Medical Management

Running a Heart Failure Clinic

1. Scope

This document provides strategies for the improved diagnosis and management of adults (19 years and older) with heart failure (HF). It is intended for primary care practitioners, allied health professionals and patients with HF. It focuses on approaches needed to provide care to patients with this complex syndrome.

2. Diagnostic Code:

428

3. Clinical Highlights

HF is a complex syndrome associated with a high rate of hospitalization and short-term mortality, especially in elderly patients with comorbidities. Early diagnosis and treatment can prevent complications.

  • Successful HF management begins with an accurate diagnosis. All patients should have an objective determination of left ventricular ejection fraction (LVEF) by echocardiogram, or radionuclide ventriculogram (RNV) if echocardiogram is unavailable
  • Treat underlying vascular risk factors (see guidelines on Hypertension and Diabetes Care), comorbidities and other chronic diseases
  • Patient and caregiver education should be tailored and repeated
  • Encourage the patient to accept responsibility for their HF care through an individualized management plan with self-care objectives, including salt restriction, weight monitoring and medication adherence strategies
  • Reinforce the importance of healthy lifestyle modifications, including healthy eating, regular exercise, weight management, social support and smoking cessation
  • Treatment requires combination drug therapy
  • All systolic HF patients should receive an ACE-I and a BB at target dose unless contraindicated. These therapies should be considered in all patients with HF with preserved systolic function (PSF)
  • Additional therapy should be guided by clinical situation
  • As polypharmacy remains a concern - match drugs to goals of treatment
  • Care should be individualized based on symptoms, underlying cause, disease severity and goals of care
  • Plan effective systems to ensure follow-up and patient education to improve outcomes
  • Engage patients in open discussions on the end of life issues

4. Prevention of Heart Failure

  • Assess all patients for known or potential risk factors for HF (hypertension, ischemic heart disease, diabetes mellitus, dyslipidemia and tobacco use)
  • Modifiable risk factors should be treated according to current guidelines
  • Routine screening for asymptomatic LV dysfunction is currently not recommended
  • For selected patients at high risk for HF due to multiple risk factors, the decision to screen (such as by echocardiography) should be individualized
  • The prognosis of HF at the earliest appropriate time

5. Patients with Asymptomatic LV Dysfunction

  • ACE-I should be used in all asymptomatic patients with LV dysfunction and
    LVEF < 40%
  • BB should be considered in all patients with asymptomatic LV dysfunction
    and LVEF < 40% (especially if there is a history of ischemic heart disease)

6. Diagnosis of Heart Failure

HF is under diagnosed in its early stages. Diagnostic accuracy improves when there is a high index of suspicion and a consistent approach to diagnosis.

7. Definition of Heart Failure

HF is a clinical syndrome defined by symptoms suggestive of impaired cardiac output and/or volume overload with concurrent cardiac dysfunction. While a normal LVEF is >60%, the threshold of 40% is used for the purposes of diagnostic classification. As such, HF can be classified into systolic heart failure, as defined by the presence of signs and symptoms of HF with an LVEF <40%, and heart failure with preserved systolic function (HF with PSF – previously called diastolic dysfunction) is defined by the presence of signs and symptoms of HF in the absence of systolic dysfunction (LVEF ≥ 40%). Prognosis for systolic HF is significantly worse than HF with PSF. Research evidence for treatment is best established for systolic HF but, in general, the pharmacologic and nonpharmacologic strategies are similar for both.

8. Evaluation of HF should include:

  • A thorough history and physical exam focusing on:
    • Current and past symptoms of HF (i.e. fatigue, shortness of breath, diminished exercise capacity and fluid retention/weight gain)
    • Functional limitation by New York Heart Association (NYHA)
    • Cardiovascular risk factors, cardiovascular disease, and other comorbid conditions
    • Assessment of a patient’s endurance, cognition, and ability to perform activities of self-management and daily living
    • Assessment of volume status (e.g. peripheral edema, rales, hepatomegaly, ascites, weight, jugular venous pressure, and postural hypotension)

  • Initial investigations in all patients (where available):
    • Complete blood count
    • Serum electrolytes
    • Creatinine (Cr), eGFR
    • Urinalysis
    • Microalbuminuria
    • Fasting blood glucose
    • Fasting lipid profile, AST
    • Albumin
    • Thyroid-stimulating hormone (TSH)
    • 12-lead electrocardiogram and chest radiograph
    • All patients should have an objective determination of LVEF by transthoracic echocardiogram (preferred as it also provides information on cardiac dimensions, valvular function and may suggest the underlying etiology of HF) or RNV if echocardiogram is unavailable
    • BNP has high diagnostic value for both types of HF and is recommended where available, when diagnosis is unclear. The use of BNP in non-acute heart failure and community outpatient practice remains to be clarified. (See Table 1)

Table 1. Brain natriuretic peptide (BNP) and prohormone of BNP (NT-proBNP) assay cut-off points for the diagnosis of heart failure.

  • In cases where there is doubt, or an objective determination of LVEF is not immediately available, response to a therapeutic trial may increase the diagnostic accuracy (See Figure 1)
  • When the etiology of HF is uncertain, consider referral for more specialized cardiac testing as clinically indicated

Figure 1. Diagnosis of heart failure (Adapted from CCS Guidelines, 2006).

9. Non-Pharmacologic Management Strategies

HF care depends on the patient’s understanding of, and participation in, optimal care. Patients can be important partners in individualized goal setting, salt restriction, weight monitoring, and adherence.

9.1. Goals of Care

  • Determine the goals of managing their HF with the patient, i.e. aggressiveness from a goal of an advanced cardiac technology and transplantation through to a goal of symptom control and palliation
  • Identify an appropriate substitute decision maker (health proxy)
  • Advance Directives / Representation Agreements regarding end-of-life care should be addressed at the earliest appropriate time
  • Above decisions should be reviewed regularly and specifically when there is a change in the patient’s clinical status

9.2. Self-Monitoring

  • Discuss the importance of self-management with the patient and their network of support
  • Work with the patient on the specifics of the plan as outlined below (9.3-9.9)

9.3. Weight

  • All patients should be encouraged to weigh themselves daily and recognize symptoms of worsening HF
  • Initially: Report a weight gain of 2.5 kg/week or a worsening of symptoms
  • Goal: Self-assessment and adjustment of fluid/sodium restriction and/or diuretic dosing in response to a weight gain of ≥1 kg (patient-based algorithm)

9.4. Salt Intake

  • All HF patients should limit sodium intake, avoid processed foods and avoid adding salt
  • Review salt intake when weight gain is experienced

9.5. Fluid Intake

All HF patients with hyponatremia, or severe fluid retention/congestion that is not easily controlled with diuretics, should limit fluid intake to 6-8 cups of liquid/day (1 cup = 8 ounces = 250 mL), including frozen items and fruit (1 serving = 1/2 cup of liquid).

9.6. Alcohol

Not more than one drink per day is recommended. This is equal to a glass of wine (5 oz./150 mL/12% alcohol), beer (12 oz./350 mL/5% alcohol), or one mixed drink (1 1/2 oz./50 mL/40% alcohol). In alcohol related heart failure, alcohol must be totally avoided.

9.7. Exercise Training

  • All HF patients with stable symptoms and volume status should undertake regular, moderate intensity physical activity (aerobic and resistance exercises to maintain muscle mass)
  • Aerobic physical activity: Start with 5-10 minute sessions every other day, working to a goal of 30-45 minutes per day 4-5 days per week
  • Resistance exercises (do 10-15 repetitions at 50-60% of normal effort)

9.8. Immunization

All HF patients should be immunized for influenza (annually) and pneumococcal pneumonia (if not received in the last six years) to reduce the risk of respiratory infections.

9.9. Collaboration with complementary health care providers

  • Involve Nurses, Pharmacists, Dieticians and Cardiac Exercise Therapists for individual or group visits when possible
  • A Dietician can provide valuable education regarding the practical aspects of implementing a salt and water restriction, how to make healthy food choices and/or a group grocery store tour to help facilitate low-salt food and drink selections
  • A Pharmacist may help patients remain on therapy when they are faced with side-effects and provide useful advice to help with medication compliance
  • A Cardiac Exercise Therapist may be instrumental in helping HF patients develop and continue a structured exercise program

10. Pharmacotherapy for Heart Failure

  • In general, research evidence for treatment is best established for systolic HF, although the underlying principles and pharmacotherapy also apply to HF with PSF. However, when treating HF with PSF, extra caution is required with ACE-I, vasodilators and diuretics to prevent symptomatic hypotension or pre-renal failure as LV filling pressures are volume dependent
  • It is important to treat the following underlying cause where possible, especially in the case of HF with PSF:
    • Hypertension (goal is blood pressure <140/90 mmHg)
    • Ischemic heart disease
    • Atrial fibrillation (goal ventricular rate between 60-80 at rest and <110 with exercise)
    • Hypertrophic cardiomyopathy (consider referral to specialist)
  • All patients with systolic HF should be on an ACE-I and a BB unless contraindicated (these medications should be strongly considered in patients with HF with PSF)
  • Historically, an ACE-I was started first and titrated to target dose before starting a BB but current evidence suggests that it does not matter which drug is started first as long as both are titrated to target dose
  • See Appendices regarding medication initiation and titration - BB should not be initiated in patients with volume overload
  • ARB can be substituted for BB or ACE-I if they are not tolerated
  • ARB can be cautiously added to patients with persistent symptoms despite optimal ACE-I and BB dose
  • In the elderly, initial doses should be low and titrated slowly
  • Concerns may arise as these medications are titrated upwards

Blood Pressure:

  • When the systolic BP is below 80 mmHg, limit increase in medication if the patient shows symptoms of low BP (consider measuring postural vitals in the elderly)
  • Take blood pressure lowering medication with food
  • Separate the dosing of blood pressure lowering medications by at least 2 hours (i.e. give the ACE-I at noon and BB in the morning and at bedtime)
  • If hypotension occurs during medication titration consider:
    • Adding a higher dose at bedtime first, then increase the morning dose (if BID dosing)
    • Decrease or discontinue the diuretic and/or vasodilator
    • Consider temporarily reducing the ACE-I dose during BB titration
    • Decrease the BB dose by 50% and reinitiate titration once condition stabilizes

Renal Function:

  • If Creatinine (Cr) increases by >30% evaluate the patient’s volume status and consider reducing/holding diuretic (if volume deplete) before reducing/holding digoxin, ACE-I, ARB, spironolactone or BB
  • Referral to a Nephrologist is encouraged when there is kidney impairment as defined by a Cr increase by >30%, an eGFR <30 mL/min or eGFR <45 mL/min if cause is unknown
  • If a drug with proven mortality benefit is not tolerated by the patient (because of hypotension, bradycardia or progressive renal dysfunction) then reduce or discontinue other drugs without proven mortality benefit (namely digoxin, diuretics, calcium channel blockers, amiodarone)
  • Diuretics are used to control fluid overload but the goal is to use the minimum effective dose. These drugs can sometimes be discontinued once the patient is asymptomatic
  • An effective diuretic dose reduction is more often achieved after ACE-I and BB reach target doses
  • By using the minimum effective diuretic dose, it is more likely that symptomatic hypotension and/or unacceptable increases in Cr with ACE-I or BB can be avoided

Aggressive Management of Cardiovascular (CV) Risk Factors (hypertension, diabetes, dyslipidemia, smoking, obesity) and other comorbid conditions is recommended:

  • ASA 81 mg daily for patients with CV risk factors or established atherosclerosis
  • Treat comorbidities and risk factors as per current guidelines

11. Indications for Referral to a Medical Specialist

  • Cause of heart failure unknown
  • Suspicion of ischemia or valvular disease as the primary cause
  • Severe heart failure that is refractory or difficult to control
  • Symptomatic arrhythmias
  • LVEF≤ 35% (consideration of cardioverter-defibrillator implantation)
  • Consideration for heart transplantation/implantable defibrillator/cardiac resynchronization
  • Serum sodium <132 mmol/L (persistent after water restriction)
  • Refer to a Nephrologist when renal function is impaired and/or deteriorating and the reason is not apparent (see chronic kidney disease guidelines)
  • Refer to the Heart Function Clinic, Cardiac Rehabilitation or Risk Reduction Centre, and to a local Chronic Disease Management Program where available
  • Refer to a Geriatric Medicine Specialist or to Long-Term Care Managers when an elderly patient has significant medical comorbidity, medication management issues, and/or significant cognitive, psychological and functional issues
  • Advanced Practice Nurses provide integral specialist support of cardiac care in HF clinics where they provide nursing case management for ongoing surveillance and education of patients and family members

12. Heart Failure in the Elderly

  • Elderly patients constitute one of the largest groups of patients with HF
  • In general, HF medications are under prescribed despite the fact that this group derives a greater absolute benefit from these medications
  • Treatment strategies in the elderly patient with HF are the same as other groups. However, care must be taken with respect to medication initiation and uptitration
  • A gentle strategy to maximize long-term adherence is preferred because of the propensity for adverse events in this group (especially postural hypotension and digoxin toxicity)
  • Assess for relevant comorbid conditions, such as cognitive impairment, that may affect treatment, adherence, follow-up and prognosis
  • Identify a capable caregiver
  • Consider referral to a specialist in geriatric medicine and/or community support staff

13. Management of Heart Failure with Comorbid Conditions

13.1. Chronic Kidney Disease

  • HF patients with stable renal function (Cr < 200 µmol/L and eGFR >30 mL/min) should receive standard therapy with an ACE-I, ARB or spironolactone (use digoxin with extreme caution)
    • Monitor serum Potassium (K+) and Cr levels more frequently, especially with combination therapy or in the case of an acute intercurrent illness
  • HF patients with persistent volume overload or deteriorating renal function should be assessed for reversible causes - medications (especially NSAIDs), hypovolemia, hypotension, urinary tract obstruction or infection
  • Stable oliguric HF patients - daily evaluation of the dose of diuretics, ACE-I, ARB, spironolactone and non-HF drugs that impair renal function is recommended (preferably as an inpatient)
  • Stable non-oliguric HF and Cr increase >30% from baseline - consider reducing the dose of diuretics, ACE-I, ARB and spironolactone until renal function stabilizes
  • Referral to a Nephrologist is encouraged when there is kidney impairment as defined by a Cr increase of >30%, an eGFR <30 mL/min or eGFR <45 mL/min if cause is unknown

13.2 Anemia (hemoglobin <110 g/L; generally symptomatic if <90 g/L)

  • Investigations and treatment should be directed at the underlying cause
  • Substrate deficiencies should also be replaced (iron, vitamin B12 or folate)
  • There is no evidence to support the use of erythropoietin (or darbepoietin) in HF
  • Consider blood transfusion if, after substrate deficiencies have been corrected, anemia and advanced symptoms persist

14. Management during Intercurrent Illness

  • During acute intercurrent illness (i.e. pneumonia, COPD exacerbation) BB, ACEI and ARBs should be continued at their usual dose unless they are not tolerated
  • If there is a concern about their use, then the dose can be halved during the illness and then uptitrated rapidly as soon as safely possible
  • Only with a life-threatening complication should BB, ACEI and ARBs be discontinued abruptly
  • HF patients with acute dehydrating illness should have prompt evaluation of their renal function and electrolytes even if they are not overtly volume depleted or overloaded
    • If renal function worsens, adjust doses of diuretics, spironolactone, digoxin, ACEI, ARB as necessary
  • If surgery is required, then patients with HF should be evaluated by a Physician experienced in HF management perioperatively
  • If a patient with HF develops a gout exacerbation, the preferred treatment would include oral colchicine ± prednisone; avoid NSAIDs due to their role in exacerbating HF. Gout can be prevented with the use of allopurinol and/or a reduction in diuretic dose (as tolerated)

15. Ongoing Management

Comprehensive HF management is based on setting treatment goals and monitoring the effectiveness of management:

  • Define and monitor cardiovascular goals and the key clinical indicators using a systematic approach (e.g. electronic medical record, flow sheet, file cards)
  • Reverse congestion
  • Control arrhythmia and ischemia
  • Prevent emboli
  • Stabilize vital signs (pulse, sit/stand blood pressure, weight)
  • Use current drug and non-drug therapy for HF and for cardiovascular and non-cardiovascular comorbidity
  • Review medications for intended and unintended effects (inappropriate polypharmacy, potential drug interactions, inadvertent aggravation of comorbid conditions)
    • Monitor serum biochemistry (electrolytes, Cr/eGFR) over the short-term (days to two weeks) if the clinical condition or medications have changed . The frequency will depend on whether the current values are normal or abnormal and whether the patient continues to worsen or improve. When stable, remeasurement at six month intervals may be sufficient but will depend on clincal stability and changes in medications
    • Monitor serum digoxin only if toxicity is suspected or for checking adherence
  • Monitor and treat psychosocial consequences (i.e. non-compliance, anxiety, depression, fear, delirium, dementia, social isolation, home supports and need for respite care)
  • Define and re-define the goals of treatment over time with the patient

16. Prognosis of Heart Failure

Outcomes in heart failure are highly variable and it is important to provide accurate information to patients about prognosis to enable them to make informed decisions about medications, devices, transplantation and end of life.

Poor prognostic factors include:

  • Recurrent hospitalization for acute HF
  • Advanced age (>75 years)
  • Female gender
  • Ventricular arrhythmias (non-sustained ventricular tachycardia) and atrial fibrillation
  • NYHA HF Classes 3 and 4
  • LVEF (<35%) or combined systolic and diastolic left ventricular dysfunction
  • Marked left ventricular dilatation (LVEDD > 70 mm)
  • High BNP levels (See Table 1) - use of BNP for prognostication requires further study
  • Low-serum sodium (< 132 mmol/L)
  • Hypocholesterolemia
The Seattle Heart Failure model is a valuable resource for prognostication found at http://depts.washington.edu/shfm/

17. Palliative and End-of-Life Care

Predicting time of death in HF is challenging given the cyclical nature of the disease. Helpful clinical prediction tools have been established. Discussions regarding end-of-life care should be initiated with patients who have persistent NYHA Class IV symptomatology or an EF < 25% despite maximal medical therapy (at target doses of study drugs as mentioned above).

Prior to initiating end-of-life care ensure that:
  • All precipitating factors have been addressed including:
    • Residual angina and hypertension
    • Adherence to salt and fluid restrictions
    • Adherence to medications
    • Contributory conditions (arrhythmias, anemia, infections, thyroid dysfunction)

  • All active therapeutic options have been appropriately considered:
    • The patient is taking maximal medical therapy (target doses of study drugs)
    • Biventricular pacing (possibly indicated with QRS > 120 ms)
    • Implantable defibrillator (possibly indicated with LVEF < 30%)
    • Revascularization (percutaneous intervention or bypass surgery)
    • Transplantation options have been explored
Once the decision to initiate end-of-life care is made, the goal of therapy is to manage all symptoms (including those of comorbid conditions, e.g. chronic pain) and address function and quality of life issues.

Subsequent care should be based on the following principles:

  • Support of dying patients and their families
    • Caregivers should be consulted to determine their degree of burden
    • It is important to ensure that advance care planning has been carried out, including financial and health care decisions (e.g. Representation Agreement)

  • Control of pain and other symptoms
    • Symptoms related to volume overload:
      • Adequate diuretic use (sometimes more than one agent) is important
      • ACE-I dose may need to be reduced if limited by symptomatic hypotension and renal impairment (Cr > 250 µmol/L or > 30% from baseline)
      • Consider choice and dose of narcotic as renal function is likely impaired – i.e. Hydromorphone for narcotic naïve, Duragesic patch. → Consider home oxygen (See COPD Guidelines for indications)

  • Decisions on the use of life-sustaining therapies
    • Decisions need to be made as to whether and when to pursue hospital admission
    • Consider referral to palliative care/hospice teams if available in the community
    • Consider narcotic use with uncontrolled angina, or as a first-line for dyspnea

*Images provided by Microsoft Clip Art

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