Clinical Guidelines: Heart Failure - Physician Management

KEY RECOMMENDATIONS

1. Diagnosis: Patients with dyspnea and fluid retention who are suspected of having heart failure require echocardiographic determination of ventricular architecture and function. Key measurements include left ventricular ejection fraction (LVEF), uniformity of wall motion, and determination of wall thickness.

2. Patient Education and Counseling: Patients and/or appropriate family members should be informed that heart failure is almost always progressive, but that adherence to an appropriate medical regimen can be expected to increase life expectancy, improve well being, and reduce costs. Moderate exercise appears to be safe and to improve well-being, and should be recommended. Salt restriction should also be recommended. Patients in whom heart failure is due to ischemic heart disease should be counseled to follow appropriate life style modification and, where appropriate, take medications to minimize the risk of myocardial infarction.

3. Therapy: Treatment should be directed both to relieving congestion and slowing progression.

1. Diuretics should be given initially to relieve congestion in most patients. Diuretic dose can often be decreased when the medications listed below are added.
2. ACE Inhibitors (ACEI) and Angiotensin Receptor Blockers (ARBs). ACEI have been shown to reduce mortality in heart failure associated with low LVEF, and should be prescribed to all patients with heart failure unless contraindicated. Initial doses can be low, but optimal responses are obtained with a full dose. ARBs can be given when ACEI are not tolerated.
3. Beta-blockers, when added to ACEI prolong survival, and so should be given to all patients with heart failure except those who are unstable or bedridden (Class iv). Beta-blockers initially worsen failure and so must be started at a low dose; with careful monitoring, dosage can generally be increased over several weeks to the full, recommended dose.
4. Digoxin, which does not improve survival but alleviates symptoms, can be added to the medications listed above in symptomatic patients with low LVEF. Overdose must be avoided, especially where renal function is impaired. Most symptomatic benefit may be obtained with a low dose.
5. Aldosterone antagonists: Aldactone, added to ACEI, appears to improve survival in seriously ill patients (Class iii and iv). When given with ACEI or ARBs, this drug can cause serious hyperkalemia.
6. Anticoagulants: Many patients with advanced heart failure experience pulmonary and other emboli; however, except in atrial fibrillation, benefits of anticoagulation are not proven.
7. Antiarrhythmic therapy: Most appropriately treated heart failure patients die suddenly, rather than of progressive heart failure. However, except for amiodarone, antiarrhythmic drugs are dangerous and should not be prescribed routinely. Implantable defibrillators have been shown to prevent sudden death and may be used in selected patients.

4. Patient Monitoring: Careful management of an informed patient significantly improves outcome, so that frequent contact should be made with patients to determine stability of symptoms and weight. Ideally, this is done by a nurse or other trained health care professional; communication can be maintained by phone and, where necessary, supplemented by home visits.

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Vermont Program for Quality in Health Care, Inc.
132 Main Street, P.O. Box 1356, Montpelier, VT 05601