Indication:

Suspected Heart Failure With abnormal ECG or Intermediate BNP (100-400)

BNP:

Asymptomatic Murmur

Asymptomatic Cardiomegaly On CXR

Direct Access Echo RSCH

Footnote:

Please do not use open accessEcho but refer directly to consultant for:

1.Pts with symptoms and signs of CHF or very high BNP2.Pts with symtomatic heart murmurs3.Known heart failure with previous echo4.Other cardiac problems

Direct Access Echo RSCH

Drug therapy in CHF• Diuretics• ACE inhibitors• B - blockers • Spironolactone (Class III & IV

patients)• Angiotensin II receptor blockers

(Alternative to ACE I) • Hydralazine & ISDN (ACE I/ARB

intolerance or in renal failure or in Afro-Carribeans as in the AHeFT trial)

• Digoxin if still symptomatic or in AF

Dose of ACE Inhibitors in CHF

• Enalapril2.5 mg od 10-20 mg bd

• Lisinopril2.5 mg od 20-40 mg od

• Perindopril 2 mg od 4 mg od

• Ramipril 1.25-2.5 mg od 10 mg od

Initial Dose* Optimal Dose

* If there are signs of dehydration, stop diuretics for 24 hrs before initial dose of ACE inhibitor

Summary of Drug Treatment of CHF

CHF Confirmed

ACE Inhibitors (or ARBs)

Oedema

Diuretics + Consider Spironolactone in Class III/IV pts

No congestionBeta-blockers

AF

Digoxin + Warfarin

Angina

ISMN / Amlodipine

Conclusions• BNP will help exclude heart failure• ECG also useful in excluding CHF - can use

this for triage• Intermediate BNP levels can be found in

CHF/IHD/ACS, treated CHF with non-cardiac cause of dyspnoea or non-CHF with non-cardiac cause of dyspnoea including PE and pneumonia

• Echocardiography for definitive diagnosis• BNP and open access echocardiography now

available for primary care in Guildford