See related separate articles Heart Failure Diagnosis and Investigation, Cardiac Rehabilitation and Palliative Care of Heart Failure.

Chronic heart failure may be 'compensated' and stable with few signs and baseline symptoms, or 'decompensated' with a recent clinical deterioration and physical evidence of impaired perfusion and oxygenation.

In cases of decompensation, always consider both the original aetiology of the heart failure and potential causes of any deterioration such as:

• Further/worsening ischaemia.
• Myocardial infarction (MI).
• Additional valvular or diastolic dysfunction.
• Infections.
• Arrhythmias (commonly atrial fibrillation (AF)).
• Electrolyte imbalance.
• Worsening comorbidities - e.g. anaemia, thyroid dysfunction, pulmonary disease, renal dysfunction, diabetes.
• New medications.

Aims of management

• Reducing morbidity, improving symptom control and quality of life:
  • Drugs - diuretics, inotropes, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockade, digoxin.
  • Nondrug interventions - e.g. revascularisation, valvular surgery, resynchronisation therapy, cardiac rehabilitation.
  • Facilitating patient self-care.
  • Psychological and social support.
  • Palliative care.
• Reducing mortality and prolonging survival through evidence-based use of:
  • Drugs:
    • ACE inhibitors/angiotensin receptor blockade.
    • Betablockers.
    • Aldosterone antagonists.
    • Nitrates.
  • Nondrug therapies - e.g. implantable cardiac defibrillator (ICD), cardiac transplantation.
• Prevention of:
  • Progression of myocardial damage.
  • Hospitalisation.

Patient education and self-care

Patient and family education and training in self-care is effective at improving adherence, symptom control, functional capacity and wellbeing.¹ Topics should include:

• Nature and cause of symptoms.
• Available treatments, likely side-effects and responses.
• Recognition and reaction to symptoms - e.g. flexible dosing of diuretics which can be titrated to symptoms with advice as to when to contact the healthcare team.
• Risk factor modification.
• Dietary and exercise advice.
• Psychosocial aspects to the disease.
• Prognosis.

Specialist heart failure nurses

Community-based heart failure nurses provide an important adjunct to self-care, as well as a bridge to secondary care.² Referral of those with moderate-to-severe heart failure to such a service improves symptom management, reduces hospital admissions and also assists in the transition to a palliative care approach when appropriate.

Lifestyle modification

Smoking

Encourage the patient who is a smoker to stop smoking, and provide support with smoking cessation.

Diet and fluid intake

• Advise patients regarding good nutrition and provide help for obese patients to reduce their weight. Cachexic patients (weight loss over 6 months >6% of previous, stable body weight) should be assessed by a dietician.
• Suggest patients should avoid foods with a high-salt content and should not add salt to their food. Salt intake should not exceed 2-3 g per day. Consider moderate sodium restriction in severe congestive cardiac failure (CCF); take care that 'low-salt' alternatives are not overused, as they can be very rich in potassium which may be a problem for patients on ACE inhibitors or spironolactone.
• Advise patients with severe CCF, particularly in conjunction with hyponatraemia, to restrict their fluid intake sensibly. Take care to avoid excessive dehydration - particularly in elderly patients on high-dose diuretics.
• Patients can contribute to monitoring their fluid retention by regularly weighing themselves. Where there is a sudden, unexpected weight gain of >2 kg in 3 days, advice should be sought. Some patients may benefit from being able to vary their diuretic dose on the basis of regular weights. Self-weighing complements ongoing monitoring of weight in the GP surgery, hospital outpatient and inpatient wards.

Alcohol

Alcohol can act as a negative inotrope, increase blood pressure and the risk of arrhythmias. Restrict alcohol intake to 10-20 g/day (equivalent to 1-2 glasses of wine) or advise abstention if there is alcohol-induced cardiomyopathy.

Exercise

Encourage aerobic exercise, preferably as part of a supervised cardiac rehabilitation programme, for patients with heart failure up to and including New York Heart Association (NYHA) class III, which has proven beneficial effect.³

Travel

NYHA class I and II are not restricted in plane travel.⁴ Oxygen may be required for class III and is recommended (with in-flight medical assistance) for class IV. High altitudes and travel to very hot and humid areas should be discouraged in symptomatic patients who may not adapt easily.

The Driver and Vehicle Licensing Agency (DVLA) need not be notified for private car use but LGV drivers are disqualified, if symptomatic.⁵

Sex and reproductive health

• There are no specific restrictions for sexual activity, although there is a slight risk of decompensation in those with NYHA class III-IV.
• Advise patients that symptoms such as dyspnoea, palpitations, and angina are unlikely to occur related to sex unless similar symptoms are experienced with moderate exercise (e.g. climbing two flights of stairs reasonably quickly). Sexual activity is least likely to cause symptoms if engaged in following sleep, with the least affected partner doing most of the physical work. The most provocative occasions will be sex with a new partner, after a hot bath or on a full stomach.
• Sexual problems are common in patients with heart failure related to concurrent cardiovascular disease, side-effects of treatment (e.g. betablockers) and psychological factors.
  • Sublingual glyceryl trinitrate may be used prophylactically against dyspnoea and chest pain during sex but nitrates must never be combined with phosphodiesterase inhibitors such as sildenafil.
  • Phosphodiesterase inhibitors are not currently recommended for use in those with advanced heart failure.
• Pregnancy risks worsening of heart failure due to increased blood volume and cardiac output and many relevant medications are contra-indicated in pregnancy. Potentially fertile women with heart failure should receive prenatal counselling to enable informed reproductive choice.

Mental health and wellbeing

Depression is very common in heart failure, occurring in at least 1 in 5 patients and at much higher levels in those with advanced disease. Screening and appropriate treatment should be considered in those with symptoms.

Immunisation

Annual influenza vaccination and single pneumococcal vaccination should be offered.

Summary of drug interventions

Heart failure with preserved ejection fraction

A significant proportion of patients with chronic heart failure are symptomatic but have preserved left ventricle systolic function.⁶ Elderly women with comorbidities such as hypertension, ischaemic heart disease and diabetes are over-represented in this group. The evidence base for their treatment is much more limited:⁷

• Treat the comorbidities aggressively.⁸
• Best evidence is for the use of angiotensin receptor antagonists (more limited for ACE inhibitors).
• Use diuretics if there is pulmonary or systemic congestion but avoid over-diuresis.
• Consider the use of betablockers.
• Refer to a cardiologist for full assessment and review of treatment.

Asymptomatic left ventricular systolic dysfunction (LVSD) (≤40% normal ejection fraction)

Use clinical judgement when deciding which drug to start first. For example, the preferred initial treatment might be a betablocker, if the person has angina but an ACE inhibitor, if the person has diabetes.⁷

• ACE inhibitor.
• Betablockers.⁹

Symptomatic LVSD

• ACE inhibitor.
• Betablockers (even if no longer symptomatic).
• Diuretics if there is evidence of fluid retention.

Severe or refractory heart failure

Usually following specialist referral, consider the addition of:

• Angiotensin receptor antagonist.
• Digoxin.
• Aldosterone antagonist, e.g. spironolactone, eplerenone.

Third line drugs include:

• Hydralazine and isosorbide dinitrate combination (H-ISDN).
• Amiodarone.
• Intravenous (IV) inotropes (e.g. dobutamine) - short-term only.

Nondrug options may be indicated:

• Cardiac transplant.
• Resynchronisation therapy.
• ICD.
• Other surgical options, e.g. coronary revascularisation, mitral valve repair, left ventricle aneurysmectomy.

See also separate article Acute Pulmonary Oedema where management is discussed.

Commonly used drugs

ACE inhibitors¹

• All patients with a left ventricular ejection fraction (LVEF) of 40% or less, regardless of symptom severity, should receive an ACE inhibitor unless contraindicated or not tolerated.⁸
• This is because ACE inhibitors have been shown to improve ventricular function and patient well-being, to reduce mortality and hospital admissions in many large clinical trials and are indicated in all stages of left ventricular systolic dysfunction (LVSD).
• Contra-indications include a history of angioedema, bilateral renal artery stenosis, hyperkalaemia (>5 mmol/L), severe renal impairment (serum creatinine >220 μmol/L) and severe aortic stenosis.
• Check U&Es and renal function prior to starting treatment and then after 1-2 weeks of treatment or dose adjustment.
• Titrate the dose up after 2-4 weeks, provided there is no worsening of renal function or hyperkalaemia, aiming for the evidence-based target dose or maximum tolerated dose.
• Recheck U&Es at 1, 3 and 6 months after achieving the maintenance dose, and twice-yearly thereafter.
• If renal function worsens, check and eliminate other nephrotoxic drugs such as non-steroidal anti-inflammatory drugs (NSAIDs). An increase of up to 50% from baseline or to an absolute creatinine concentration of 265 μmol/L is deemed acceptable, but above this reduce the ACE inhibitor dose. Stop the ACE inhibitor where the creatinine concentration is ≥310 μmol/L.
• Warn the patient regarding initial symptoms of dizziness; where this does not improve with time or causes risk of falling, reduce the dose or stop other hypotensive medications. Switch to an angiotensin receptor blocker if a chronic cough develops.

Diuretics¹

• Symptomatic failure usually requires loop diuretics such as furosemide. Diuretics give symptom relief but do not alter prognosis. They should usually be used in combination with an ACE inhibitor.
• Give initial doses intravenously in cases of severe failure as their onset of action is faster (5 minutes compared with 1–2 hours p.o.) and oral absorption may be reduced by intestinal mucosal oedema (bumetanide has slightly better bioavailability in the oedematous gut).
• Beware of both overtreatment and undertreatment with diuretics (start with a low dose and increase depending on response), and review clinical condition and electrolytes regularly - watch for hypokalaemia, hypovolaemia leading to circulatory collapse and uraemia, particularly in the older patient. Note that creatinine is not a reliable indicator of overall renal function and that glomerular filtration rate (GFR) may be reduced by up to 75% before it begins to rise, particularly in patients with a low muscle mass.
• Weight monitoring is invaluable in assessing the degree of fluid retention and optimal diuretic strategy. Aim to maintain 'dry weight' with the lowest achievable dose of diuretic.
• Where diuretic response is insufficient:
  • Check compliance and fluid intake.
  • Increase dose of diuretic.
  • Consider switch from furosemide to bumetanide or torasemide.
  • Add an aldosterone antagonist.
  • Combine a loop diuretic with a thiazide (e.g. metolazone).
  • Give the loop diuretic bd or on an empty stomach.
  • Consider short-term use of IV infusion of loop diuretic.
• Excessive diuresis increases the risk of hypotension and renal dysfunction associated with ACE inhibitor therapy. Where ACE inhibitors or aldosterone antagonists are used with a diuretic, potassium replacement is not usually required.

Betablockers¹

• Current guidance suggests that betablockers should be used in all patients with symptomatic heart failure and an LVEF ≤40%, where tolerated and not contra-indicated. Trial evidence shows betablockers increase ejection fraction, exercise tolerance, reduce morbidity, mortality and hospital admissions additional to that produced by co-prescription of ACE inhibitors.
• They should be initiated in stabilised patients already on diuretics and ACE inhibitors, regardless of whether or not symptoms persist.⁸
• Evidence for the benefit of beta blockade in heart failure is limited to bisoprolol, carvedilol, metoprolol and nebivolol. National Institute for Health and Clinical Excellence (NICE) guidance states that if patients were already taking a non-recommended betablocker (such as atenolol) they should continue with this.
• A study looking at betablocker prescribing in British general practice showed that only about a fifth of patients with heart failure received betablockers.¹⁰ A major barrier to this practice is the prior, long-standing contra-indication of betablockers in heart failure and concerns about the difficulty of initiating betablockers in such patients. They can be safely initiated/titrated in the community in elderly patients and others with relative contra-indications - e.g. diabetes, mild hypotension, fixed airways obstruction.
• Asthma, second- or third-degree heart block, sick sinus syndrome (without pacemaker) and sinus bradycardia (<50 beats per minute (bpm)) remain contra-indications to betablocker use.
• Initiate at a low dose, with increases every 2-3 weeks until the target evidence-based dose or maximum tolerated dose are reached.
• Monitor blood pressure and heart rate with each increase in dose. If hypotensive, discontinue other vasodilator drugs (e.g. nitrates, calcium-channel blockers) where possible. Where bradycardia (<60 bpm) develops, stop other contributory medications (e.g. digoxin, amiodarone).
• Do not abruptly stop betablockers as this risks an MI or arrhythmia.

Angiotensin-II receptor antagonists¹

• Angiotensin-II receptor antagonists can be used in patients intolerant of standard ACE inhibitors. Candesartan and valsartan are now licensed for this indication. They do not cause the chronic cough side-effect associated with ACE inhibitors.
• They are also recommended in combination with an ACE inhibitor and a betablocker in patients with heart failure and an LVEF ≤40% who, nonetheless, remain symptomatic.
• They must only be used in patients with adequate renal function and a normal serum potassium. Serial monitoring of renal function and U&Es is vital, particularly when used in combination with an ACE inhibitor.

Aldosterone antagonists¹

• A low-dose aldosterone antagonist should be considered in all patients with an LVEF ≤35% and severe symptoms (NYHA class III or IV), unless contra-indicated or not tolerated and in the absence of hyperkalaemia and significant renal dysfunction.
• The Randomized Aldactone Evaluation Study (RALES) suggested that, in moderate or severe heart failure, the combination of ACE inhibitor, loop diuretic and spironolactone reduces deterioration and mortality.¹¹
• Hyperkalaemia was unlikely under trial conditions where low doses of spironolactone were used (<25 mg/day)¹² but is more common in clinical practice, particularly in elderly patients or those with poor renal function. The combination of an ACE inhibitor and aldosterone antagonist increases the risk of severe hyperkalaemia and careful monitoring is required.
• Measure renal function and U&Es at 1 week and 4 weeks after starting/increasing the dose. This should be repeated monthly for the first 3 months and then at least twice a year on maintenance treatment.
• Where breast tenderness or enlargement occurs, switch from spironlactone to eplerenone.

Digoxin¹

• In AF, digoxin is very useful in controlling heart rate, and as a positive inotrope where there is concomitant heart failure. It is often used to gain initial rate control and to treat decompensated heart failure prior to the initiation of a betablocker. In the longer-term, a betablocker, either alone or in combination with digoxin, is preferred for rate control in patients with an LVEF ≤40%.
• It also improves symptoms in those patients with moderate and severe failure who are in sinus rhythm, and hence should be considered if symptoms of failure continue in spite of optimal treatment with diuretics and ACE inhibitors.
• Digoxin is of use in severe LVSD and, whilst it does not appear to alter mortality rates, did appear to help prevent recurrent admissions to hospital.^13,14
• A single daily maintenance dose of 0.25 mg is suggested in adults with normal renal function (reduced to 0.125 mg or 0.0625 mg in the elderly or those with renal impairment).
• In patients on digoxin, monitor U&Es and maintain potassium at 4–5 mmol/L.
• Digoxin levels may also need monitoring - 6 hours post dose, to ensure therapeutic (but not toxic) levels. Therapeutic range occurs between 0.6-1.2 ng/mL.
• For use of other inotropes (e.g. dobutamine) see separate Acute Pulmonary Oedema article.

Vasodilators¹

• Long-acting nitrates work in a complex manner by reducing venous filling pressure (preload), reducing output impedance and improving coronary filling.
• They are particularly appropriate if the patient has episodes of angina.
• H-ISDN does reduce mortality (although inferior to ACE inhibitors) in symptomatic patients with LVEF ≤40% and such a combination may be considered in patients intolerant of ACE inhibitors or those still symptomatic despite maximal first- and second-line therapy. Evidence is strongest in patients of African-American descent.
• Alpha-blockers should be avoided, as the Antihypertensive and Lipid-lowering Treatment to Prevent Heart Attack Trial (ALLHAT) hypertensive study suggests they cause significantly more congestive cardiac failure and cardiac events than a simple diuretic.¹⁵
• Calcium-channel blockers should also be avoided, as they are generally negatively inotropic and also increase morbidity and mortality. However, amlodipine is recommended by NICE to treat concomitant angina/hypertension, as it appears to have no net effect.¹⁶

Opiates or opioids (morphine or diamorphine)

• These may relieve anxiety, distress and pain and are important in the management of severe acute heart failure, or in terminal disease (particularly if there is difficulty sleeping).
• They also produce transient venodilation, thus reducing cardiac filling pressures, preload and pulmonary congestion.

Drugs to treat cardiovascular comorbidity¹

Anticoagulants and antiplatelet agents

• Patients with severe heart failure have a greater incidence of strokes and emboli.
• Warfarin is recommended in patients with heart failure and permanent, persistent or paroxysmal AF without contra-indication to anticoagulation. It is also recommended for those with intracardiac thrombus or with evidence of systemic embolism.
• Aspirin is less effective than warfarin in preventing thromboembolism in patients with AF. There is no evidence that antiplatelet agents reduce atherosclerotic risk in patients with heart failure but they are widely used in all patients with ischaemic heart disease without contra-indications.
• There has been a long-running controversy about a potential, negative interaction between aspirin and ACE inhibitors which now seems to have been largely discounted.

Statins

In elderly patients with symptomatic chronic heart failure caused by coronary artery disease, secondary prevention with statins may reduce hospitalisations.

Drugs to avoid in heart failure¹⁷

• Pro-antiarrythmics with potentially negative inotropic effects, e.g. flecainide.
• Calcium-channel blockers - e.g. verapamil, diltiazem (only amlodipine is advisable).
• Tricyclic antidepressants.
• Lithium.
• NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors.¹⁸
• Corticosteroids.
• Drugs prolonging QT interval and potentially precipitating ventricular arrhythmias - e.g. erythromycin, terfenadine.

Nondrug therapies

• Where heart failure is caused, or exacerbated, by surgically correctable conditions, these should be detected and treated appropriately by:
  • Revascularisation - surgical (coronary artery bypass grafting) or radiological (percutaneous coronary intervention) techniques should be considered in selected heart failure patients with coronary artery disease.
  • Valvular disease - decisions regarding surgery should be individualised. Medical management of heart failure and comorbidities should be optimised prior to surgery.
• Cardiomyoplasty and partial left ventriculectomy (Batista's operation) are not recommended as a treatment of heart failure or alternative to heart transplantation.¹⁹
• Cardiac resynchronisation therapy (CRT), also known as biventricular pacing, is recommended to reduce mortality and morbidity in patients with moderate-to-severe heart failure who remain symptomatic despite optimal medical therapy, have a reduced LVEF ≤35% and QRS prolongation (≥120 ms).²⁰ Pacing improves the co-ordination of ventricular contraction with subsequent gains in cardiac output. CRT can be combined with ICD function but its survival benefit has yet to be determined.
• ICD is recommended:
  • For secondary prevention in survivors of ventricular fibrillation and for those who have experienced haemodynamically unstable ventricular tachycardia (VT) or VT with syncope, in those with LVEF ≤40%, on optimal medical treatment and with an expectation of survival with good functional status of over a year.
  • For primary prevention in those with LV dysfunction due to a previous MI or non-ischaemic cardiomyopathy, with an LVEF ≤35%, in NYHA functional class II or III, receiving optimal medical treatment and with a reasonable expectation of survival with good functional status of over a year.
• Heart transplantation may be considered in selected patients when end-stage heart failure is reached without other treatment options. Constraints include lack of donor hearts and problems of rejection/long-term immunosuppression.
• Left ventricular assist devices (LVADs) and artificial hearts are used currently for bridging to transplantation and managing patients with acute, severe myocarditis.

Post-discharge management for chronic heart failure

Following discharge from hospital, cardiac failure patients can either be monitored via a clinic-based outpatient service or by a home-based service. Both models of care principally rely on the appointment of a specialist heart failure nurse to provide healthcare designed to optimise drug therapy, promote self-care (e.g. fluid and dietary management), provide a means for early detection of clinical deterioration and apply more appropriate follow-up according to the needs of each patient.²¹

• Clinic-based service:
  • This involves the establishment of a specific heart failure clinic that is usually situated in the hospital outpatient department.
  • Follow-up after hospitalisation at a nurse-led heart failure clinic can improve survival and self-care behaviour in patients with heart failure as well as reduce the number of events, re-admissions and days in hospital.²
• Home-based service:
  • This model appears to have an even greater effect on associated hospital bed utilisation by reducing days of re-admission by up to 60% relative to usual care.²¹
  • 'The Heart Manual' is a rehabilitation programme consisting of a self-help manual, supported by a facilitator.²² It is the only validated home-based programme that is recommended by NICE as an alternative to clinic-based programmes.
• Hybrid service:
  • Comprising home plus clinic-based follow-up.

Prognosis

Despite advances in therapy, the life expectancy for patients with chronic heart failure is worse than for any of the common cancers (except lung cancer) and is associated with a comparable number of expected life-years lost.²³ In Scotland the five-year survival rate is approximately 25% for both sexes.²⁴

Document references

1. Guidelines for the diagnosis and treatment of acute and chronic heart failure, European Society of Cardiology (January 2008)
2. Stromberg A, Martensson J, Fridlund B, et al; Nurse-led heart failure clinics improve survival and self-care behaviour in patients with heart failure: results from a prospective, randomised trial. Eur Heart J. 2003 Jun;24(11):1014-23. [abstract]
3. Jonsdottir S, Andersen KK, Sigurosson AF, et al; The effect of physical training in chronic heart failure. Eur J Heart Fail. 2006 Jan;8(1):97-101. Epub 2005 Sep 27. [abstract]
4. Fitness to fly for passengers with cardiovascular disease, British Cardiovascular Society (May 2010)
5. At a Glance Guide to the Current Medical Standards of Fitness to Drive - August 2011, Driver and Vehicle Licensing Agency, Swansea (link to current guide)
6. Sanderson JE; Heart failure with a normal ejection fraction. Heart. 2007 Feb;93(2):155-8. Epub 2005 Dec 30. [abstract]
7. Heart failure - chronic, Clinical Knowledge Summaries (November 2010)
8. Chronic heart failure, NICE Clinical Guideline (August 2010); Chronic heart failure: management of chronic heart failure in adults in primary and secondary care
9. Krum H; Consider beta blockers for patients with heart failure. BMJ. 2009 Jun 1;338:b1728. doi: 10.1136/bmj.b1728.
10. Shah SM, Carey IM, DeWilde S, et al; Trends and inequities in beta-blocker prescribing for heart failure. Br J Gen Pract. 2008 Dec;58(557):862-9. [abstract]
11. No authors listed; Effectiveness of spironolactone added to an angiotensin-converting enzyme inhibitor and a loop diuretic for severe chronic congestive heart failure (the Randomized Aldactone Evaluation Study ). Am J Cardiol. 1996 Oct 15;78(8):902-7. [abstract]
12. Pitt B, Zannad F, Remme WJ, et al; The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators.; N Engl J Med. 1999 Sep 2;341(10):709-17. [abstract]
13. Young JB, Gheorghiade M, Uretsky BF, et al; Superiority of "triple" drug therapy in heart failure: insights from the PROVED and RADIANCE trials. Prospective Randomized Study of Ventricular Function and Efficacy of Digoxin. Randomized Assessment of Digoxin and Inhibitors of Angiotensin-Converting Enzyme. J Am Coll Cardiol. 1998 Sep;32(3):686-92. [abstract]
14. Jaeschke R, Oxman AD, Guyatt GH; To what extent do congestive heart failure patients in sinus rhythm benefit from digoxin therapy? A systematic overview and meta-analysis. Am J Med. 1990 Mar;88(3):279-86. [abstract]
15. Messerli FH; Implications of discontinuation of doxazosin arm of ALLHAT. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Lancet. 2000 Mar 11;355(9207):863-4.
16. Packer M, O'Connor CM, Ghali JK, et al; Effect of amlodipine on morbidity and mortality in severe chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation Study Group. N Engl J Med. 1996 Oct 10;335(15):1107-14. [abstract]
17. Krum H, Abraham WT; Heart failure. Lancet. 2009 Mar 14;373(9667):941-55. [abstract]
18. Gislason GH, Rasmussen JN, Abildstrom SZ, et al; Increased mortality and cardiovascular morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure. Arch Intern Med. 2009 Jan 26;169(2):141-9. [abstract]
19. Partial left ventriculectomy, NICE (2004)
20. Cubbon RM, Witte KK; Cardiac resynchronisation therapy for chronic heart failure and conduction delay. BMJ. 2009 Apr 28;338:b1265. doi: 10.1136/bmj.b1265.
21. Stewart S, Blue L, Walker A, et al; An economic analysis of specialist heart failure nurse management in the UK; can we afford not to implement it? Eur Heart J. 2002 Sep;23(17):1369-78. [abstract]
22. The Heart Manual; Home-based cardiac rehabilitation programme
23. Stewart S, MacIntyre K, Hole DJ, et al; More 'malignant' than cancer? Five-year survival following a first admission for heart failure. Eur J Heart Fail. 2001 Jun;3(3):315-22. [abstract]
24. Management of chronic heart failure, Scottish Intercollegiate Guidelines Network - SIGN (2007)

Internet and further reading

• Hunt SA, Abraham WT, Chin MH, et al; 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):e391-479. Epub 2009 Mar 26.
• Heart failure matters; Internet tool provided by the Heart Failure Association of the ESC providing practical information for patients and their families.