Clinical Knowledge Summaries CKS Heart failure - chronic Management in primary care of: oChronic heart failure with left ventricular systolic dysfunction

Clinical Knowledge Summaries CKS

Heart failure - chronic

Management in primary care of:

o Chronic heart failure with left ventricular systolic dysfunction on echocardiography.

o Heart failure symptoms with preserved left ventricular ejection fraction.o Comorbidities.

Educational slides based on the CKS topic Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Key learning points and objectives• To be able to:

o Outline which drug treatments should be offered to people with LVSD, and in what sequence.

o Explain the benefits of drug treatments for HF. o Describe how to initiate and titrate drug treatment.o Describe when an AIIRA may be prescribed in preference

to an ACE inhibitor.o Distinguish between beta-blockers which are licensed for

HF and which are not. o Describe how HF with preserved ejection fraction should

be managed.o Outline how common morbidities such as angina should

be managed.o Recognise the role of the GP and the role of the specialist

and how they relate.

Overview of management• Management of heart failure involves:

o On going liaison with the secondary care specialist.o Initial drug treatment is usually with:

• Diuretics, ACE inhibitors and a beta-blocker.o Treatments usually started by a specialist; may

include:• Aldosterone antagonists, digoxin, hydralazine plus a

nitrate or ivabradine, dual therapy with an AIIRA with an ACE inhibitor.

o Managing co-morbidities (e.g. angina).o Lifestyle advice and rehabilitation.o Implantable cardiovertor defibrillators.o Discussion of end of life issues and planning.

Left ventricular systolic dysfunction

on echocardiography

Based on the CKS topic Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

http://cks.nice.org.uk/heart-failure-chronic

Which drug treatments to offer

• To relieve symptoms of fluid overload:o Prescribe a diuretic (e.g. furosemide).o Titrate the dose up or down according to

symptoms.o Review the dose and adjust as necessary after

introducing other drug treatments for heart failure.

Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Which drug treatments to offer• To reduce morbidity and mortality prescribe:

o An angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker.

o An angiotensin-II receptor antagonist (AIIRA) may be considered if the person develops intolerable side effects to the ACE inhibitor.

• Introduce one drug at a time. • Add the second drug once the person is

stable on the first drug.


Which angiotensin-II system drug

• ACE inhibitor (first-line).

• AIIRA (only if intolerable side effect to an ACE).


Which drug to start first?• Use clinical judgement when deciding which

drug to start first. • For example, the preferred initial treatment

might be: o A beta-blocker, if the person has angina.o An ACE inhibitor, if the person has diabetes.o An ACE inhibitor, if the person still has signs of

fluid overload (beta-blocker may make the symptoms of heart failure worse).


Which beta-blocker?• Bisoprolol, carvedilol, and nebivolol are

recommended as:o NICE recommends that a beta-blocker which is

licensed for treating heart failure should be prescribed.

o Bisoprolol, carvedilol, and nebivolol are the only beta-blockers licensed for treating heart failure.

o Although some evidence indicates that metoprolol reduces mortality, it is not licensed for use in heart failure.

• Switch to bisoprolol, carvedilol, or nebivolol if already taking a different beta-blocker (e.g. for angina or hypertension).


If prescribing an ACE inhibitor first• Prescribe a low dose and titrate upwards until:

o The target dose, oro The highest tolerated dose is reached.

• Monitor renal function and serum electrolytes:o Before starting treatment.o 1–2 weeks after starting treatment, and o After each dose increase.

• Do not increase the dose further if there is:o Worsening renal function. o Hyperkalaemia.

• Seek specialist advice before starting treatment if already taking 80 mg furosemide or more.


If prescribing an ACE inhibitor first• Once stable, add a beta-blocker, unless

contraindicated (e.g. asthma, heart block), or intolerant of beta-blockers.

• Start at a low dose and titrate slowly upwards until:o The target dose, oro The highest tolerated dose is reached.

• After each dose increase monitor:o Heart rateo Blood pressure, and o Stability of the clinical status.


When to follow up• Follow up regularly to assess any need for

changes and to detect possible drug adverse effects.

• Follow up:o Every few days to every 2 weeks if the clinical condition or

medication has changed.o At least every 6 months if the person's condition is stable.

• More frequent follow up required for:o Significant comorbidity (e.g. angina, atrial fibrillation), or o If the condition has deteriorated since the previous

review. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

At follow up• Assess and monitor:

o Psychosocial needs (including depression).o Functional capacity. o Intercurrent infection (e.g. respiratory tract

infection).o Fluid status (e.g. change in body weight).o Cardiac rhythm (e.g. syncopal or presyncopal

symptoms, pulse and heart rate).o Biochemistry.


Referral • Refer to a specialist for the management of:

o Severe HF (NYHA class IV - inability to carry on physical activity with out discomfort. Symptoms of cardiac failure are present even at rest).

o HF that does not respond to treatment despite optimal treatment.

o HF that can no longer be managed effectively in the home setting.

• Refer for specialist advice:o Women who are planning a pregnancy or who are pregnant.

• Specialist advice may also be appropriate when managing people with HF and a comorbidity. For example:o If considering prescribing nicorandil in people with HF and

angina. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Other management• Assess and manage cardiovascular risk.• Review current medicines that may affect

heart failure:o NSAIDs (associated with fluid retention and renal

toxicity).o Calcium-channel blockers (may cause fluid

retention and have no mortality benefit). o Antiarrhythmics.

• Manage comorbidities (e.g. angina, diabetes).


Summary LVSD• Prescribe a diuretic to control symptoms.• Start an ACE inhibitor and a beta-blocker.

o Start with one drug add the second one after the person is stabilised on the first.

• Only use an AIIRA if intolerable side effect to an ACE inhibitor.• Review and stop medicines that may affect heart failure (e.g. NSAIDs).• Frequent follow up may be required:

o Every few days to every 2 weeks if the clinical condition or medication has changed.

o At least every 6 months if the person's condition is stable. • Consider referral if, severe HF or:

o HF that does not respond to optimal treatment.o HF that can no longer be managed effectively in the home setting.o Pregnant or women who want to become pregnant.o If there is a comorbidity.

Heart failure symptoms with preserved left

ventricular ejection fraction.


http://cks.nice.org.uk/heart-failure-chronic

Managing preserved ejection fraction (PEF)• To relieve symptoms of fluid overload:

o Prescribe a low- to medium-dose diuretic (e.g. up to 80 mg furosemide).

• Seek specialist advice if:o Diuretics do give sufficient relief of symptoms, and o Additional drug treatments are being considered.


Managing PEF• Ensure any comorbidities and precipitating

factors are optimally managed, for example:o Hypertension.o Myocardial ischaemia.o Atrial fibrillation.

• Monitor medical and psychosocial status regularly.

• Follow up and referral advice are the same as for LVEF.


Summary – HFPEF

• Prescribe a low- to medium-dose diuretic to relieve symptoms of fluid overload.

• If diuretics do not work and considering additional drugs seek specialist advice.

• Ensure any comorbidities and precipitating factors are optimally managed.

• Monitor medical and psychosocial status regularly.• Follow up and referral advice are the same as for LVEF.


Managing comorbidities in

heart failure


Managing angina• Consider referral for a specialist opinion on

treatment, including revascularisation.• Ensure that angina symptoms are well

controlled, with optimum use of medical management.

• Ensure that fluid retention is well controlled with diuretics.


Managing angina• Treatments recommended:

o Low-dose aspirin – recommended for people with HF and angina.

o Beta-blockers – recommended for people with HF and angina.

o Nitrates – good safety profile for use in HF.o Calcium-channel blockers are effective at

controlling angina symptoms, but some may aggravate heart failure (e.g. verapamil and diltiazem).


Managing angina • Treatments not recommended:

o Verapamil, diltiazem, and short-acting dihydropyridines – may aggravate heart failure

o Nicorandil – contraindicated in people with HF with low filling pressure.

• Seek specialist advice if considering prescribing nicorandil.

o Ivabradine – contraindicated in unstable or acute HF.

• May be considered by some specialists, but heart failure must be stable before it is initiated.


Managing asthma or COPD• Beta-blockers:

o Contraindicated in people with a history of asthma or bronchospasm.

o May be used in stable COPD without reversibility:o People who have COPD without reversibility should be able to

tolerate beta-blockers and are likely to benefit significantly from their use.

o These people are often undertreated when they develop heart failure and their outcomes are worse than the average person with heart failure.

o Bisoprolol or nebivolol are more cardioselective.o Start with a low dose and slowly titrate up.o If symptoms worsen reduce the dose, or stop treatment.


Managing atrial fibrillation • The onset of AF may lead to worsening of

symptoms and poor prognosis. • Consider referral for cardioversion, rhythm or

rate control.• If rate control is chosen:

o A beta-blocker is usually chosen first-line. o Digoxin may be an alternative if a beta-blocker

cannot be taken.• Antithrombtic treatment is recommended.


Managing diabetes• Maintain good glycaemic control – reduces thirst

that can lead to excessive fluid intake.• If using metformin, monitor renal function and

review if:o Serum creatinine is > 130 micromol/L, or

o eGFR < 45 mL/min/1.73 m2.• Do not prescribe a glitazone (contraindicated in HF).• Cardioselective beta-blockers (e.g.bisoprolol or

nebivolol) preferred.o Non-selective beta-blockers can mask warning signs of

hypoglycaemia.Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing gout• Loop diuretics may precipitate or aggravate

gout o Can cause an increase in uric acid levels.

• Avoid NSAIDs – colchicine is preferred.• Consider systemic corticosteroids if NSAIDs

and colchicine are contraindicated.• Monitor renal function if using allopurinol to

prevent recurrence.Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing renal impairment• Manage any reversible causes, for example:

o Dehydration. • Reduce dose or temporarily stop diuretic.

o Deterioration caused by ACE inhibitor or AIIRA.• Reduce the dose or temporarily stop the ACE inhibitor

or AIIRA.o Coincident renal disease (e.g. diabetic

nephropathy or renovascular disease).


Managing renal impairment• If taking an aldosterone antagonist:

o Monitor serum potassium closely. o Aldosterone antagonists may cause significant

hyperkalaemia if there is renal impairment.• If taking digoxin:

o Consider reducing the dose.o Monitor for signs and symptoms of toxicity (e.g. nausea,

vomiting, blurred or yellow vision).oConsider checking serum digoxin levels if toxicity is

suspected.o Renal impairment is associated with reduced digoxin

clearance and toxicity.Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Summary comorbidities• Angina

o Ensure that fluid retention is well controlled with diuretics.o Ensure symptoms are well controlled and consider - low-dose aspirin

beta-blockers, nitrates and CCBs (but not diltiazem or verapamil). o Consider referral.

• Asthma/COPDo Avoid betablockers but they may be used in stable COPD without

reversibility.o Bisoprolol or nebivolol are more cardioselective.

• AFo Consider referral for cardioversion, rhythm or rate control.o If rate control is chosen, a beta-blocker (first-line) or digoxin may be

used.o Antithrombtic treatment is recommended.

Summary comorbidities• Diabetes

o Maintain good glycaemic control - reduces thirst that can lead to excessive fluid intake.

o If using metformin, monitor renal function.o Glitazones contraindicated in HF.o Non-selective beta-blockers can mask warning signs of hypoglycaemia

• Gouto Loop diuretics may precipitate or aggravate gout. o Avoid NSAIDS – colchicine preferred, but can use systemic steroids.

• Renal impairmento Manage any reversible causes (e.g. dehydration).o If patient on an aldosterone antagonist - monitor serum potassium.o If taking digoxin – monitor for and advise the patient about the signs of

toxicity (consider reducing the dose).

Summary - LVSD• Prescribe a diuretic to control symptoms.• Start an ACE inhibitor and a beta-blocker.

o Start with one drug add the second one after the person is stabilised on the first.

• Only use an AIIRA if intolerable side effect to an ACE inhibitor.• Review and stop medicines that may affect heart failure (e.g. NSAIDs).• Frequent follow up may be required:

o Every few days to every 2 weeks if the clinical condition or medication has changed.

o At least every 6 months if the person's condition is stable. • Consider referral if, severe HF or:

o HF that does not respond to optimal treatment.o HF that can no longer be managed effectively in the home setting.o Pregnant or women who want to become pregnant.o If there is a comorbidity.

Summary – HFPEF

• Prescribe a low- to medium-dose diuretic to relieve symptoms of fluid overload.

• If diuretics do not work and considering additional drugs seek specialist advice.

• Ensure any comorbidities and precipitating factors are optimally managed.

• Monitor medical and psychosocial status regularly.• Follow up and referral advice are the same as for LVEF.


Documents

Clinical Knowledge Summaries CKS Heart failure - chronic Management in primary care of: oChronic heart failure with left ventricular systolic dysfunction