Causes of heart failure | |
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The most common causes (80-90% of cases) | Alone or in different combinations
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More rare causes | Cardiac or circulatory faults
Metabolic cause
Infectious
Infiltrating
Associated with chemotherapy
Toxic
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Diagnostic criteria | Signs and symptoms |
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1. Patient has symptoms typical to HF or he/she is known to have a heart disease that predisposes to HF such as hypertension, coronary heart disease, sequelae of myocardial infarction, valvular disease. |
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2. Patient has clinical findings specific to HF |
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3. Imaging studies show structural and/or functional impairment of the heart (echocardiography, radionuclide ventriculography, left ventricular angiography, cardiac MRI) |
Diagnosis of HF | Other diseases and conditions to consider | |
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is supported by | is opposed by | |
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NYHA class | Symptoms |
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NYHA I | No significant limitation of physical activity. Activities of daily living do not cause symptoms even though left ventricular dysfunction can be noted with echocardiography. |
NYHA II | Limitation of physical activity. Strenuous physical activity results in dyspnoea or abnormal fatigue. |
NYHA III | Marked limitation of physical activity. Less than ordinary physical activity results in dyspnoea or fatigue. |
NYHA IV | All physical activity causes symptoms. Symptoms may also occur at rest. |
BNP and proBNP concentration | Interpretation |
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* The reference values are according to the 2021 ESC recommendations; pg/ml = ng/l. Interpretation should also take into account the method, age and sex specific reference values supplied by the laboratory. ** Echocardiography indicated | |
| HF is unlikely; look for other causes of the symptoms. |
| Further investigations necessary ** See abnormal and slightly elevated concentrations below. |
BNP/proBNP abnormal or slightly elevated (within the grey area) | |
| Uncertain diagnosis; findings should be related to clinical symptoms and sex- and age-specific reference values taken into account. However, further investigations are often necessary **. |
| Chronic HF likely * Further investigations necessary ** |
Drug | Starting dose | Maintenance/target dose |
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ACE inhibitors | ||
Captopril | 6.25 mg three times daily | 50 mg three times daily |
Enalapril | 2.5 mg twice daily | 20 mg twice daily |
Lisinopril | 2.5-5 mg once daily | 20 mg once daily |
Ramipril | 2.5 mg once daily | 5 mg twice daily |
Perindopril | 2 mg once daily | 4 mg once daily |
ARBs | ||
Candesartan | 4-8 mg once daily | 32 mg once daily |
Valsartan | 40 mg twice daily | 160 mg twice daily |
Losartan | 50 mg once daily | 150 mg once daily |
Telmisartan | 40 mg once daily | 80 mg once daily |
ARB and neprilysin inhibitor in combination | ||
Sacubitril + valsartan | 49/51 mg twice daily | 97/103 mg twice daily |
Beta-blocker | Test dose | Subsequent doses | Target | |
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Bisoprolol | 1.25 mg | 2.5 mg | 5 mg | 10 mg |
Carvedilol | 3.125 mg | 6.25 mg | 12.5 mg | 50 mg |
Metoprolol succinate | 12.5 mg | 25 mg | 50 mg | 200 mg |
Nebivolol | 1.25 mg | 2.5 mg | 5 mg | 10 mg |
Diuretics | Starting dose | Usual maintenance dose |
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* Dose when used with an ACE inhibitor/ARB (** dose if an ACE inhibitor/ARB is not in use) | ||
Loop diuretic | ||
Furosemide | 20-40 mg | 40-250 mg |
Thiazides | ||
Hydrochlorothiazide | 25 mg | 50 mg |
Indapamide | 2.5 mg | 2.5-5 mg |
Metolazone | 1.25 mg | 2.5 mg |
Potassium-sparing diuretics * | ||
Amiloride | 2.5 mg | 20 mg |
Triamterene | 25 mg | 100 mg |
Spironolactone | 12.5 mg (25 mg**) | 50 mg (100 mg**) |
Eplerenone | 12.5 mg | 50 mg |