Management of chronic heart failure: SIGN 147, 2016

The aim of the guideline is to improve the care of patients with heart failure (HF): it focuses on those with stable HF rather than the in-hospital management of acute HF, and covers diagnosis, lifestyle modification to reduce risk and progression, and pharmacological and interventional therapies.

Heart failure is a clinical syndrome of symptoms e.g. breathlessnes, fatigue, and signs e.g. oedema, crepitations resulting from structural and/or functional abnormalities of cardiac function, which leads to reduced cardiac output. No symptom or sign is both sensitive and specific for the diagnosis of HF, and a purely clinical diagnosis is difficult.

Symptoms and signs typical of heart failure

In clinical practice the combination of symptoms and signs and the presence or absence of a likely cause of HF are more useful than any of the above in isolation.

DIAGNOSTIC INVESTIGATIONS

In patients with suspected HF, natriuretic peptide (BNP-type natriuretic peptide or NT-proBNP) levels should be measured to decide if echocardiography is needed.

Very low BNP levels rule out a diagnosis of HF. Very high levels make the diagnosis more likely in the absence of other causes of raised BNP. Intermediate to high levels should be regarded as indeterminate and prompt further investigations.

If BNP testing is not available, an ECG should be done. ECG abnormalities may include:

• Pathological Q waves
• Left bundle branch block
• Left ventricular hypertrophy
• Atrial fibrillation
• Non-specific ST and/or T-wave changes

Other investigations for patients with suspected HF should include:

• Full blood count
• Fasting blood glucose
• Urea and electrolytes
• Urinalysis
• Thyroid function
• Chest X-ray

Echocardiography is recommended in patients with suspected HF who have either a raised BNP or NT-proBNP level or abnormal ECG. Echocardiography is used to confirm the diagnosis and establish the underlying cause. The investigation should include overall left ventricular systolic function, Doppler assessment of any valve disease and estimation of pulmonary artery systolic pressure. Coronary artery imaging is not recommended as a routine test unless the patient has symptoms suggestive of cardiac ischaemia or has had cardiac arrest.

CLASSIFICATION

New York Heart Association classification

I No limitation: ordinary physical exercise does not cause undue fatigue, breathlessness or palpitations

II Slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea

III Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms

IV Unable to carry out any physical activity: symptoms present even at rest

EMOTIONAL WELLBEING AND HEALTH BEHAVIOUR CHANGE

Depression

Depression is common in patients with HF and may be linked to an increased risk of mortality, increased morbidity and hospital re-admission. Patients with HF should be screened for depression. In patients with HF and clinical depression, consider cognitive behavioural therapy. If medication is prescribed, do not prescribe a tricyclic antidepressant.

Diet

Advise patients to limit salt intake to less than 6g/day. Food labels often include sodium content rather than salt content – to convert, multiply the sodium level by 2.5.

Weight monitoring

Patients with chronic HF should be encouraged to weigh themselves at a set time every day and report any weight gain of more than 1.5-2 kgs (3-4 lbs) in two days.

Dietary advice

Patients with HF who are taking warfarin should avoid cranberry juice (increases drug potency)

Patients with HF who are taking simvastatin should avoid grapefruit juice (interferes with liver metabolism)

Patients with heart failure should not take St John’s wort supplement (interaction with warfarin, digoxin, eplerenone and SSRIs).

Alcohol

Heavy alcohol consumption can cause cardiomyopathy: >11 units/day for 5 years increases risk. Patients with HF should be advised to refrain from excessive alcohol consumption. When HF is alcohol-related, patients should be strongly encouraged to stop drinking alcohol.

Smoking

Patients with HF should be strongly advised not to smoke, and should be offered smoking cessation advice and support

Exercise

Patients with stable HF NYHA class II-III should be offered a supervised exercise programme to give improved exercise tolerance and quality of life. Patients should be encouraged to take low intensity physical exercise within limits dictated by their symptoms, even though the recommendation to become more physically active may be frightening.

PHARMACOTHERAPY

All patients with HF with reduced ejection fraction (HF-REJ), NYHA class II-IV should be started on a beta blocker as soon as their condition is stable.

Patients with HF-REJ (all NYHA classes) should be prescribed an ACE inhibitor, or if not tolerated, an angiotensin receptor blocker (ARB).

Patients with HF-REJ who have ongoing symptoms, NYHA class II-IV, LVEF ≤35% despite optimal treatment, should be prescribed mineralocorticoid receptor antagonists (spiralactone) unless renal impairment (chronic kidney disease >4-5) and/or elevated serum potassium concentration (K>5.0meq/l).

Patients with HF-REJ who have ongoing symptoms, NYHA class II-IV, LVEF ≤40% despite optimal treatment, should be prescribed sacubitril/valsartan instead of ACE inhibitor or ARB. Stop ACE inhibitor for 36 hours before initiating sacubitril/valsartan to minimise the risk of angioedema.

Ivabradine may be prescribed for appropriate patients following specialist assessment.

The majority of patients with HF will experience fluid retention, causing ankle oedema, pulmonary oedema or both, contributing to breathlessness. Diuretic treatment relieves oedema and dyspnoea. In most cases the agent of choice will be a loop diuretic although in cases of very mild fluid retention, a thiazide may be sufficient. The dose should be individualised to reduce fluid retention without overtreating, which may cause dehydration or renal dysfunction.

Digoxin should be considered as add-on therapy for patients with HF in sinus rhythm who are still symptomatic after optimum therapy.

Vaccinations

Patients with HF should be given pneumococcal vaccination (once) and annual flu vaccination.

INTERVENTIONAL PROCEDURES

Implantable cardioverter defibrillators, cardiac resynchronisation therapy with defibrillator or pacing are recommended as treatment options for patient with HF-REJ, LVEF ≤35%.

DISCHARGE AND ANTICIPATORY CARE PLANNING

Comprehensive discharge planning should ensure that postdischarge services are in place for all patients with symptomatic HF. This requires communication between primary and secondary care teams following a hospital admission to allow for anticipatory care planning, specialist nurse input, and where appropriate, home-based care.

PALLIATIVE CARE

Patients with advanced HF with ongoing symptoms despite optimal treatment should have access to a collaborative approach to their care, which should include

• Active management aiming for symptom control
• Rationalisation of medical therapy
• Anticipatory care planning
• Co-ordination of care
• Multidisciplinary team working
• Communication across primary and secondary care
• Good end of life care

General palliative care should be delivered by the patient’s usual healthcare professional team, appropriately trained to provide it, with access to specialist teams as needed or when complexity of care increases. Because of the complexity of HF, making a prognosis is challenging: often palliative care is only offered when it is known when a patient is going to die – which means that patients with HF and carers may miss out on the opportunity of a collaborative cardiology and palliative care approach.

QUALITY OF LIFE

In patients with HF, quality of life decreases as NYHA functional class worsens. Patients may experience psychological distress due to increased dependence on others, the need for assistance with activities of daily living, disruption of social life, income, faith and daily function.

SYMPTOM MANAGEMENT

Healthcare professionals should take a careful history of symptoms and tailor care to the individual’s needs and wishes. Management strategies may be based on those used in cancer care, but the use of NSAIDS and TCAs should be avoided. After optimising diet, fluid intake and standard management for chronic HF, low dose opioids may improve symptoms of breathlessness, reducing the demand for ventilation without significant respiratory depression. In older patients, start with smaller doses and titrate slowly to minimise adverse effects.

Scottish Intercollegiate Guidelines Network

Management of chronic heart failure (SIGN 147), 2016

http://www.sign.ac.uk/assets/sign147.pdf