Guidelines and Protocols Advisory Committee

This guideline 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, and focuses on approaches needed to provide care to patients with this complex syndrome.

Diagnostic Code: 428

Major updates

Microalbuminuria added to routine investigations as it has been shown to be a marker of underlying endothelial dysfunction.
The brain natriuretic peptide (BNP) section is expanded.
Flow charts on diagnosis and management reflect 2007 Canadian Cardiovascular Society (CCS) guidelines.
Non-pharmacologic management is given its own recommendation.
Pharmacotherapy section is standardized, expanded and updated to reflect current evidence.
Distinction between HF with preserved systolic function (HF with PSF, previously called diastolic dysfunction) and HF with reduced systolic function (systolic HF) is de-emphasized.

Evidence of benefit for angiotensin converting enzyme inhibitors (ACE-I) and beta-blockers (BB) in HF with PSF without ischemic heart disease remains controversial (see Recommendations 2, 3 and 4).

Emphasis is placed on management of comorbidities.
New sections on the management of HF during intercurrent illness are added.

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 (see Recommendation 2).

Treat underlying vascular risk factors (see guidelines on Hypertension and Diabetes Care), comorbidities and other chronic diseases (see Recommendation 4).
Patient and caregiver education should be tailored and repeated (see Recommendation 3)

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 (see Recommendation 4)

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 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 (see Recommendation 10).
Engage patients in open discussions on the prognosis of HF at the earliest appropriate time (see Recommendations 11, 12 and 13).

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RECOMMENDATION 1: 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 British Columbia guidelines.

Routine screening for asymptomatic LV dysfunction is currently not recommended. For selected patients at high risk for heart failure due to multiple risk factors, the decision to screen (such as by echocardiography) should be individualized.

In 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)

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RECOMMENDATION 2: Diagnosis of Heart Failure

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

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 non-pharmacologic strategies are similar for both.

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) Class (see Figure 1)
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 and 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 (See Table 1). The use of BNP in non-acute heart failure and community outpatient practice remains to be clarified.

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
When the etiology of HF is uncertain, consider referral for more specialized cardiac testing as clinically indicated (see Recommendation 5)

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

(printable PDF)

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

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

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

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RECOMMENDATION 3: 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.

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 (see Recommendations 11, 12 and 13)

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

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

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)

Salt intake (goal of 2-3 g of sodium per day)

All HF patients should limit sodium intake, avoid processed foods and avoid adding salt

Review salt intake when weight gain is experienced

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 = 240 mL), including frozen items and fruit (1 serving = 1/2 cup of liquid)

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.

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)

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

Collaboration with complementary health care providers

Involve nurses, pharmacists, dieticians and cardiac exercise therapists for individual or group visits when possible

An experienced nurse can help the patient understand the pathophysiology of HF and help with self-management, weight monitoring and diuretic adjustment.
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.

Note: Patients may obtain a copy of the booklet Managing Congestive Heart Failure from the Heart and Stroke Foundation Web site: www.heartandstroke.ca

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RECOMMENDATION 4: 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 (see Recommendation 7)

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 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 (see Recommendation 8)
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 (see relevant GPAC guidelines)

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

Figure 2. Management

(printable PDF)

Figure 2. Management

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RECOMMENDATION 5: 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 guideline)
Refer to the Heart Function Clinics, Cardiac Rehabilitation or Risk Reduction Centres, 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.

Note: 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.

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RECOMMENDATION 6: Management of Acute Heart Failure (AHF)

HF is characterized by recurrent exacerbations and decompensations. The following should serve as a brief resource for the management of an acute decompensation. For further information please refer to the CCS consensus conference recommendations on heart failure care 2007 (www.hfcc.ca).

Clinical Evaluation

Clinical assessment of Perfusion (cold or warm) and Volume Status (wet or dry)
Initial Investigations

Complete blood count, electrolytes, Cr, eGFR, troponin, BNP, ECG, chest x-ray

Repeat frequently if patient presents in shock with renal dysfunction

An echocardiogram should be performed if no recent echocardiogram is available

Initial Management

General Principles:

Promptly identify and treat the precipitating cause when possible

Tachyarrhythmia, ischemia, infection, anemia, thyroid dysfunction
Compliance issues (excessive sodium intake, medication non-adherence)

Monitoring

Reassess heart rate, blood pressure, oxygen saturation and response to therapy frequently
Consider bladder catheterization to monitor fluid balance (urine output)
Consider invasive monitoring (arterial lines, central venous pressure) for patients in shock or for those who require inotropes or vasopressors

Initial therapy should be directed at the clinical situation

Oxygen should be given initially to all patients presenting with AHF and hypoxia

Consider bilevel positive airway pressure ventilation (BiPAP) if patient does not appear to be responding to progressive increases in fraction of inspired oxygen (FiO2 ) but do not delay intubation if required

Warm (well perfused, stable blood pressure) and Wet (volume overloaded)

IV Diuretics (furosemide) - first-line for patients with AHF and congestion

Initial dose is based on clinical judgment, however, a good starting point is to double the patients usual oral dose and give it through IV
Reassess response after 60-90 minutes and titrate as necessary

Vasodilators (nitroglycerin SL, IV, or PO; nitroprusside IV)
Morphine - as an adjunct may help to relieve subjective dyspnea with the increased risk of respiratory and circulatory depression

Cold (poor perfusion, hypotensive) and Wet – i.e. Cardiogenic shock

Positive inotropes for short-term therapy to stabilize the patient

Dobutamine 2-5 µg/kg/min (preferred) or milrinone 0.25 µg/kg/min and titrated to effect
Consider early transfer to a tertiary care centre for patients in cardiogenic shock with a low comorbid disease burden for circulatory mechanical support and transplantation consideration

Once Stabilized:

Consider combined IV diuretics and inotropes
Consider initiation of vasodilators (ACE-I, hydralazine, nitrates)
Patient education regarding HF care
Return to Recommendation 3 and 4 regarding on-going management of HF

For patients with concomitant renal failure

Consider early nephrology consultation

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RECOMMENDATION 7: Heart Failure in the Elderly

Elderly patients constitute one of the largest groups of patients with HF.

In general, HF medications are underprescribed 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.

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RECOMMENDATION 8: Management of Heart Failure with Comorbid Conditions

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 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

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

Further information can be found at:
www.ccs.ca/download/consensus_conference/
consensus_conference_archives/2007_HFCC_update.pdf

A downloadable pocket reference card is available from CCS. It can be found at:
www.hfcc.ca/downloads/educational_tools/pocket_card/pocket_card.html

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RECOMMENDATION 9: 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).

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RECOMMENDATION 10: Practice Management Strategies

Management strategies such as recall and regular review can improve the care of patients with HF. Physicians are encouraged to:

Identify all patients in your practice with HF (use an electronic medical record, file card system or the CDM toolkit)
Flag patient chart covers with a label (red dot or heart) identifying the patient as a HF patient (this may be used as an alert to the medical office assistant to weigh and obtain BP of patients when they are brought into the examining room)
Monitor key clinical indicators of HF: a flow sheet or EMR template is recommended
Make use of planned visits and recall systems to ensure that patients with HF are seen at appropriate intervals
Review patient records to ensure the goals of care have been met
Visit the chronic disease management web site: www.primaryhealthcarebc.ca

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RECOMMENDATION 11: 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 if the clinical condition or medications have changed (days to two weeks) and at least every six months when stable.

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

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RECOMMENDATION 12: 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 care.

Poor prognostic factors include:

Recurrent hospitalization for acute heart failure
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:
depts.washington.edu/shfm/

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RECOMMENDATION 13: 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 (see Recommendation 12). 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 for 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 narcotic use with uncontrolled angina, or as a first-line for dyspnea

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 Guideline 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

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Rationale

Heart failure (HF) is a clinical syndrome defined by symptoms suggestive of impaired cardiac output and/or volume overload in the setting of objective evidence of cardiac dysfunction. Most patients with cardiac dysfunction have not yet been diagnosed. It is estimated that 30% of the people who have cardiac dysfunction but are unaware of it will develop overt HF in the subsequent 3 years.¹ The one-year mortality rate for all ages for men and women is about 33% and increases to about 50% in patients with 3 or more comorbid conditions.² The one-year mortality rate can be as high as 61% in more elderly patients with comorbid conditions.²

Heart failure is most often caused by coronary artery disease³ and/or hypertension and it is a major cause of hospitalization of the elderly in Canada.⁴ About 80,500 British Columbians have been diagnosed with HF and the cost of managing HF patients in BC was about $260 million in fiscal year 2005/06. The number of people with HF has risen from 71,600 in 2002/03, but the age-standardized mortality rate has declined by 22% due to increased use of beta-blockers (BB) and ACE Inhibitors (ACE-I) and better general care of patients with cardiovascular disease.⁵

Improvements in team-based coordination and case management with early intervention, improved pharmaceutical management, close follow-up, and caregiver and patient education about self-management have resulted in reduced hospital admissions.^6-9 In one study, patients in the intervention group had fewer admissions for HF (37% vs 53%) and spent fewer days in hospital for HF (3.43 vs 7.46 days) than the control group.⁹ These studies have largely been based upon the model of nurse clinical care coordination from a HF clinic and need to be extended into primary care settings as outlined in this guideline.

Recent research provides guidance related to worsening renal function and decompensated HF.^10,11 New guidelines from the Canadian Cardiovascular Society emphasize prevention, use of biomarkers such as brain natriuretic peptide (BNP) and management of intercurrent illness, acute decompensation, and HF in the elderly and those with comorbidity.¹² Natriuretic peptides such as BNP have been shown to be useful in the diagnosis of HF in patients with unexplained dyspnea in the acute and ambulatory care settings. Other clinical uses such as screening or guiding therapy, have not been sufficiently validated for widespread use.¹³

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References

Hoes AW, Mosterd A, Grobbee DE. An epidemic of heart failure? Recent evidence from Europe. Eur Heart J. 1998;19 (suppl L): L2-L9.
Jong P, Vowinckel E, Liu PP, et al. Prognosis and determinants of survival in patients newly hospitalized for heart failure. Arch Intern Med 2002;162:1689-94.
Parmley WW. Pathophysiology of congestive heart failure. Clin Cardiol 1992;15, (Suppl 1) 5-12
Health and Welfare Canada. The Changing Face of Heart and Stroke in Canada, 2000, Ottawa. dsp-psd.pwgsc.gc.ca/Collection/H88-3-30-2001/pdfs/age/face_e.pdf.
Province of British Columbia. Ministry of Health. Information support data report. 2007
West JA, Miller NH, Parker KM et al. A comprehensive management system for heart failure improves clinical outcomes and reduces medical resource utilization. Am J Cardiol 1997;79:58-63.
Cline CMJ, Israelsson BYA, Willenheimer RB, et al. Cost-effective management programme for heart failure reduces hospitalization. Heart 1998;80:442-68.
McAlister FA, Lawson FME,Teo KK, et al. A systematic review of randomized trials of disease management programs in heart failure. Am J Med 2001;110:378-384.
Blue L, Lang E, McMurray JJ, et al. Randomised controlled trial of specialist nurse intervention in heart failure. BMJ 2001;323:715-8.
Smith GL, Vaccarino V, Kosiborod M, et al. Worsening renal function: What is a clinically meaningful change during hospitalization for heart failure? J of Cardiac Failure 2003;9(1): 13-25.
Allen LA, O'Connor CM. Management of decompensated heart failure. CMAJ 2007;176:797-805.
Arnold JM, Howlett J, Dorian P, et al. Canadian Cardiovascular Consensus Conference: prevention, management during intercurrent illness or acute decompensation and use of biomarkers. Can J Cardiol 2007;23:21-45.
Felker GM, Petersen JW, Mark DB. Natriuretic peptides in the diagnosis and management of heart failure. CMAJ 2006;175:611-7.

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Appendices

Appendix A: Diuretics

Appendix B: Beta blockers

Appendix C: ACE inhibitors

Appendix D: Angiotensin receptor blockers

Appendix E: Direct acting vasodilators

Appendix F: Spironolactone

Appendix G: Digoxin

The principles of the Guidelines and Protocols Advisory Committee are to:

encourage appropriate responses to common medical situations
recommend actions that are sufficient and efficient, neither excessive nor deficient
permit exceptions when justified by clinical circumstances.

Contact Information
Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1
E-mail: hlth.guidelines@gov.bc.ca
Web site: www.BCGuidelines.ca

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.

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