
13
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for the use of Metolazone for „Confirmed‟ Heart Failure in Primary Care
Confirmed Left Ventricular Systolic Dysfunction (LVSD)
Suitable for initiation of Metolazone
Step 1- Assess whether suitable for treatment
Patient not responding to a loop diuretic who
presents one or more of the following
signs/symptoms;
 Increase in weight > 2kg
 Evidence of leg oedema and / or abdominal
distension
 Basal crepitations
 Gallop rhythm
 Raised Jugular Venous Pressure
 Increased dyspnoea
Step 2 – Refer to Heart Failure Complex
Case Manager
 Minimum interval between doses is 24
hours
 Minimum interval between increased
doses is one day
 Educate the patient re: purpose,
benefits and signs of worsening heart
failure e.g. patients should be taught
how to weight themselves correctly
 Advised to stop taking metolazone if
weight loss > 3kg in 24 hours
Metolazone contraindicted
 Weight loss > 3kg in 24 hours
 Blood pressure systolic < 90mmHG
 Serum urea or creatinine rising compared to
previous results
 Sreum postassium < 3.5mmol
 Serum sodium < 125mmol
 Patients unwilling or able to self medicate
 Renal failure with anuria
 Pregnancy with breast feeding
 Liver Failure
 Porphyria
Refer to Cardiologist
14
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for the use of cardiac synchronisation (CRT) therapy &/or internal cardioverter
defibrillators (ICD), or both (CRT-D) Based on NICE technology appraisal guidance 120 & 95
Confirmed Left ventricular Systolic Dysfunction (LVSD)
Suitable for CRT? Or ICD or CRT-D?
Assess whether suitable for
CRT?
 They are experiencing or have
recently experienced class IIIIV symptoms.
 They are in sinus rhythm:
- Either with a QRS duration of
150 ms or longer estimated by
standard
 Electrocardiogram (ECG)
- or with a QRS duration of 120149 ms estimated by ECG and
mechanical dyssynchrony that is
confirmed by echocardiography
 They have a left ventricular
ejection fraction of 35% or less
 They are receiving optimal
pharmacological therapy
Assess whether suitable for
ICD?
„Secondary prevention‟ that is for
patients who present, in the
absence of a treatable cause, with
one of the following:
 Having survived a cardiac


arrest due to either ventricular
tachycardia (VT) or ventricular
fibrillation (VF)
Spontaneous sustained VT
causing syncope or significant
haemodynamic compromise
Sustained VT without syncope
or cardiac arrest, and who have
an associated reduction in
ejection fraction (LVEF of less
than 35%) (no worse than class
III of the N.Y.H.A. functional
classification of heart failure)
 N.B.This criteria does not cover
the use of implantable
defibrillators for non-ischaemic
dilated cardiomyopathy
Assess whether suitable for ICD
„Primary prevention‟ that is for
patients who have:
Either LVSD with LVEF of less
than 35% (no worse than class 3
N.Y.H.A and non-sustainable VT
on Holter (24 hour ECG
monitoring) and inductible VT on
electrophysiological (EP) testing
or LVSD with an LVEF of than
30%, no worse than class 3
N.Y.H.A and QRS duration of
equal to or more than 120
milliseconds
Asses whether suitable for
CRT-D?
Cardiac resynchronisation therapy
with a defibrillator device (CRT-D)
may be considered for people who
fulfil the criteria for implantation of
CRF device and who also
separately fulfil the criteria for the
use of an ICD device.
If meets criteria refer for cardiology refer for cardiology assessment at tertiary centre
N.B. Re primary prevention- A familial cardiac condition with a high risk of sudden death
including long QT syndrome, hypertrophic cardiomyopathy, Brugada syndrome or
arrythmogenic right ventricular dysplasia, or have undergone surgical repair of congenital
heart disease.
15
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Algorithm for Non Pharmacological Management for „Confirmed‟ Heart Failure in Primary Care
Prognosis-explore potential disease progression to include long
term condition and symptom control
Diagnosis
Ensure patient/carer has received
the Information Booklet, i.e.
Living with Heart Failure
Discuss Causes
Explain Anatomy & Physiology
Chest Examination – if competent listen for signs of
clued overload
Clinical
Assessment
Record Height, weight, BMI, BP & HR,
respiration rate, Oedema
Identify NYHA
Classification
Explain general symptom management including





Paroxysmal Nocturnal Dyspnoea, Breathlessness, Cough, Sputum, Orthopnoea
Fatigue including energy conversation and advise on pacing activities, exercise
and sexual activity.
Nausea
Early recognition of worsening symptoms
When and where to seek help
Explain self management of fluids




Educate on the signs & symptoms or peripheral & central oedema
Advise no more than 1 ½ -2 litres/day, depending on clinical signs & symptoms
Consider increased dose of diuretics
Provide patient /
carer with contact
numbers for both in
office hours and out
of hours
Educate on daily weights including who to contact for advice if > 4Ibs over 2 days
Self Management
Diet- Discuss a balanced nutritional intake and explain rationale for the increased risk
of malnutrition and cardiac cachexia
Salt


Consider referral for
Cardiac/lifestyle
rehabilitation. This
may include exercise
Consider referral to
dietician for patients
with cachexia /
obesity
Educate on reducing salt intake
Caution on the use of ―Low Salt‖ and raise awareness on the salt in processed
food.

Advise on 2g sodium per day.
Alcohol


Educate on reducing alcohol intake
Negotiate intake with individual if appropriate
Smoking – Advise on benefits of stopping
Medication – discuss reasons for medications and concordance issues is needed


Psychological/
Social Needs
Advise on avoiding aggravating medication, e.g. NSAIDs and rate increasing
calcium channel blockers
Advise on immunisation
 Psychological Needs
 Assess for symptoms of depression- as per NICE guidance (2009)
 Assess for symptoms of anxiety
 Advise on support groups- British Heart Foundation, Cardiomyopathy Association
Carers Needs
Encourage carer involvement including joint attendance at appointments
Check their understanding of condition & care
Next Review
Home & social situation
 Assess environment and peer support mechanisms.
Following initial assessment, frequency of review of Non pharmacological management
is indicated by clinical need. Minimum review is annual
Review Date June 2012
Consider referral to
smoking cessation
programme
If symptoms of
depression noted,
advise patient to refer
self to GP or refer to
the local Mental Health
team
Advise on relaxation
techniques
Draw patient‘s attention
to the contact details in
the information booklet
Consider referral to
Social Services
including OT
assessment
Consider benefits
advice including
attendance disability
badge etc.
16
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Part Two
Management of symptoms commonly experienced in advanced heart failure
Indication for the development of this clinical guidance
Heart Failure is very difficult to palliative effectively and there are many disease specific barriers to
palliation.
Many previously published guidelines for heart failure focus on active interventional aspects of
management rather than palliation of the disease.
I comparison with cancer patients, Heart Failure patients:





Receive less information and support regarding their illness
Have poorer understanding of the illness and it‘s prognosis
Tend to be less involved in decision-making regarding treatment or non-treatment
Do not perceive themselves as ‖dying‖
Experience frustrations with progressive loss (social and physical), complex medical regimes,
social isolation and exclusion, poorly co-ordinated services and little palliation of symptoms
Common Symptoms and Problems Experienced by Heart Failure Patients














Breathlessness
Cough
Fatigue
Peripheral Oedema
Nausea and Vomiting
Sleep Disturbance
Pain
Anorexia and weight loss
Agitation and Delirium
Increasing Dependence on others
Psychological Concerns: Depression and Anxiety
Constipation
Itch
Carer crisis
These guidance aim to provide advice on the above. It is important to remember that many
symptoms can be iatrogenic nature, some of these are listed also.
17
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
When does a Heart Failure Patient become “Palliative”?
1. You would not be surprised if this patient were to die in the next 6-12months based
on your intuition which integrates co-morbidity, social and other factors.
2. Choice/ Need-patient makes a choice to have only comfort care and no curative
therapy or is believed to need supportive/ palliative care
3. Clinical Indicators
General
Multiple co-morbidities
Weight loss greater than 10% over 6 months
General physical decline
Serum albumin <25g/1
Reduced performance status
Dependence in most activities of daily living
At least 2 of the Indicators specific to Heart Failure
New York Association Class III or IV despite optimal tolerated therapy
Repeated episodes of symptomatic heart failure (this may be seen in terms of
repeated hospital admissions or intensive community management) often with
shorter periods of stability in between episodes.
Difficult physical or psychological symptoms despite optimum tolerated therapy
Deteriorating renal function Chronic Kidney Disease stage 4 or 5
Failure to respond within 2-3 days to changes I diuretic or vasodilating drugs
Place patient on Palliative/ Supportive Care Register
Issue green Card and Fax Out of Hours Handover sheet & complete DS1500
Ensure pre-emptive plan and drugs are organised if appropriate
Days
Consider place of care
Continuing Care funding
Liverpool Care Pathway
Days to Weeks
Consider place of care
Continuing Care Funding
Social care package,
Community Nursing,
Complex Case Manager,
CHFMDT
Weeks to Months
Consider place of care
Consider social care
package, Community
Nursing, Complex Case
Manager support, Day
Hospice, CHFMDT
Consider Referral to Specialist Palliative CareTeam
18
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Issues for consideration when assessing patient‟s needs
Diagnosis and prognosis should be discussed using the principles established as good practice for
―Breaking Bad News‖, bearing in mind that many heart failure patients and their families have little
comprehension of the severity of their illness. Exploration of patient‘s expectations may be of benefit.
Prognosis is particularly difficult to estimate in heart failure and underlying causes of deterioration in
condition/ symptoms such as infection should be treated before considering prognosis in light of
indicators.
Preferred Priorities of Care should be discussed and documented
The complexity of chronic heart failure necessities an individualised approach to the risks and
benefits of various medical therapies. This is often a multidisciplinary process and should always
include the patient. Medicines management should be an ongoing process ensuring optimal medical
management suitable to stage of disease, e.g. withdrawal of satin therapy in last weeks of life.
Discussion of resuscitation status should be undertaken and documented in patient‘s records and
where appropriate communicated to healthcare professionals and ambulance service. This is a
pertinent issue for people with heart failure as their risk of sudden cardiac death (SCD) is 50%
higher than in the general population. SCD is also more prevalent in class I & ii heart failure patients.
Following the issue if NICE guidance there are now increasing numbers of people who will be fitted
with an implantable cardioverter defibrillators (ICD). If someone had an ICD, there will need to be
an open and honest discussion about when and how the defibrillator should be deactivated. Guidance
on Page 38 provides further guidance
Patients should be asked if they have an Advance Decision to Refuse Treatment (ADRT) of have
considered having one- bear in mind new guidance on advanced decisions and mental capacity act.
A Management Plan should be drawn up with the patient and with a written record provided. This
should be communicated to other healthcare professionals as appropriate.
Anticipatory prescribing and planning should be a priority and where appropriate patients should
be supplied with a pack of anticipatory medications and local contact numbers, to avoid problems at
nights, weekends and public holidays. The issue of a green card and faxing of a handover sheet
will allow out of hours and emergency services staff to provide care more appropriately.
Provision of supportive printed information should be given where available and appropriate e.g.
End of Life Booklet (Marie Curie & Cancer Bacup) which is aimed at all conditions not just cancer.
Consideration needs to be given to carer support and referrals to appropriate agencies made.
Follow up arrangements should be discussed and the patients should have clear understanding of
what is likely to happen next.
19
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Place Patient on Palliative and Supportive Care Register (GSF)
Days
Days to Weeks
Weeks to Months
Preferred priorities of
Preferred Priorities of
Identify preferred
care
Care
priorities of care and
social care package
OOH Green Card
Funding of Care
Care Package
Continuing Care
Funding
DS1500 Benefit
OOH Green Card
Care Package
Consider referral to:
 Support Group
 Welfare Advice
 Community Nursing
 Therapists
 Day Hospice for
Palliative
Rehabilitation
 Advanced CHF MDT
 Specialist Palliative
Care
 Carer Support Group
Community Nursing
Support
Liverpool Care Pathway
Advanced CHFMDT
Specialist Palliative
Care
OOH Green Card
Carer Support Group
Months to Years
Social Care
OOH Blue Card
Consider referral to:
Support Group
Benefits Advice
Community Nurses
Therapists
Cardio respiratory
Rehabilitation
 Day Hospice for
Palliative
Rehabilitation
 Advanced CHF MDT
 Carer Support Group





20
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Suspected Acute Confusion / Delirium
 Onset typically hours to days and
Non- Pharmacological Management
clinical features, from which underlying
cause may be elicited.
 Listen to patient and try to explore their fears and
Common Clinical Features
anxieties. These can manifest themselves in
hallucinations and nightmares
 Restlessness, anxiety, sleep
disturbance, irritability, emotional
lability, anger, sadness, euphoria
 Disorientation
 Memory Impairment
 Disorganised thought processes,
altered perception, illusions
hallucinations, delusions
 Incoherent speech
 Attention span reduced, easily
distracted
 Motor abnormalities such as tremor,
altered tone and reflexes
 Remain calm and avoid confronting the patient
 Try to keep patient in as normal and familiar a routine and
place as is possible.
 Explore perceptions and validate those that are accurate
 Explain clearly what is happening and why to patient and
carer(s)
 Try to provide an action plan for what can be done
 Explain management plan and repeat information to assist
retention by patient and family
 If medication is required ensure the length of treatment
course is discussed and stress that delirium is not mental
illness but a state in which periods of lucidity can be
expected.
 Do not use restraints and allow to mobilise if safe to
Treat Underlying Causes
 Infection
 Hypoxia
 Renal Impairment
 Hepatic Impairment/congestion
 Drug toxicity-beta blockers, digoxin,
anti-cholinergics
 Drug withdrawal-opiods, alcohol,
Pharmacological Management
 Benzodiazepines should not be used alone as they can
worsen delirium (unless associated with alcohol
withdrawal)
Consider:
1. Haloperidol either PO,SC (low dose in elderly but can be
increased if poor response)
2. Haloperidol + Benzodiazepine e.g. diazepam or
midazolam
3. If severe Midazolam and levompromazine combined
may be necessary to provide sedation
4. Consider use of a syringe driver
benzodiazepines, SSRIs, nicotine
 Unrelieved pain
 Constipation, urinary retention
If No Improvement after exclusion of underlying causes or it
is inappropriate to treat:
Consider whether this is Terminal Restlessness, which is a
feature of dying.
If dying is diagnosed follow Liverpool Care Pathway
21
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Breathlessness
Assessment
Non pharmacological Management
 Do not Assume due to CHF as
 Consider teaching breathing techniques –refer to
breathlessness is usually multi-factorial
 Assess when they feel breathlessness is
physiotherapist or occupational therapist
 Use a fan to improve airflow around face
a problem
 How much of the day, including
investigating its affect on sleep
 Assess effect on functional abilities and
activity
 Pace activities and plan recovery time
 Consider referral to cardiopulmonary Rehabilitation
or physiotherapy activity programme
 Consider referral to Palliative Rehabilitation Group
 What makes it better or worse
 Consider referral to Hospice Day Care
 Explore Fears
 Consider use of complementary therapies
 Associated symptoms
Pharmacological Management
Identify and Treat Underlying Causes
 Consider:
 Anaemia- common in people with kidney
impairment as blood cells are damaged
and can‘t carry as much oxygen
 Infections or respiratory disease
 Concommitant Problems e.g. COPD, renal
impairment
 Saline nebuliser prn
 Low dose opiates, e.g. codeine phosphate 30mg 4
hourly, low dose oramorph or MST
 Consider laxatives if commenced on opiates
 Lorazepam 0.5-1mg chewed or sublingually prn
 Oxygen
Short of
breath on
exertion
(SOBOE)
 Medication e.g. betablockers
Consider
 Poor symptom control- e.g.
 Nebuliser
 Oxygen
 Diuretics
breathlessness, pain, leg swelling
 Psychological and spiritual issues – e.g.
frustration, stress and low mood, anxiety /
concerns about what the future holds.
 Is disease management optimal?
Short of breath
anxiety related or
at rest
(SOBAR)

Consider
 Oxygen
 Opiate
 Nebuliser
 Benzodiazepine
Terminal SOB
Consider
 Opiate
 Midazolam
 levomepromazine
 If blood oxygen saturation impaired
consider Long Term Oxygen Therapy
Assessment, see appendix for guidelines
Review Date June 2012
22
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of constipation
Assessment
Non-Pharmacologist Management
Assess using Lincolnshire
PCT bowel health
assessment form
 Encourage adequate diet and fluid intake
Establish dietary and fluid
intake
 Stay as active as possible
 Consider the use of prune juice
 Provide information on best position to sit in to pass stool
Record stool chart
 Encourage to sit on the toilet 20 minutes after meals to
Review medication list
take advantage of the gastro colic reflex
 Consider referral to the Community Nursing Team or
Explore attitudes and current
functional capacity e.g. has
mobility recently reduced?
Specialist Continence Clinical Nurse Specialist
Consider DRE (digital rectal
examination) if competent
Pharmacological Management
Identify and treat causative
factors
 Consider use of magrocols e.g. movicol
Inadequate dietary intake
 Consider stool softener e.g. lactulose, sodium docusate
Dehydration from diuretics or
not drinking enough
Immobility
Medications such as opoids
or iron supplements
 Consider stimulant, e.g. senna, glycerine, suppositories,
microlax enema, bisacodyl.
 Consider combination agent e.g. co-danthramer
 Consider sodium docusate enema
 Consider referral to the Community Nursing Team or
Specialist Continence Clinical Nurse Specialist

If opioid-induced constipation, follow:
Mid-Trent Cancer Network Symptom Control Guidelines accessed at: http://
www.information4u.org.uk/files/midtrentsymptomcontrolguidlinesfinal 170506.pdf
23
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Cough
Assessment
Frequency
Non-Pharmacological management

Consider teaching breathing techniques-refer
to physiotherapist or occupational therapist

Use a fan to improve airflow around face
Sputum
Aggravating factors
Relieving Factors
Identify and Treat Underlying
Causes
Consider
Infections
Concomitant Problems e.g.
Respiratory Conditions
Medication e.g. ACE Inhibitors
Is disease management optimal?
Pharmacological Management
 Optimise Heart Failure Management whilst
trying to minimise side effects of drugs.
 Simple linctus or codeine linctus prn
 Low dose Oramorph, e.g. 2mg prn. Consider
prophylactic laxatives if commenced on opiate
 Saline nebuliser of thick secretions
 Consider whether related to ACE I or other
therapy
 Consider mucolytics / glcopyrronium
24
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Fatigue
Assessment
Assess when they feel fatigued, how
much of the day, including investigating
sleep patterns both at night and day
Assess functional abilities and activity
patterns e.g. if able to wash and dress,
how long it takes, how they feel
afterwards etc.
Non-Pharmacological management of Fatigue
 Encourage the patient to:
 Eat small regular meals
 Exercise regularly (even a very small amount)
 Plan activities, but plan to do what they can definitely achieve,
nothing what they completed and what they had to stop before
finishing
 Plan to rest after each activity and after meals for a short time
 Keep a diary and note when the best and worst parts of the
day are, then use the best times to undertake activities
 Plan to do less on days when you will be tired, e.g. plan less
Identify and Treat Underlying Causes
on the day of a hospital appointment and the day after as
energy will be needed to get there and to recover afterwards
Consider:
Anaemia- common in people with kidney
impairment as blood cells are damaged
and can‘t carry as much oxygen
 Consider referral to cardiopulmonary Rehabilitation,
Physiotherapy activity programme or palliative rehabilitation
 Make adaptations to home to aid energy conservation
Infections
 Energy conservation advice sheet
Concomitant Problems e.g. diabetes,
renal impairment, thyroid dysfunction
 Review Home Care package
Medication e.g. betablockers, opiates,
digoxin, psychotropics.
Eating problems - loss of appetite,
nausea, altered taste may reduce the
amount and variety of foods eaten. Less
calories = less energy available
Poor symptom control- e.g.
breathlessness, pain, leg swelling
Psychological and spiritual issues – e.g.
frustration, stress and low mood, anxiety /
concerns about what the future holds.
 Consider referral to support Group or Expert Patient
Programme
Pharmacological Management
 Treat Underlying Causes
 Optimise Heart Failure Management whilst trying to
minimise side effects of drugs
AVOID
APPETITE STIMULANTS (Dexamethasone, progestogens,
amphetamines)
Tricyclic Antidepressants
25
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Itching
Assessment
General Management
Where is the itching?








When does it itch?
What makes it worse?
How long does it last?
What is the impact on life/ functional abilities
/ Sleep?
What is the condition of the skin like?
Treat Underlying Causes
Dry Skin
Wet Skin including sweating
Renal Impairment
Liver function impairment
Thyroid Dysfunction
Iron Deficiency
Drug induced – opioids, aspirin, hormonal
treatments
Note: Many of these causes are not
histamine related and are more likely to be a
central effect of the underlying abuse. i.e.
they may not respond to anti-histamines
Wear Cotton Clothing
Discourage scratching
Avoid Hot Baths
Avoid Soap and Bubble Bath
Avoid Overheating
Avoid Sweating
Loose bedding
Consider use of fan to aid cooling
Management of Specific Underlying Causes
Dry skin
 Avoid soap
 Use emulsifying ointment or baby soap
 Consider using Cetraben or Diprobase creams as
soap substitutes.
 Apply emollients esp. after washing (note
sometimes using greasier preparation such as
Epaderm at night and something less greasy e.g.
Cetraben in the day works well)
 Note bath emollients are wasteful and costly
Wet skin (incontinence, sweating)
 Use barrier cream e.g. Cavilon
 Consider the use of appropriate fitting incontinence
wear , and only when indicated the assessment for
a catheter or sheath drainage.
 Protect skin from stool leakage (absorbent pads and
barrier cream/ manage constipation or diarrhoea
effectively)
 NOTE Co-danthramer can cause unpleasant rash
on buttocks or thighs.
 Consider treatable causes of sweating – e.g.
infection, hormonal, drug-induced. Cancer related.
 Consider using paracetamol for fever
Renal and Liver Impairment
 General measures + antihistamine trial
 Ondansetron 4mg bd orally (unlicensed use)
 Consider levomepromazine 3—6mg orally if
resistant
 Consider dexamethasone if severe
Opioid Induced
 General Measures + try alternative opioid
26
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Special Issues for Consideration when Managing Pain in Heart Failure
 Types of Pain
o
o
o
Adequate pain assessment is vital
Attempt to define the origin(s) of the patient‘s pain
Major types of pain are: musculo-sketal, somatic,neurpathis, spasmodic, pain of a
psychical nature (also referred to as spiritual pain).
 Not all pains are opiate responsive
o
o
o
Somatic pain is usually very responsive to opiates
Some musculo-skeletal and neuropathic pains may respond partially to opiates but may
require the addition of adjuvant analgesics
See Mid-Trent Cancer Network Guidelines for further advice
 Remember the Analgesics Ladder
o
o
Problems associated with opiate toxicity can be avoided by following the steps outlined in
the ladder.
Always Start Low with opiate Doses and Go Slow when increasing
 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) – Risks/ Benefits
o
o
In some circumstances the risk of increased oedema and/or worsening renal function
associated with the use of NSAIDs can be outweighed by the benefit to the patient in
terms of pain relief
In the management of Acute Gout, a short course of NSAIDs can be well tolerated.
Colchicine is a useful alternative and Allopurinol should be considered for prevention
after a second episode of acute gout has been treated.(N.B. In patients with renal
dysfunction a reduction in standard dose is appropriate) See full guideline at
www.rheumatology.oxfordjournals.org
 Trans-dermal Analgesics
o
o
Buprenorphine and Fentanyl Patches are being increasingly used in the management or
non-malignant chronic pain. They are designed to be used for stable opiate sensitive
pain and should not be used for acute pain relief or where titration of analgesia is
required.
Their use in the terminal, end of life situation is problematic for many reasons and their
substitution/replacement with an alternative form of opiate should be considered. The use
of a syringe driver should be considered in these situations
 Routes of Administration
o
o
In the presence of extensive peripheral and visceral oedema, the absorption of oral
medication may be erratic, unpredictable.
Consider other routes of administration sub-lingual, trans-dermal (avoid placing patches
on oedematous areas), sub-cutaneous.
27
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Nausea and Vomiting
Assessment
Assess symptom-nausea
and or vomiting
If vomiting, what is being
produced?
When are symptoms
present
Any precipitating factors
e.g. eating food
Any relieving factors
Consider asking patient to
keep a symptom diary
Review after treating







Non-Pharmacological Management
 Consider psychological and spiritual care to treat
anxiety
 Consider relaxation therapy, refer to
physiotherapist/Occupational Therapist
 Consider Complementary therapy, suggest self
referral to private provider or hospice
Pharmacological Management
Avoid cyclizine (increase heart rate and
decreases cardiac output)
Consider causative factors and
correct where possible
 Drugs e.g. morphine or
antimuscarinics
 Renal or liver dysfunction
 Gastric stasis caused by enlarged






liver, constipation or gastric
outflow obstruction
Oedema
Constipation
Anxiety
Pain
Infection
Cough
Review medication and identify risk/ benefit of any
drugs believed to cause nausea or vomiting and
discontinue therapy if appropriate.

For chemical causes e.g. morphine, renal
failure
- Consider Haloperidol or Metoclopramide.
 Consider Metoclopramide or Domperidone if:
- Related to meals
- Vomiting undigested food
- Hepatomegaly

If nausea is constant or there is renal
impairment/failure
- Consider Haloperidol at night
- Levomepromazine which has a sedative effect
but may cause postural hypotension. Use in low
doses (3-6mg) and cautiously with elderly people
28
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of peripheral oedema
Non-Pharmacological Management
Assessment
 Rest
Assess Tissue Viability
 Colour
 Texture
 Temperature
 Restrict fluid intake
Record daily weights is able to
 Review home support and arrange additional
 Sit with feet up and legs well supported when
possible
care as required
Assess oedema including whether:
 Bilateral
 Height up leg
 Abdominal distension
 Sacral oedema
 Pitting
Identify and treat if appropriate any
alternative underlying causes such
as:
 Renal failure
 Dependant oedema
 Infection
 Deep vein thrombosis
 Liver dysfunction
Pharmacological Management
First line is loop diuretic
If persistent oedema addition of an aldosterone
antagonist should be considered.
Resistant oedema may require the addition of a
thiazide diuretic periodically and referral for
specialist advice should be sought as careful
monitoring of clinical status, renal and liver
function is required in this group of patients
29
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Poor Appetite and Weight Loss/ Cachexia
Assessment
Use Malnutrition Universal screening
Tool and LPCT guidelines for
management
Non- Pharmacological Management

As desired diet
Establish daily dietary and fluid
intake

Advise small meals often

Consider a small amount of alcohol before
meals

Suggest high calorie, high protein, no added
salt diet- see local guidelines for details

Encourage good oral hygiene

Consider alternative flavouring for foods

Refer to dietician

Consider referral to Palliative rehabilitation
Establish likes and dislikes
Explore expectations
Consider environmental factors
Are there any problems with eating,
swallowing?
Consider examining mouth
Identify and treat causative factors
 Drug toxicity e.g. Digoxin
 Renal or liver dysfunction
 Oedema
 Constipation
 Anxiety
 Dry or sore mouth
Pharmacological Management
Avoid appetite stimulants – (Dexamethasone
progestogens, amphetamines)
Supplement drinks or dietary fortifications may
be prescribed (use LPCT guidelines to aid
prescribing)
 Ill fitting dentures or no teeth
Consider discontinuing statin
 Unable to prepare food
Consider whether related to medication
 Overdiuresis
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Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Psychological Concerns
Non- pharmacological Advice
Assessment
Assess mood for signs of

Anxiety

Depression- as per NICE
guidline (2009)
Discuss expectations

Identify hopes and fears

Explore beliefs and wishes
Use MDT to address issues using therapies,
where available such as:












Relaxation
Counselling
Imaging techniques
Complementary therapies
Spiritual support
Chaplaincy support
Palliative Rehabilitation
Support groups
Carer support
Cognitive Behavioural therapy
Psychology
Mental health referral/ crisis team if stating
suicidal intent
Identify and Treat Underlying
Causes of Anxiety and Depression
Consider:
Poor symptom control- e.g.
breathlessness, pain, leg swelling
Pharmacological Management
Avoid tricyclics as cardio-toxic
AVOID St John‟s Wort
Psychological and spiritual
issues- e.g. frustration, stress, and
low mood, anxiety/ concerns about
what the future holds.
 Antidepressant, e.g. sertraline is first-line
Sleep disturbance and insomnia
 Nausea and Poor appetite consider
Fatigue
Poor Appetite
treatment
 Anxiety depression, e.g. citalopram
antidepressant e.g. mirtazepine
 Night sedation, e.g. Ziplicone, lorazepam,
lormetazepam, lorazepam
 Anxiolytics e.g. lorazepam sub lingual or
chewed especially for panic attacks
 Anxiety, e.g. diazepam is first-line treatment
(buspirone is second line treatment)
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Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Sleep Disturbance and Insomnia
Non-pharmacological management of
Insomnia
Assessment
Assess including investigating sleep
patterns both at night and day, e.g.
What time did you go to bed?
What did you do beforehand, e.g.
activities, food and drink taken?

Encourage the patient:

To establish a bedtime routine, e.g. having a
warm drink but avoiding caffeine/alcohol from
mid afternoon and/ or a snack before bed

To make the bedroom quiet and the right
temperature

If they are lying awake not able to sleep, to
get up and do something then come back to
bed

To try to relaxation techniques or mental
exercises

To set the alarm and try to get up at the same
time every morning

To avoid napping late afternoon

Follow advice given in Sleeping Well Leaflet
available at www.rcpsych.ac.uk
Did you get off to sleep right way?
When did you wake in the night?
How often did you wake in the night?
Any other symptoms associated with being
awake?
What naps in the day did you have? (Time,
place and length)
Is snoring a problem?
Any episodes or witnessed apnoea?
Treat Underlying Causes
Poor symptom control- e.g.
breathlessness, pain, leg swelling
Psychological and spiritual issues- e.g.
frustration, stress and low mood,
anxiety/ concerns about what the
future holds.
Sleep Apnoea- see NICE Guidance
Pharmacological Management
AVOID tricyclics as cardio-toxic
Night sedation, e.g. zopiclone, lorazepam,
lormetazepam,lorazepam,temazepam.
Antidepressant, e.g. sertaline is first-line
treatment
Anxiety depression, e.g. citalopram
Anxiolytics, e.g. lorazepam sub lingual or
chewed especially for panic attacks
Anxiety, e.g. diazepam is first-line treatment
(buspirone is second line treatment)
32
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Stomatitis / Sore Mouth
Non-Pharmacological Management
Assessment
Undertake assessment in good light and
note the colour, moisture, texture of the
mucosa.
Note any plaques, lesions, discolouration
or injury seen.
Note if dentures or dental prosthesis
worn
Ask when last reviewed by dentist
Review medication
Review dietary and fluid intake
 Teach good mouth and lip care regime
 Rinse with water regularly
 Try sucking ice cubes, lollies or ice chips
 Try chewing gum
 Rinse mouth with pineapple juice
 Promote a healthy diet
General Pharmacological Management

Use paraffin gel on lips if not using oxygen

If using Oxygen consider humidifying it
Infection (bacterial or viral)

Consider use of antibacterial mouth wash
Oxygen Use via Nasal Cannula

Oral balance products/artificial saliva
Ulceration

Consider dietary supplements/fortification of
food if nutritional intake is poor
Treat Underlying Causes
Ill-fitting dental prosthesis
Thrush
Herpes Simplex
Poor blood glucose control
Heart failure causes dry mouth and thirst
Drug Side Effects
Examples include:
Nicorandil which is associated with
mouth ulceration in some people
Steroid Inhalers and long term
omeprazole use which can be cause
thrush
Specific Pharmacological Management
Thrush
 Consider nystatin suspension or lozenges
 If persistent, oral fluconazole may be usedsee BNF for prescribing information
Herpes Simplex
Consider acyclovir preparations
Mouth Ulceration
Consider Difflam Mouthwash or Orabase gel
33
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Medicines Management in Advanced Heart Failure
 Review Medications at each visit
 Consider discussing with GP, Pharmacist or at Multidisciplinary Team Meeting
 Consider stopping medications that derive no short term benefits such as statins.
 Maintain ACE Inhibition, Betablocker, Aldosterone Antagonist and Digoxin if possible as
these all aid heart function and symptom control
 Diuretics are used only for symptom control and should be reviewed in light of signs and
symptoms see
 Weigh up risks/benefits of therapies
 Use therapy guidelines where available to aid a systematic approach to care
 Consider best route for administration of essential medicines
 The use of drugs outside their license is more common in palliative care and there are
some clearly identified instances in these guidelines. Clinicians should seek further
advice from pharmacist or specialist palliative care team before prescribing if they are
unfamiliar with the use of that particular drug in these circumstances.
34
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Management of Anaemia
Anaemia is a common problem in heart failure and should be investigated to
enable the treatment of the underlying cause
Hb < 11g/dl?
Assess Renal function and
Haematinic‘s
Non renal causes and
Haematinic deficiency
excluded?
See NICE clinical guideline 39 for further
guidance on Anaemia Management in
people with chronic kidney disease if
GFR < 60 ml/min.
http://guidance .nice.org.uk/cg39
Management of Gout
Gout is common in heart failure due to the use of diuretics.
The use of NSAID‘s or Corticosteroids is to be avoided in the management of acute gout in
heart failure.
The preferred drug treatment is Colchicine with a view to commencinglow dose Allopunnol
once the acute attack has been treated
Please see http://www.rheumatology.oxfordjournals.org for further guidance.
35
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Pathway for Advance Care Planning in patients with Chronic Heart Failure
Patients condition prompts discussion regarding preferred priorities of Care/goals of care
Provide documentation on Preferred Priorities of Care/Information Record
Discuss the patient‘s goals of care/preferred priorities of care and treatment plan
If the patient wishes to, discuss to refuse Treatment/resuscitation status
Provide patient information regarding ADRT including frequently asked questions for the
patient to discuss with family/significant others
Explain ADRT-the circumstances that it would be followed as per the ADRT documentation
If the patients wishes to complete an ADRT they complete themselves/with assistance if
required
Document mental capacity in patients notes
Once ADRT completed:
Fax to all health care professionals involved with a covering letter (GP/CM/OOH/Hospice)
If the patient has decided not for resuscitation complete EMAS registration form and fax with
a copy of the ADRT
Return the original documents to the patient
Review the patient‘s wishes at regular intervals
36
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Iatrogenic Problems
Iatrogenic Problems
Overdiuresis
Symptoms
Hypokalaemia
Hypotension
Falls
Nausea
Loss of appetite
Confusion
Nausea
Loss of appetite
Diarrhoea
Abdominal Pain
Confusion
Bradycardia/ Heart Block
Hypotension
Loss of awareness of impending
hypoglycaemia
Confusion
Constipation
Dry Mouth
Nausea
Muscle Spasm (Myoclonus)
Can precipitate deterioration in heart
failure, renal function and blood glucose
control.
Digoxin Toxicity
Opiates
Steroids
Drugs to Avoid In Heart Failure
Cyclizine
NSAIDS
Steroids
Calcium Channel Blockers
Glitazones
Amphetamines
Progestagens
Tricyclic Antidepressants
St Johns Wort
37
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Pathway for Deactivation of Implantable Cardioverter Defibrillators at End of Life
Indications for consideration of deactivation of ICD
Patient preference in advanced disease
In the event that the patient has completed an Advanced Decision to Refuse
Treatment
Approaching end of life when activation would be inappropriate
Following withdrawal of anti-arrhythmic drug therapy as per medicines review at
end of life
While an active DNR order is in force
Process prior to deactivation
Open discussion with the patient, next of kin/carer or patient advocate as part of
advance care planning please see guidance on page 32
Multidisciplinary review including cardiologist where appropriate
Points of discussion may include:
Resuscitation status and possible completion of an ADRT
Withdrawal will not result in immediate death but the safety not provided by the
device will no longer apply
Deactivation is achieved using an external programmer and is not painful
Multi-organ failure associated with electrolyte disturbance may be proarrhythmic and result in device discharge
Inappropriate shocks are uncomfortable and inconsistent with symptomatic care
Some ICDs incorporate both defibrillation and pacing modalities and it may be
appropriate to selectively disable the defibrillation element as untreated
bradycardias may exacerbate patient symptoms.
Procedure for deactivation:
The patient should complete the locally agreed deactivation consent formappendix
Liaise with local senior cardiac physiologist to arrange a mutually convenient
time and appropriate place identified for deactivation
Deactivation of ICD by cardiac physiologist
NB, After death, ICD generators may need to be explanted if cremation is being considered
Further guidance available at www.arrhythmiaaliance.org.uk
Or
www.bhf.org.uk
38
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Useful Weblinks/ contacts
Organisation
American Heart Association
British Cardiovascular Society
British Heart Foundation
Cardiomyopathy Association
European Society for Cardiology
Mid- Trent Cancer Network
National heart and lung library
National Specialist Library for
cardiovascular diseases
Palliativedrugs.com
Prodigy Prescribing Information
Royal College Psychiatrists
Patient Information Sites
Contact Information
www.americanheart.org
www.bcs.com
www.bhf.org.uk
Tel: 0845 70 80 70
www.cardiomyopathy.org
www.escardio.org
www.mtcn.nhs.uk
email: [email protected]
Tel: 0115 9627988
www.nhlbi.nih.gov
www.libary.nhs.uk/cardiovascular
www.palliativedrugs.com
www.prodigy.nhs.uk
www.rcpsych.ac.uk
www.CHFpatients.com
www.heart-transplant.uk
www.patient.co.uk
Local Support Group -HOPE
www.heartfailurematters.org
www.arrhythmiaaliance.org.uk
www.hopelinks.org.uk
Advance Decision to Refuse Treatment
www.adrtnhs.co.uk
Other Useful Information
Trent midcancer network symptom control guidelines hold valuable advice on the
following:
 Opiate Conversion Charts
 Opioids for breathlessness
 Opioid-induced constipation
 Acute inflammatory episodes in Lymphoedema
 Depression
 Dry skin in lymphoedema
 Pain Relief
39
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
References
Arrhythmia Alliance (2007) Implantable Cardioverter Defibrillators (ICD‘S) in Dying Patients
Baines, M. (1997) The emetic process-,pathways or emesis and the neurotransmitters
involved. BMJ Vol 315 pp. 1148-1150
Beattie J (2007) ‗End of life Issues and Cardiac Device therapy‘ www.heart.nhs.uk
British Medical Association and royal Pharmaceutical Society of Great Britain (2006) British
National Formulary No 51. London. BMJ Publishing Group Ltd and RPS Publishing
Buckman, R.A.(2005) Breaking bad news; the S-P-I-K-E-S strategy. Community Oncology
Vol.2 pp 138-142
Ellershaw J.E Wilkinson S. (2003) Care of the dying: a pathway to excellence. Oxford
University Press.
Gibbs, L.M.E., Addington-Hall, J, Simon, J, Gibbs, R. (1998) Dying from Heart failure:
lessons from palliative care: Many patients would benefit from palliative care at end of their
lives. British Medical Journal. Vol 317 No 7164 pp 961-2
Johnson, M.J (2006) A palliative care approach for patients with heart failure. Palliative
Medicine Vol.20 pp 182-185
Johnson M.J., Houghton,T. (2006) Palliative care for patients with heart failure: description
of a service. Palliative Medicine Vol.20 pp 211-214
Jordon, K.M., Cameron, J.S. Smith, M.,Zhang, W., Doherty, M., Seckl, J., Hingorani, A.,
Jacques, R., Nuki, G on behalf of the British Society for Rheumatology and British
HealthProfessionals in Rheumatology Standards, Guidelines and Audit Working Group
(SGAWG) (2007) British Society for Rheumatology and British Health Professionals in
Rheumatology Guideline for the management of Gout, Accessed online at
http://rheumatology.oxfordjournals.org/cgi/content/full/kem05av1 on the 13th July
2007Lincoln.
Jordhoy, M.S., Grande, G. (2006) Living alone and dying at home: a realistic alternative?
European Journal of Palliative Care. Vol 30 pp 325-8
Mid-Trent Cancer Network Publications (2006) consulted:
 Guidelines for communicating Bad News with Patients and their Families, 2006.
 Symptom Control Guidelines, 2006
 Palliative Care Pocket Book (2nd Ed) 2006
Available via www.mtcn.nhs.uk
40
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
National Institute for Clinical Excellence Clinical Guidline 5 Chronic heart failure:
Management of chronic heart failure in adults in primary and secondary care. London.
National Institute for Clinical Excellence 2003
Sica, D.A (2003) Drug absorption and the management of Conjestive Heart Failure: Loop
Diuretics. CHF Volume 9 No.5 pp 287-292
Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ (2001) More ‗malignant than
cancer? Five-year survival following a first admission for heart failure. European Journal of
Heart Failure Vol 3. pp 315-22
SymptomControl.com(2006) Symptom Control info. (online)
www.SymptomControl.com/1430.html Accessed at Lincoln on 5th January 2007
Tan, L/B.,Bryant, S. Murray, R.G, (1988) Detrimental haemodynamic effects of cyclizine in
heart failure. The Lancet Vol 8585 pp 560-1
Tsuyuki, R.T.,Mckelvie, R.S, Malcolm,J.,Arnold,O.,Avezum A.Jr.,Barretto,A.C.P.,
Carvalho,A.C.C, Isaac,D.L, Kitching,A.D.,Piegas, L.S., Teo,K.T., Yusuf,S. (2001) Acute
Precipitants of Congestive Heart Failure Exacerbations Archives of Internal Medicine. Vol.
161:2337-2342
Twycross R, Wilcock A (2001) Symptom Management in Advanced Cancer (3rd Edition)
Radcliffe Medical Press Ltd, Oxon
Twycross R, Wilcock A, Charlesworth S and Dickman A (2002) Palliative Care Formulary
(2nd Edition), Radcliffe Medical Press Ltd,Oxon. See also www.palliativedrugs.com.
Verma, AK., Da Silva, J.H., Kuhl, D.r. (2004) Diuretic Effects of Subcutaneous Furosemide
on Healthy Volunteers: A Randomized Pilot Study. The Annals of Pharmacology. Vol.38
No.4 pp 544-549
Zambroski, C.H (2006) Managing beyind an uncertain illness trajectory:palliative care in
advanced heart failure. International Journal of Palliative Nursing. Vol 12 No.12 pp.566-573
British Heart Foundation (2007) Implantable cardioverter defibrillators in patients who are
reaching end of life, London BHF
Advance Care Planning: a guide for health and social care staff (2008) available:
www.endoflifecareforadults.nhs.uk
41
Review Date June 2012
Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Coronary Heart Disease Collaborative (2004) Supportive and Palliative Care for Advanced
Heart Failure. Available at www.heart.nhs.uk
Department for Constitutional Affairs (2007) Mental Capacity Act 2005. Code of Practice,
London JSO
Department of Health (2008) End of life Care strategy London DOH
National Council for Palliative Care (2008). Advance Decisions to refuse treatment, a guide
for the Health and Social Care Professionals. London DOH
Prognostic Indicator Guidance Gold Standards Framework, Available at:
www.goldstandardsframework.nhs.uk
ICD TA95 and CRT TAI20 guidance available at www.nice.org.uk
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Clinical guidance for the management of patients with confirmed Heart Failure in
primary care in Lincolnshire- June 2010
Audit/ Monitoring of policy Implementation
The implementation of the policy will be audited by the service managers through the Audit
Tool attached at Appendix E of the ―Guidance on Policy Development‖ available on the trust
website
Audit is also undertaken via the Gold Standards Framework which will provide information
regarding heart failure patients on this register
Implementation Strategy
The corporate Directorate will ensure that the guideline after approval is put on the trust
website for dissemination and sent out in staff newsletter issued by the communications
department via Postmaster. Additionally, the individual teams will also be informed by their
team leaders about the policy.
Training will be offered through the Trust‘s Chronic Heart Failure Study Days, Palliative Care
Education Forum and on request.
43
Review Date June 2012