Heart Failure Management

See related articles: Heart failure (diagnosis and investigation) and severe pulmonary oedema.

The aims of heart failure management are:

Improving symptoms

Through use of:

• Diuretics
• Inotropes
• ACE inhibitors/angiotensin receptor blockade.

Prolonging survival

Through use of:

• ACE inhibitors/angiotensin receptor blockade
• Beta-blockers
• Spironolactone
• Nitrates.

This may be 'compensated' and stable with few signs and baseline symptoms, or 'decompensated' with a recent clinical deterioration and physical evidence of impaired corporeal perfusion and oxygenation. In cases of decompensation consider both the original aetiology of the heart failure and potential causes of any deterioration, such as:

• Further/worsening ischaemia
• MI
• Infections
• Arrhythmias (commonly AF)
• Electrolyte imbalance
• Thyroid dysfunction
• New medications.

1. Non-pharmacological measures ¹
   • Initial bed rest (increases venous return and renal perfusion).
   • Give advice re the nature of the disease, ongoing treatment and self-help strategies to encourage compliance.
   • Advise to stop smoking.
   • Try to avoid NSAIDs: they cause fluid retention and may interact with diuretics and ACE inhibitors to cause chronic renal failure.
   • Advise re good nutrition and help obese patients to reduce their weight.
   • Suggest patients avoid foods with a high-salt content and don't add salt to their food.
   • Consider moderate sodium restriction in severe CCF; take care that 'low-salt' alternatives are not over-used as they can be very rich in potassium which may be a problem for patients on ACE inhibitors or spironolactone.
   • Advise patients with fluid overload and those with severe CCF to sensibly restrict their fluid intake (but take care to avoid excessive dehydration – particularly in elderly patients on high-dose diuretics).
   • Patients can contribute to the monitoring of their degree of fluid retention by regularly weighing themselves and seeking advice if there is a trend in either direction, particularly following any recent changes in drug therapy.
   • Recent guidelines suggest that some patients may benefit from being able to vary their diuretic dose on the basis of regular weights.
   • Regular monitoring of weight in the GP surgery, hospital outpatients and on inpatient wards can be an invaluable piece of clinical information.
   • Restrict alcohol intake (if excessive) or advise abstention if alcohol-induced cardiomyopathy.
   • Encourage aerobic exercise, preferably as part of a supervised cardiac rehabilitation program, for patients with heart failure up to and including NYHA grade III which has proven beneficial effect.²
   • Echocardiography, if not already conducted, 'should be performed to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle and detect intracardiac shunts' (NICE guidance).³
   • Non-pharmacological measures such as revascularisation, resynchronisation, transplantation, defibrillator implantation and other advanced interventions should be considered where their benefit may outweigh or significantly enhance drug therapy, under appropriate specialist guidance.
2. Diuretics:
   • Symptomatic failure usually requires loop diuretics such as furosemide (formerly frusemide).
   • Give initial doses intravenously in cases of severe failure as their onset of action is faster (5 minutes compared to 1–2 hours p.o.) and oral absorption may be reduced by intestinal mucosal oedema (bumetanide has slightly better bioavailability in the oedematous gut).⁴
   • Beware of both over- and under-treatment with diuretics (start with 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.
   • Weight monitoring is invaluable in assessing the degree of fluid retention and optimal diuretic strategy.
   • In resistant cases, adding a thiazide (e.g. metolazone) to the loop diuretic is an effective strategy.
   • Recent evidence suggests that in moderate or severe heart failure, the combination of ACE, loop diuretic and spironolactone reduces deterioration and mortality.⁵
   • Hyperkalaemia is unlikely if low doses of spironolactone are used (<25mg/day);⁶ but measure potassium a week after starting and at least 3 monthly thereafter.
   • Be particularly careful if renal function is poor.⁴
   • Take care not to use other potassium-sparing diuretics in patients on ACE inhibitors and/or spironolactone as this is likely to lead to hyperkalaemia.
   • Note that creatinine is not a reliable indicator of overall renal function and that GFR may be reduced by up to 75% before it begins to rise, particularly in patients with a low muscle mass.
   • Creatinine clearance can be estimated using the abbreviated MDRD (modification of diet in renal disease) calculation.
   • Consider measuring creatinine clearance by conducting a 24-hour urine collection to accurately assess renal function.
3. ACE Inhibitors:
   • All patients with heart failure due to left ventricular systolic dysfunction should be considered for treatment with an ACE inhibitor (NICE guidance).³
   • They have been shown to have beneficial effects on mortality, morbidity, and quality of life in many large clinical trials and are indicated in all stages of heart failure resulting from left ventricular systolic dysfunction (LVSD) – the poorer the LV function the greater the benefit.^4,7
   • Angiotensin II receptor antagonists can be used in patients intolerant of standard ACE inhibitors (currently unlicensed but widely accepted indication, likely to become licensed following further research).
   • The jury is still out on whether angiotensin II receptor antagonists can be used effectively in place of, or in addition to ACE inhibitors, in cases of mild but symptomatic heart failure, with conflicting initial trial data.⁸
   • The case for the addition of an aldosterone antagonist such as spironolactone/aldactone to ACE inhibitors in cases of mild but symptomatic heart failure is not certain but some trials suggest a benefit is likely.
   • See ACE inhibitors for recommendations and warnings.
4. Beta-blockers:
   • Some beta-blockers have a reputation of precipitating heart failure in patients with impaired ventricular function; however in carefully selected patients with stable chronic heart failure, low dose treatment with selective beta-blockers such as carvedilol or metoprolol have been shown to increase ejection fraction, exercise tolerance, and to reduce morbidity and mortality as compared with conventional therapy alone.^9,10
   • Beta-blockers licensed for use in heart failure should be initiated in patients with heart failure due to left ventricular systolic dysfunction after diuretic and ACE inhibitor therapy – regardless of whether or not symptoms persist (NICE guidance).³
5. Inotropes:
   • Digoxin is very useful in controlling heart rate, and as a positive inotrope, in cases of heart failure with atrial fibrillation.
   • 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 left ventricular systolic dysfunction (S₃ gallop and a large heart with no valvular obstruction) and can help prevent recurrent admissions to hospital.^11,12,13
   • In patients on digoxin, monitor U+E and maintain potassium at 4–5 mmol/L.
   • Digoxin levels may also need monitoring – 6 hrs post dose, to ensure therapeutic (but not toxic) levels.
   • For use of other inotropes (e.g. dobutamine) see article on severe pulmonary oedema.
6. Vasodilators:
   • Long-acting nitrates such as isosorbide mononitrate M/R 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.⁴
   • Adding a second-line agent (e.g. a combination of hydralazine and nitrates) does reduce mortality (although inferior to ACE inhibitors).
   • Such a combination may be considered in patients intolerant of ACE inhibitors or on maximal ACE therapy.⁴
   • Alpha-blockers should be avoided as the ALLHAT hypertensive study suggests they cause significantly more CCF and cardiac events than a simple diuretic.¹⁴
   • Calcium channel blockers should also be avoided as they are generally negatively inotropic and also increase morbidity and mortality; amlodipine is recommended by NICE to treat concomitant angina/hypertension as it appears to have no net effect.^4,15
7. Opiates or opioids (morphine or diamorphine):
   • They may relieve anxiety, distress and pain and are important in the management of severe acute heart failure, or in terminal disease (particularly if difficulty sleeping).
   • They also produce transient venodilation, thus reducing cardiac filling pressures, preload and pulmonary congestion.¹⁶
8. Antithrombotic treatment:
   • Patients with severe heart failure have a greater incidence of strokes and emboli.
   • Use aspirin in all patients with ischaemic heart disease who have no contraindications.
   • 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.
   • The benefits of aspirin in patients with ischaemic disease seems to outweigh any possible concerns.¹⁷
   • Consider anticoagulation in any patients with atrial fibrillation, marked atrial or ventricular dilatation, extremely poor LV function or any evidence of intracardiac thrombus on echo.

• Monitor patient's clinical condition, BP, U&E, creatinine and body weight regularly (daily weight measurement in severe failure).³
• In primary care measure creatinine and U&E before, and 1 week or so after starting any new drugs, and ideally every 6 months or so once potassium levels are stable.¹⁸
• If HCO₃^– is elevated, ± malaise, thirst or hypotension then suspect over-diuresis.
• Consider referral for cardiac rehabilitation in patients who may benefit from a graded increase in exertion.

• Doubt in diagnosis
• Specialist investigations indicated
• Murmurs and valve disease
• Co-existing arrhythmias (e.g. AF)
• Secondary causes (e.g. thyroid disease, suspected cardiomyopathy)
• Very poor ventricular function (ejection fraction <20%)
• Metabolic abnormalities (e.g. hyponatraemia – Na <130 mmol/l, renal impairment)
• Renovascular disease
• Relative hypotension (SBP <100 mmHg before ACE inhibitor therapy)
• Poor response to treatment or help required in optimizing therapy
• Need for advice on managing deterioration in ischaemic heart disease symptoms
• For consideration for heart transplant.

See also: Heart disease and exercise.

• Reassure that if he/she can mount two flights of stairs reasonably quickly, sex should not be a problem.
• If dyspnoea and angina are a problem, keep a nitrate spray by the bed.
• Sexual activity is least likely to cause symptoms if engaged in after a good night's 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.

• To reduce the incidence of heart failure it is essential that primary care services detect and treat risk factors for heart failure such as undiagnosed or poorly managed diabetes, hypertension and ischaemic heart disease.
• Address cardiovascular risk factors such as smoking and hyperlipidaemia (see primary prevention of cardiovascular disease).
• If high-risk patients (post MI, diabetics, AF or hypertension) can be identified and started on ACE inhibitors early, accompanied with interventions such as aspirin, beta-blockers, statins and smoking cessation it is possible to minimize the progression to symptomatic heart failure.

• Hypertension
• Left ventricular hypertrophy (independent of hypertension)
• Smoking (particularly in men)
• Hyperlipidaemia
• Diabetes mellitus
• Microalbuminuria is an independent predictor of heart failure (HOPE trial)²⁰
• Obesity
• Asymptomatic left ventricular systolic dysfunction (LVSD).

• When the above heart failure management strategies fail, then reassess aetiology of heart failure and compliance with treatment.
• Aim to regain lost ground and restore the patient to their former out-patient-manageable state.
• Admit to hospital for:
  • Observation of strict bed rest.
  • Use of a bedside commode.
  • Avoidance of straining at stool (constipation common).
  • DVT prevention with sc heparin/anti-thromboembolic stockings.
  • IV furosemide (frusemide) and oral thiazide.
  • Commencement of spironolactone (provided potassium normal and not in severe renal failure).
  • Monitoring of daily weight and U&E.
  • Titration of ACE inhibitors/vasodilator dosage to maximum tolerated.
  • Sometimes a compromise needs to be struck – accepting some oedema or exercise limitation in order to avoid unacceptable symptoms of low output, or renal failure.
  • In extremis, the patient may benefit from a period on IV inotropes to tide them over an acute exacerbation; weaning from inotropes can be very difficult.
  • Finally, consider the patient for heart transplantation.

Prognosis is poor with around 80% of patients dying within 6 years of diagnosis. Optimal and early therapy with ACE inhibitors, beta-blockers and appropriate non-pharmacological care can improve this outlook in individuals and it is hoped that the prognosis in the general heart failure population will improve as diagnoses are made earlier and optimal treatment strategies are followed.

'Many patients would benefit from palliative care at the end of their lives'.²¹ There are considerable similarities between dying from cancer and dying from heart failure, with anxiety, severe dyspnoea and pain being prominent in both cases. The terminal stages of heart failure have been successfully treated using the same approach that helps cancer sufferers – consider involving hospice care and other support workers, as a multidisciplinary approach will benefit patient and relatives.²²

Some GP practices are offering heart failure clinics run primarily by practice nurses, nurse practitioners or GPs with a specialist interest. Such clinics can facilitate monitoring, patient education and audit. Suitable topics to audit might be:

• Has diagnosis been confirmed (e.g. by echocardiography)?
• Are all appropriate patients taking ACE inhibitors (unless contra-indicated) and are doses high enough (as those used in the large clinical trials)?
• Have BP, U&E and renal function been monitored with appropriate frequency?
• Have patients been given risk factor advice and offered influenza and pneumococcal vaccination?