Diagnosis
- Heart failure due to Left Ventricular Systolic Dysfunction LVSD – reduced LV ejection fraction
- Heart failure with impaired Left Ventricle Relaxation HFPEF – preserved LV ejection fraction
Investigation
- Suspected Heart Failure without previous MI: Measure BNP > 400 pg/ml or NT-proBNP > 2000 pg/ml should have urgent referral for 2D echo-cardiography assessment within 2 wks
- If BNP 100 - 400, NT-proBNP 400-2000 2D echo-cardiography within 6 wks
- Suspected Heart Failure with previous MI should have urgent referral for 2D echo-cardiography assessment within 2 wks
- Note: obesity, diuretics, ACE, ARB reduce BNP, and high levels can be cuased other than heart failure e.g. LVH, sepsis, hypoxaemia, renal dysfunction
- Cardiac –MRI or TOE should be considered if echo poor quality
- ECG and chest X-ray to look for aggravating factors
- FBC, LFTs, TFTs, eGFR, lipids, urinalysis
Management
Conservative
- Heart Failure care should be delivered by an MDT with an integrated approach across the community
- Exercise: offer group exercise based rehabilitation if stable and condition does not preclude
- Smoking cessation
- Alcohol related should abstain
- Offer annual influenza vaccination
Pharmacological
- First Line in LV systolic dysfunction:
- ACE inhibitor (start low and titrate upwards) or ARB if not tolerated. Measure U+Es post commencement on ACE after each dose increment
- Beta blocker (start low, go slow) including those with PAD, IPF, DM & COPD, switching to a Beta Blocker licensed for Heart Failure
- Second Line:
- Aldosterone antagonist, especially post MI or moderate to severe HF (NY class III-IV), while monitoring potassium, eGFR, creatinine
- If afro-Caribbean then consider Hydralazine, with specialised advice
- Digoxin considered if still symptomatic
- Diuretics should be considered in congestive heart failure, especially in HFPEF where loop diuretics should be considered
- Anti-coagulants should be considered in those with a history of thromboembolism
- In HF associated with valvular disease specialist referral required, Do not start ACE until assessment made
- Regular review of functional capacity, medications and renal function
NICE Source: CG108 Chronic heart failure in adults: management. Summary compiled by Dr D P Sheppard MBBS.
