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Information ⬇

Author(s): John B. Chambers and David Sprigings

This may present with acute pulmonary oedema or cardiogenic shock, but more often presents sub-acutely, with sodium and water retention causing progressive breathlessness and oedema.

Priorities ⬆ ⬇

If there is acute pulmonary oedema, see Chapter 47, or if cardiogenic shock, see Chapter 49. If the patient is clinically stable, complete your assessment (Table 48.1). Investigations needed urgently are given in Table 48.2.

Make a formulation, addressing the following points:

Further Management ⬆ ⬇

Outline

Establish and Treat the Cause and Precipitants of Heart Failure!!navigator!!

  • Heart failure may be caused by myocardial, valvular or pericardial disease, or metabolic disorders (e.g. thyrotoxicosis). Clinical assessment, ECG and echocardiography will usually identify the likely diagnosis. Further investigation (e.g. coronary angiography or cardiac magnetic resonance imaging) may be needed for definitive diagnosis.
  • Heart failure (HF) due to left ventricular (LV) dysfunction is categorized by the LV ejection fraction (EF) as HF with preserved EF (≥50%) (HFpEF), HF with reduced EF (<40%) (HFrEF), and HF with mid-range EF (40-49%) (HFmrEF).
  • In patients with decompensated chronic heart failure, consider and exclude the precipitating or aggravating factors listed above.

Seek advice from the specialist heart failure team. Input from a cardiologist is particularly important if:

  • This is a new presentation of heart failure.
  • Echocardiography shows more than mild heart valve disease or a heavily thickened and immobile aortic valve, even with a low transvalvular gradient: the gradient in severe aortic stenosis may be low in the presence of heart failure.
  • There is an LV ejection fraction <35%, as cardiac resynchronization therapy (CRT) or an implantable cardioverter-defibrillator (ICD) may be indicated.

Correct sodium and water retention

  • If new-onset heart failure or no previous diuretic therapy, give furosemide 40 mg IV bolus (or equivalent dose of another loop diuretic).
  • If decompensated chronic heart failure, give furosemide IV bolus at least equivalent to the usual oral dose.
  • If there is no significant diuresis in response to this initial IV bolus, consider an infusion (e.g. furosemide 250 mg over 24h).
  • Monitor with a weight chart and check electrolyte and creatinine levels daily.
  • For selected patients with diuretic-resistant fluid retention, haemofiltration may be an option: discuss with a cardiologist and nephrologist.

Vasodilator therapy

  • Start or up-titrate ACE-inhibitor/angiotensin-receptor blocker (ARB) therapy if there is HF with reduced LV ejection fraction (EF <40%) and systolic BP is >90 mmHg, plasma potassium <5 mmol/L and eGFR >30 mL/min.
  • If ACE-inhibitor/ARB contraindicated (e.g. bilateral renal artery stenosis, eGFR <30 mL/min), use hydralazine (initially 25 mg 12-hourly PO) and isosorbide mononitrate (initially 10 mg 12-hourly PO).

Mineralocorticoid receptor antagonist (MRA) therapy

  • Start spironolactone or eplerenone if there is reduced LV ejection fraction (EF <40%) and plasma potassium is <5 mmol/L.
  • Stop MRA if plasma potassium is >5.5 mmol/L or eGFR <30 mL/min.

Heart rate and rhythm control

  • If in atrial fibrillation, control the ventricular rate with a beta blocker initially, adding digoxin if heart rate remains >100/min. See Chapter 43.
  • If in sinus rhythm, start or up-titrate beta-blocker therapy (bisoprolol or carvedilol) unless there is bradycardia or AV block, or systolic BP is <90 mmHg.
  • Consider ivabradine for patients in sinus rhythm with contraindications to beta blockade.

Thromboprophylaxis against systemic and venous thromboembolism

  • Treatment-dose, low-molecular-weight heparin or oral anticoagulation if paroxysmal, persistent or permanent atrial fibrillation/flutter, or LV thrombus on echocardiography. See Chapter 103.
  • Prophylactic-dose low-molecular-weight heparin for other patients.

Drugs to avoid

Avoid the following drugs which may cause harm:

  • Glitazones which can exacerbate existing HF and increase the risk of new-onset HF
  • Calcium channel blockers (except amlodipine and felodipine), which have a negative inotropic effect
  • NSAIDs and COX-2 inhibitors, which cause sodium and water retention
  • Angiotensin-receptor blocker, if already taking an ACE-inhibitor and a mineralocorticoid antagonist, because of the risk of hyperkalaemia

Problems!!navigator!!

Heart failure with mid-range and preserved LV ejection fraction (EF ≥40%)

  • Treat congestion with a diuretic.
  • Maintain sinus rhythm. If persistent/permanent atrial fibrillation, aim for a resting heart rate <100/min.
  • Treat systolic hypertension, aiming for systolic BP <130–140 mmHg.
  • Seek advice from a cardiologist regarding further investigation for coronary artery disease.
  • Avoid medications which can exacerbate heart failure (see above Drugs to avoid)

Palliative care

Judging when palliative care (Chapter 110) is appropriate may be difficult. It should be considered for patients in whom transplantation, circulatory support or other definitive treatment including heart valve surgery has been ruled out and:

  • In whom palliation has already been discussed and agreed as part of a chronic care plan
  • With severe recurrent and progressive heart failure despite maximally tolerated therapy
  • With multi-organ failure not responding to therapy
  • With a chronically poor quality of life and NYHA class 4 symptoms

Further Reading ⬆

Harjola V-P, Mebazaa A, Celutkiene J,et al. (2016) Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on pulmonary circulation and right ventricular function of the European Society of Cardiology. European Journal of Heart Failure 18, 226–241.

Page RL, O'Bryant CL, Cheng D, et al. (2016) Drugs that may cause or exacerbate heart failure. A scientific statement from the American Heart Association. Circulation 134, e32–e69. http://dx.doi.org/10.1161/CIR.0000000000000426.

The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal 37, 2129–2200.