Download Cardiac Failure Protocol

Cardiac Failure ProtocolAim
To ensure that all patients with cardiac failure are appropriately investigated, treated
and followed up.
Objectives
To confirm the diagnosis of heart failure by electrocardiography where
possible.
To consider all possible treatment options to improve the quality of life.
To promote the use of angiotensin-converting enzyme inhibitors
Identification of target population
Cardiac failure is a clinical syndrome comprising breathlessness, fatigue and fluid
retention due to cardiac dysfunction. All patients with suspected cardiac failure should
undergo clinical examination and a 12 lead ECG. Symptoms such as breathlessness,
fatigue and ankle swelling & clinical such as tachycardia, oedema and lung
crepitations are non-specific. To increase the likelihood of diagnosis look for the
following:
 Pointers in history: Ischaemic heart disease, especially previous myocardial
infarction, longstanding hypertension, excessive alcohol consumption, valve
disease, anaemia, thyroid disease.
 Pointers in examination: elevated JVP, third hear sound, displaced apex beat,
murmur.
 Significant cardiac failure is unlikely if the ECG is normal.
Disease register
Patients with a firm clinical diagnosis of cardiac failure are Read-coded by the GP and
entered on the computerised disease register
Investigation of patients with suspected heart failure
 ECG
 Echocardiogram
 Full blood count, are & electrolytes and thyroid function blood tests.
Frequency & content of review
Once investigated, patients are reviewed by the GP to initiate appropriate drug & nondrug therapy. Frequency of review will be dictated by clinical condition & response to
treatment.
Management of patients with confirmed systolic dysfunction
If possible, stop NSAID, calcium blockers such as nifedipine, diltazium, or if severe
heart failure, stop beta blocker.
Non-pharmological measures: avoid salt in diet, excess alcohol, encourage exercise,
weight reduction where appropriate and smoking cessation.
Start ACE inhibitor:
 Stop potassium supplements or potassium sparing diuretics. Advise re:
possible symptomatic hypotension – lie for 4 hours after starting low dose
ACE inhibitor.
 Increase does after 1 week and recheck urea and electrolytes.
 Titrate dose over 1 month, check for dizziness, cough and abnormal U&Es.
 Refer if urea >12, creatinine>200, Na <130, systolic BP <100mmHg or if on
>80mg Furosemide, or if known renal artery stenosis.
If Atrial Fibrillation present, consider referral as warfarin and digoxin may be helpful.
If angina present, consider referral as CABG may be indicated
If still dyspnoea or fluid retention present, increase dose of loop diuretic, add digoxin
or consider referral
If ACE inhibitor contraindicated or not tolerated, angiotensin 11 receptor antagonists
may be used as an alternative.