Note from the National Guideline Clearinghouse: Throughout the original guideline document, boxed "practice points" highlight key issues, while summaries of graded recommendations are provided for most sections.
The grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
Symptoms of Chronic Heart Failure (CHF)
Clinical diagnosis of CHF is often unreliable, especially in obese patients, those with pulmonary disease and the elderly. Therefore, it is important to perform investigations to confirm the diagnosis.
The classic symptom of CHF is exertional dyspnoea or fatigue. Orthopnoea, paroxysmal nocturnal dyspnoea (PND) and ankle oedema may appear at a later stage. Physical signs are often normal in the early stages. Examination should include assessment of vital signs, cardiac auscultation (murmurs, S3 gallop) and checking for signs of fluid retention (e.g., raised jugular venous pressure, peripheral oedema, basal inspiratory crepitations).
All patients with suspected CHF should undergo an electrocardiogram (ECG), chest x-ray, and echocardiogram, even if the physical signs are normal. Full blood count, plasma urea, creatinine, and electrolytes should be measured during the initial workup, and if there are any changes in the patient's clinical status. Urea, creatinine, and electrolytes should also be checked regularly in stable patients, and when changes are made to medical therapy.
The role of plasma B-type natriuretic peptide (BNP) measurements is evolving, but it has been shown to improve diagnostic accuracy in patients presenting with unexplained dyspnoea. In patients with new symptoms, where the diagnosis is not clear following the initial clinical assessment and an echocardiogram cannot be organised in a timely fashion, then measurement of BNP or N-terminal proBNP may be helpful. In this setting, a normal level makes the diagnosis of heart failure unlikely (especially if the patient is not taking cardioactive medicine). If the level is raised, further investigation—including echocardiography—is warranted.
Underlying aggravating or precipitating factors (e.g., arrhythmias, ischaemia, non-adherence to diet or medicines, infections, anaemia, thyroid disease, addition of exacerbating medicines) should be considered and managed appropriately.
Recommendations for Diagnostic Investigation of CHF
- All patients with suspected CHF should undergo an echocardiogram to improve diagnostic accuracy and determine the mechanism of heart failure. (Grade of recommendation = C)
- Coronary angiography should be considered in patients with a history of exertional angina or suspected ischaemic left ventricular (LV) dysfunction. (Grade of recommendation = D)
- Plasma BNP or N-terminal pro-BNP measurement may be helpful in patients presenting with recent-onset dyspnoea; it has been shown to improve diagnostic accuracy with a high negative predictive value (Januzzi et al., 2005; Doust et al., 2004; Mueller et al., 2004; Maisel et al., 2003). (Grade of recommendation = B)
- Repeated measurement of plasma BNP or N-terminal pro-BNP to monitor and adjust therapy in CHF should be confined to patients with CHF and systolic dysfunction who are not doing well on conventional management. Further, more definitive trials are required to fully establish the role of hormone level measurement in guiding CHF treatment (Troughton et al., 2000; Jourdain et al., 2007; Pfisterer et al., 2009; Lainchbury et al., 2009; Felker et al., 2009; Porapakkham et al., 2010). (Grade of recommendation = B)
- Haemodynamic testing should not be used routinely, but on a case-by-case basis. It may be particularly helpful in patients with refractory CHF, recurrent heart failure with preserved systolic function (HFPSF) (diastolic CHF), or in whom the diagnosis of CHF is in doubt (Stevenson, Tillisch, & Hamilton, 1990). (Grade of recommendation = B)
- Endomyocardial biopsy may be indicated in patients with cardiomyopathy with recent onset of symptoms, where coronary heart disease (CHD) has been excluded by angiography, or where an inflammatory or infiltrative process is suspected (McCarthy et al., 2000). (Grade of recommendation = D)
- Nuclear cardiology, stress echocardiography, and positron emission tomography (PET) can be used to assess reversibility of ischaemia and viability of myocardium in patients with CHF who have myocardial dysfunction and CHD. Protocols have been developed using magnetic resonance imaging (MRI) to assess ischaemia and myocardial viability, and to diagnose infiltrative disorders. However, MRI is not widely available. (Grade of recommendation = D)
- Thyroid function tests should be considered, especially in older patients without pre-existing CHD who develop atrial fibrillation, or in whom no other cause of CHF is evident. (Grade of recommendation = D)
Recommendations for Discussion with Patients with CHF
- Lifestyle: Adopt a healthier lifestyle to address risk factors/conditions contributing to the development and progression of CHF (see Section 6, Non-Pharmacological Management, in the original guideline document).
- Personal issues: Understand the effect of CHF on personal energy levels, mood, depression, sleep disturbance, and sexual function, and develop strategies to cope with changes and emotions related to family, work, and social roles.
- Medical issues: Consider practical issues related to pregnancy, contraception, genetic predisposition and practical items, such as an alert bracelet and a diary for daily weights/medications.
- Support: Access to support services, such as Heart Support Australia, Cardiomyopathy Association of Australia, home help, and financial assistance; access to consumer resources.
Information for people with CHF can be obtained through the Heart Foundation's telephone information service, Heartline 1300 36 27 87 (local call cost) and the Heart Foundation website: www.heartfoundation.com.au . Patients should also consult their local phone directories for contact details for Heart Support Australia and the Cardiomyopathy Association of Australia in their state or territory.
Physical Activity and Rehabilitation
Non-pharmacological management may be as important as prescribing appropriate medicines. Patients with CHF may develop physical deconditioning. Therefore, regular physical activity is recommended using a program tailored to suit the individual.
There is strong evidence supporting the benefits of regular physical activity in people with CHF (Flynn et al., 2009). All patients should be referred to a specifically designed physical activity program, if available (Grade A recommendation). The evidence is strongest for middle-aged patients with systolic heart failure. Uncertainty remains about the benefit in elderly patients and patients with CHF associated with preserved LV systolic function.
Other measures are listed in the recommendations below.
If sleep apnoea is suspected, referral to a sleep physician is indicated.
Recommendations for Non-Pharmacological Management of CHF*
- Regular physical activity is recommended (Mancini et al., 1992). All patients should be referred to a specially designed physical activity program, if available (Chati et al., 1996; Meyer et al., 1997; Sinoway, 1998). (Grade of recommendation = B)
- Patient support by a doctor and pre-discharge review and/or home visit by a nurse is recommended to prevent clinical deterioration (Rich et al., 1995; Stewart et al., 1999). (Grade of recommendation = A)
- Patients frequently have coexisting sleep apnoea and, if suspected, patients should be referred to a sleep clinician as they may benefit from nasal continuous positive airway pressure (CPAP) (Naughton, 1998). (Grade of recommendation = D)
- Patients who have an acute exacerbation, or are clinically unstable, should undergo a period of bed rest until their condition improves (McDonald, Burch, & Walsh, 1972). (Grade of recommendation = D)
- Dietary sodium should be limited to below 2 g/day (Stewart et al., 1999). (Grade of recommendation = C)
- Fluid intake should generally be limited to 1.5 L/day with mild to moderate symptoms, and 1 L/day in severe cases, especially if there is coexistent hyponatraemia (Fonarow et al., 1997). (Grade of recommendation = C)
- Alcohol intake should preferably be nil, but should not exceed 10 to 20 g a day (one to two standard drinks) (Fonarow et al., 1997). (Grade of recommendation = D)
- Smoking should be strongly discouraged. (Grade of recommendation = D)
- Patients should be advised to weigh themselves daily and to consult their doctor if weight increases by more than 2 kg in a two-day period, or if they experience dyspnoea, oedema, or abdominal bloating. (Grade of recommendation = D)
- Patients should be vaccinated against influenza and pneumococcal disease. (Grade of recommendation = B)
- High-altitude destinations should be avoided. Travel to very humid or hot climates should be undertaken with caution, and fluid status should be carefully monitored. (Grade of recommendation = C)
- Sildenafil and other phosphodiesterase V inhibitors are generally safe in patients with heart failure. However, these medications are contraindicated in patients receiving nitrate therapy, or those who have hypotension, arrhythmias, or angina pectoris (Zusman et al., 1999). (Grade of recommendation = C)
- Obese patients should be advised to lose weight. (Grade of recommendation = D)
- A diet with reduced saturated fat intake and a high fibre intake is encouraged in patients with CHF. (Grade of recommendation = D)
- No more than two cups of caffeinated beverages per day recommended. (Grade of recommendation = D)
- Pregnancy should be avoided in patients with moderate to severe CHF. (Grade of recommendation = D)
- Pregnancy in patients with mild CHF is reasonable. (Grade of recommendation = D)
* These grades of recommendation apply only to patients with CHF.
Recommendations for Preventing CHF and Treating Asymptomatic LV Dysfunction
- All patients with asymptomatic systolic LV dysfunction should be treated with an angiotensin-converting enzyme inhibitor (ACEI) indefinitely, unless intolerant (Pfeffer et al., 1992; "Effect of enalapril on mortality," 1992). (Grade of recommendation = A)
- Anti-hypertensive therapy should be used to prevent subsequent CHF in patients with elevated blood pressure (Kostis et al., 1997; Dahlof, Lindholm, & Hansson, 1991; MRC Working Party and Medical Research Council, 1992; Hansson, Lindholm, & Niskanen, 1999; Hansson, Hedner, & Lund-Johansen, 2000; Brown, Palmer, & Castaigne, 2000). (Grade of recommendation = A)
- Preventive treatment with an ACEI may be considered in individual patients at high risk of ventricular dysfunction (Yusuf et al., 2000). (Grade of recommendation = B)
- Beta-blockers should be commenced early after a myocardial infarction (MI), whether or not the patient has systolic ventricular dysfunction (Dahlof, Lindholm, & Hansson, 1991; "Medical Research Council trial," 1992). (Grade of recommendation = B)
- Statin therapy should be used as part of a risk management strategy to prevent ischaemic events and subsequent CHF in patients who fulfill criteria for lipid-lowering (Kjekshus et al., 1997). (Grade of recommendation = B)
Treatment of Symptomatic Systolic CHF
All patients with systolic LV CHF, whether symptomatic or asymptomatic, should be commenced on ACEIs with every effort made to up-titrate to the dose shown to be of benefit in major trials.
Other recommended medicines are listed in the recommendations below.
Drugs to avoid in CHF:
- Anti-arrhythmic agents (apart from beta-blockers and amiodarone)
- Non-dihydropyridine calcium-channel blockers (verapamil, diltiazem)
- Tricyclic antidepressants
- Non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 enzyme (COX-2) inhibitors
- Thiazolidinediones (pioglitazone, rosiglitazone)
- Corticosteroids (glucocorticoids and mineralocorticoids)
- Tumour necrosis factor antagonist biologicals
- Dronedarone has been associated with increased mortality in patients with New York Health Association (NYHA) Class IV CHF or NYHA Class II-III CHF (see Table 4.1 in the original guideline document for NYHA class definitions) with a recent decompensation requiring hospitalisation (Kober et al., 2008), and is contraindicated in such patients.
- Trastuzumab has been associated with the development of reduced left ventricular ejection fraction (LVEF) and heart failure (Chien & Rugo, 2010). It is contraindicated in patients with symptomatic heart failure or reduced LVEF (<45%). Baseline and periodic evaluation of cardiac status including assessment of LVEF should occur.
- Tyrosine kinase inhibitors such as sunitinib have been associated with hypertension, reduced LVEF and heart failure (Garcia-Alvarez et al., 2010). The risk–benefit profile needs to be considered with these agents in patients with a history of symptomatic heart failure or cardiac disease. Baseline and periodic evaluation of LVEF should be considered, especially in the presence of cardiac risk factors.
- Moxonidine has been associated with increased mortality in patients with heart failure and is contraindicated in such patients (Cohn et al., 2003).
- Metformin appears to be safe to use in recent analysis of patients with heart failure, except in cases of concomitant renal impairment (Evans et al., 2010).
Recommendations for Pharmacological Treatment of Symptomatic CHF
- ACEIs, unless not tolerated or contraindicated, are recommended for all patients with systolic heart failure (LVEF <40%), whether symptoms are mild, moderate, or severe (SOLVD Investigators, 1991; CONSENSUS Trial Study Group, 1987). (Grade of recommendation = A)
- Every effort should be made to increase doses of ACEIs to those shown to be of benefit in major trials ("Clinical outcome with enalapril," 1998; Packer, Poole-Wilson, & Armstrong, 1999). If this is not possible, a lower dose of ACEI is preferable to none at all. (Grade of recommendation = B)
- Diuretics should be used, if necessary, to achieve euvolaemia in fluid-overloaded patients. In patients with systolic LV dysfunction, diuretics should never be used as monotherapy, but should always be combined with an ACEI to maintain euvolaemia. (Grade of recommendation = D)
- Beta-blockers are recommended, unless not tolerated or contraindicated, for all patients with systolic CHF who remain mildly to moderately symptomatic despite appropriate doses of an ACEI (Packer, Bristow, & Cohn, 1996; "Effect of metoprolol CR/XL," 1999; "The Cardiac Insufficiency Bisoprolol Study," 1999; Packer, Coates, & Fowler, 2001; Flather et al., 2005). (Grade of recommendation = A)
- Beta-blockers are also indicated for patients with symptoms of advanced CHF (Packer, Coates, & Fowler, 2001). (Grade of recommendation = B)
- Aldosterone receptor blockade with spironolactone is recommended for patients who remain severely symptomatic, despite appropriate doses of ACEIs and diuretics (Pitt, Zannad, & Remme, 1999). (Grade of recommendation = B)
- Aldosterone blockade with eplerenone should be considered in systolic heart failure patients who still have mild (NYHA Class II) symptoms despite receiving standard therapies (ACEI, beta-blocker) (Zannad et al., 2011). (Grade of recommendation = B)
- Angiotensin II receptor antagonists may be used as an alternative in patients who do not tolerate ACEIs due to kinin-mediated adverse effects (e.g., cough) (Pitt, Segal, & Martinez, 1997). They should also be considered for reducing morbidity and mortality in patients with systolic CHF who remain symptomatic despite receiving ACEIs. (Grade of recommendation = A)
- Direct sinus node inhibition with ivabradine should be considered for CHF patients with impaired systolic function and a recent heart failure hospitalisation who are in sinus rhythm where their heart rate remains >70 bpm despite efforts to maximise dosage of background beta-blockade (Fox et al., 2008). (Grade of recommendation = B)
- Digoxin may be considered for symptom relief and to reduce hospitalisation in patients with advanced CHF (Digitalis Investigation Group, 1997). It remains a valuable therapy in CHF patients with atrial fibrillation. (Grade of recommendation = B)
- Hydralazine-isosorbide dinitrate combination should be reserved for patients who are truly intolerant of ACEIs and angiotensin II receptor antagonists, or for whom these agents are contraindicated and no other therapeutic option exists (Cohn, Archibald, & Ziesche, 1986). (Grade of recommendation = B).
- Fish oil (n-3 polyunsaturated fatty acids) should be considered as a second-line agent for patients with CHF who remain symptomatic despite standard therapy which should include ACEIs or angiotensin II receptor blockers (ARBs) and beta-blockers if tolerated (Gissi-HF Investigators et al., 2008). (Grade if recommendation = B)
- Amlodipine and felodipine can be used to treat comorbidities such as hypertension and CHD in patients with systolic CHF. They have been shown to neither increase nor decrease mortality (Packer, O'Connor, & Ghali, 1996; Cohn, Ziesche, & Smith, 1997; Packer, 2000). (Grade of recommendation = B)
- Iron deficiency should be looked for and treated in CHF patients to improve symptoms, exercise tolerance and quality of life (Anker et al., 2009). (Grade of recommendation = B)
Outpatient Treatment of Advanced Systolic CHF
Levosimendan is available in Australia on a compassionate-use basis. It should be reserved for patients who do not respond to dobutamine or in those in whom dobutamine is contraindicated due to arrhythmia or myocardial ischaemia.
Bradycardia is common in elderly patients with advanced heart disease treated with beta-blocker therapy.
Implantable Cardioverter Defibrillators
Prophylactic implantable cardioverter defibrillator (ICD) implantation may be considered in patients with an LVEF ≤35%; however, this is currently constrained by funding and other logistical issues. Until these issues are resolved, this therapy may not be universally available.
Decisions about pacing, cardiac resynchronisation therapy, defibrillators, and choice of device are complex and generally require specialist review.
Recommendations for Device-Based Treatment of Symptomatic CHF
- Biventricular pacing (cardiac resynchronisation therapy, with or without ICD) should be considered in patients with CHF who fulfill each of the following criteria (Cazeau et al., 2001). (Grade of recommendation = A):
- NYHA symptoms Class III/IV on treatment
- Dilated heart failure with left ventricular ejection fraction ≤35%
- QRS duration ≥120 ms
- Sinus rhythm
- In patients in whom implantation of an ICD is planned to reduce the risk of sudden death, it is reasonable to also consider cardiac resynchronisation therapy (CRT) to reduce the risk of death and heart failure events if the LVEF is ≤30% and the QRS duration is ≥150 ms (left bundle branch block morphology), with associated mild symptoms (NYHA Class II) despite optimal medical therapy (Abraham et al., 2004). (Grade of recommendation = A)
- ICD implantation should be considered in patients with CHF who fulfill any of the following criteria (Bristow et al., 2004). (Grade of recommendation = A):
- Survived cardiac arrest resulting from ventricular fibrillation or ventricular tachycardia not due to a transient or reversible cause
- Spontaneous sustained ventricular tachycardia in association with structural CHD
- LVEF ≤30% measured at least 1 month after acute MI, or 3 months after coronary artery revascularisation surgery
- Symptomatic CHF (i.e., NYHA functional class II/III) and left ventricular ejection fraction (LVEF) ≤35%
Coronary Revascularisation for CHD in Patients with CHF
Recent evidence suggests that surgical ventricular reconstruction to restore LV volume should not be recommended as a treatment for CHF.
The role of left ventricular assist devices (LVADs) continues to evolve with newer designs offering smaller devices with greater durability and fewer adverse events. LVADs may be considered in selected patients with advanced CHF as destination therapy. However, careful patient selection is warranted and the cost effectiveness remains uncertain (Grade B recommendation).
Indications for Cardiac Transplantation
- Persistent NYHA Class IV symptoms
- Volume of oxygen consumed per minute at maximal exercise (VO2 max) <10 mL/kg/min
- Severe ischaemia not amenable to revascularisation
- Recurrent uncontrollable ventricular arrhythmias
- NYHA Class III
- VO2 max <14 mL/kg/min + major limitation
- Recurrent unstable angina with poor LV function
- LVEF <20% without significant symptoms
- Past history of NYHA Class III or IV symptoms
- VO2 max >14 mL/kg/min without other indication
Acute Exacerbations of CHF
Management of Acute Pulmonary Oedema (APO)
APO is a life-threatening disorder. However, appropriate therapy will often result in a marked improvement in the patient's clinical status within a few hours.
In light of available data, both CPAP and bilevel positive airway pressure (BiPAP) ventilation should be considered in the management of acute exacerbations of CHF, particularly APO (Grade A recommendation).
Emergency Management of Suspected Cardiogenic APO
- Hypoxaemia (→ oxygenation)
- Respiratory fatigue (→ mechanical ventilation)
- Heart rate/rhythm (→ anti-arrhythmics/cardioversion)
- Hypotension (→ inotropes/intra-aortic balloon pump)
|D (differential diagnosis)
- Cardiogenic acute pulmonary oedema (APO)
- Non-cardiogenic pulmonary oedema
- Acute exacerbation of airways disease
- Acute massive pulmonary embolism
- Foreign body aspiration
- Hyperventilation syndrome
- Ischaemia, tachyarrhythmia, fluid overload, medicine
- Underlying pathology
- Systolic left ventricular (LV) dysfunction—coronary heart disease, dilated cardiomyopathy, mitral regurgitation
- Diastolic LV dysfunction—hypertensive heart disease, hypertrophic cardiomyopathy, aortic stenosis
- Normal LV function—mitral stenosis
See Figure 10.1 in the original guideline document for emergency therapy of acute heart failure.
Heart Failure with Preserved Systolic Function (HFPSF)
Although the epidemiology of HFPSF or diastolic heart failure has been incompletely described, the main risk factors are advanced age, hypertension, diabetes, LV hypertrophy, and CHD. Diagnosis, investigation, and treatment are summarised below.
There are still no conclusive data regarding the efficacy of any drug class in treating HFPSF.
Diagnosis, Investigation, and Treatment of HFPSF
- Clinical history of CHF
- Exclude myocardial ischaemia, valvular disease
- Objective evidence of CHF (x-ray consistent with CHF)
- Ejection fraction ≥45% (echocardiography, gated blood pool scanning, left ventriculography)
- Echocardiographic or cardiac catheterization evidence of diastolic dysfunction, where possible
- Use of plasma BNP measurement for diagnosis of diastolic heart failure is not proven
- Pseudonormal or restrictive filling pattern demonstrated by mitral inflow (age appropriate)
- Left atrial enlargement
- Reduced septal annular velocity (Ea) on tissue Doppler imaging
- Ratio of E wave to Ea >15
- Elevated LV end diastolic pressure
- Prolonged Tau
Treatment (Empirical at This Stage)
- Aggressive risk factor reduction
- Hypertension—blood pressure (BP) reduction; consider ACEIs or angiotensin II receptor antagonists to reduce LV hypertrophy
- Diabetes mellitus—strict glycaemic and BP control; consider ACEIs or angiotensin II receptor antagonists early, using lower BP recommendations for treating hypertension in diabetic patients
Treatment of Associated Disorders
See Chapter 12 in the original guideline document for a discussion of treatment of associated disorders, including cardiac arrhythmia, valvular heart disease, CHD, arthritis, chronic renal failure, anaemia, cancer, diabetes, thromboembolism, and gout.
Rate control, rather than rhythm control, together with warfarin anticoagulation, is the preferred method of treating patients with CHF and AF if their condition permits this.
The role of AV node ablation and pulmonary vein isolation for patients with CHF and AF requires further research and no specific recommendation can be made at this stage.
Post-discharge Management Programs
Multidisciplinary programs of care targeting high-risk CHF patients following acute hospitalisation prolong survival, improve quality of life, and are cost effective in reducing recurrent hospital stays.
All patients hospitalised for heart failure should have post-discharge access to best-practice multidisciplinary CHF care that is linked with health services, delivered in acute and subacute healthcare settings. Priority should be given to face-to-face management of patients with CHF. The application of remote management assisted by structured telephone support and telemonitoring should be considered for those patients who do not have ready access to a CHF management program (Grade A recommendation).
An individualised program of palliative care should be considered for patients facing the strong possibility of death within 12 months and who have advanced symptoms (i.e., NYHA Class IV) and poor quality of life, resistant to optimal pharmacological and non-pharmacological therapies.
Palliative care should only be considered when progressive symptoms prove to be refractory to optimal treatment.
Treating doctors should discuss with their patients the level of intervention appropriate and/or desirable during this phase of their illness, so that unwanted, traumatic interventions are prevented in the last few days of life. Both the patient and their family and carers may need significant emotional support during this process.
Grades of Recommendations
- Rich body of high-quality randomised controlled trial (RCT) data
- Limited body of RCT data or high-quality non-RCT data
- Limited evidence
- No evidence available – panel consensus judgment