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Management of CHF
Diagnosis of CHF
The clinical features of heart failure include symptoms such as:
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ankle swelling
exertional breathlessness
fatigue
orthopnoea
paroxysmal nocturnal dyspnoea (PND)
nocturia
anorexia
weight loss
And signs such as:
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tachycardia
reduced pulse volume
pulsus alternans
raised JVP - in right heart failure
oedema
rales, or basal crepitations
hepatomegaly
ascites
Investigations for Heart Failure
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chest radiology
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the ECG may elucidate the cause of heart failure:
o left ventricular hypertrophy which may be caused by chronic
hypertension or aortic stenosis
o evidence of ischaemic heart disease
o p-mitrale of mitral stenosis
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echocardiography identifies:
o focal or diffuse myocardial dysfunction
o valvular disease
o pericardial disease
o left ventricular systolic dysfunction
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biochemistry, haematology and urinalysis:
o defines electrolyte disturbances and assesses renal function
o excludes anaemia
o exclude thyrotoxicosis in patients with atrial fibrillation
o excludes causes of oedema such as liver disease, nephrotic syndrome
and acute renal failure
o natriuretic peptides - testing for Brain-type natriuretic peptide (BNP),
atrial natriuretic peptide (ANP), and N-terminal (NT)-ANP has been
shown to increase the reliability of diagnosis of heart failure in primary
care
 these peptides are released from ventricular myocytes in
response to volume overload (stretch), and their concentration
has been shown to an extremely sensitive marker for heart
failure
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Other possible investigations include:
o radionuclide ventriculography e.g. MUGA scan
o a myocardial biopsy to obtain histological data
NICE suggest that BNP measurement be undertaken in conjunction with ECG and
history and examination, before referral from primary care for echocardiography to
confirm the diagnosis of heart failure (1):
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the NICE clinical guideline on CHF recommends that those suspected of
having heart failure because of their history, signs and symptoms should
have a 12-lead ECG and/or BNP, with echocardiography being
performed where the result of either is abnormal (2)
General management of CHF
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the primary cause of heart failure should be treated where this is appropriate:
o hypertension
o anaemia
o hypoxia
o valve disease
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bed rest:
o erect posture and exercise exacerbate renal vasoconstriction
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dietary modification:
o salt restriction:
 daily intake of 20-30 mmol is optimal but unpleasant
 daily intake of 100 mmol is more realistic
 measure daily urinary sodium to monitor intake
o alcohol in moderation only
fluid restriction 500-1000 ml/day may be beneficial in severe heart failure
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stop smoking
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maintain optimal weight
Three types of drug treatment have been shown to reduce morbidity and mortality in
patients with heart failure:
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angiotensin converting enzyme (ACE) inhibitors
the aldosterone antagonist spironolactone
beta-blockers
Treatment of mild to moderate congestive cardiac failure consists of:
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diuretics, for symptom control
ACE inhibitor *
o NICE recommends that all patients with left ventricular dysfunction
should be taking an ACE inhibitor (1,2):
 ACE inhibitor therapy should be initiated before beta blockade
 specialist referral is required for patients requiring high doses of
diuretics, or exhibiting worsening renal function at any stage - note
that some degree of detioration of renal function after initiating
ACE inhibitors is inevitable, but if this is only small only
monitoring is necessary
beta-blocker
o beta-blockers should only be prescribed for chronic heart failure patients
after stabilisation on ACE inhibitor therapy - beta-blocker therapy should
be started at a very low dose (e.g. carvedilol 3.125mg once daily) and
titrated slowly over a period of weeks or months. The beta-blocker should
be up-titrated at fortnightly intervals (or longer in more sensitive patients)
to a target dose of carvedilol 25-50mg bd or bisoprolol 10mg od (1,2)
spironolactone
o NICE recommend spironolactone to be prescribed to patients with
moderately-severely compromised left ventricular dysfunction, as an addon to other therapies, with careful monitoring of serum potassium (1)
angiotensin receptor blocker
o NICE recommend that angiotensin receptor blockers are not used as
primary therapy for heart failure, but are reserved for use in patients who
are intolerant of ACE inhibitors (1)
o there may also be a role for angiotensin receptor blockers as 'add-on'
therapy in management of refractory heart failure (1,2)
Other therapies include:
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digoxin
o NICE recommends digoxin for use in patients with atrial fibrillation and
heart failure, or those in whom symptoms are progressing on ACE
inhibitors, beta-blocker and diuretic therapy
Implantable cardiac defibrillators (ICDs) :
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the Sudden Cardiac Death in Heart Failure (SCD-HeFT) (4) provides evidence for
the prophylactic use of ICDs in patients with congestive heart failure (CHF). This
trial showed that in patients with CCF, a conservatively programmed, shock only
ICF reduced all cause mortality. In comparison with placebo, ICD reduced
mortality in New York Heart Association (NYHA) class II but not class III CHF.
The SCD-HeFT also included an amiodarone arm, which showed no benefit in the
primary prevention of cardiac death
*ACE inhibitors in cardiac failure:
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they improve symptoms and signs, such as exercise capacity
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they decrease systemic vascular resistance, venous pressure and levels of
circulating catecholamines
they prolong survival in patients with mild to moderate severe heart failure
(CONSENSUS and SOLVD trials). In addition V-HeFT II showed improved
survival with enalapril over a hydralazine and isosorbide dinitrate regimen (24
months follow up)
These drugs actually reduce mortality by up to 50%; this is the reason the consensus
trial was prematurely halted. There is also reduced number of "events", which
includes prevention of hospitalisation and premature deaths, with obvious economic
benefits.
Management of Severe Heart failure
Patients with severe chronic heart failure may be receiving a treatment regime
including diuretics, ACE inhibitors, beta-blockers and spironolactone.
Patients with extremely resistant oedema may also be given additional therapies.
These may include:
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loop diuretic potentiated with a thiazide diuretic such as metolazone
nitrate vasodilator
digoxin
Heart transplantation is a treatment of last resort in selected patients with severe heart
failure