East London Summary Guidelines

July 2002

Heart failure Primary objectives for heart failure  A practice register of heart failure should be maintained  Annual review of patients on the register and follow-up

ISBN 1 898661 64 2

 ACE inhibitor at an adequate dose  Blood pressure maintained below 140/85 mmHg  Statins for those with angina or previous MI (if serum cholesterol ≥

5mmol/l or LDL cholesterol ≥ 3mmol/l)

 Beta-blockers (started with specialist advice)  Add Spironolactone 25 mg in more severe heart failure  NSAIDs should be avoided  Improve information for patients and carers  Audit performance towards these objectives

Key to grades of recommendations A Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation. B Requires the availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation. C Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality.

Contents

Aim of guidelines

Summary of the treatment of left ventricular dysfunction 2

The guidelines are designed for primary and outpatient services to improve the identification of people with left ventricular systolic dysfunction, to improve their treatment and quality of care and provide information for patients and carers. These are set out as the primary objectives listed above.

Prevalence and natural history 3 Heart failure without left ventricular dysfunction 3 Diagnosis of heart failure due to left ventricular dysfunction 3 Algorithm for assessment of suspected heart failure in primary care 4 Prevention and non-drug treatment of heartfailure 5 Drugs which worsen heart failure 5 Treatment of heart failure 6 Algorithm for the use of ACE inhibitors 7 Atrial fibrillation 8 Myocardial infarction and angina 8 Palliation 8

This work complements the National Service Framework for coronary heart disease. By April 2003 the PCTs should ensure that local priorities are identified and all practices have a protocol describing the systematic prevention of heart failure, management and audit.

Annual review 9 Non-response to treatment 9 Audit criteria – age 65 years and over 9 Appendix 1. Dvelopment of the guidelines 10 Appendix 2. Heart failure services in Newham, Tower Hamlets and Hackney 11 Appendix 3. Patient and carer information sheet about heart failure 12

These guidelines have been agreed locally (see appendix 1 for details). They are based on the Scottish Intercollegiate Guidelines Network (SIGN) guideline: Diagnosis and treatment of heart failure due to left ventricular systolic dysfunction, 1999 (www.sign.ac.uk/pdf/sign35.pdf)

2

Summary guidelines

Summary of the treatment of left ventricular dysfunction

Treatment of left ventricular systolic dysfunction  Confirm diagnosis by echocardiography where possible  Discontinue NSAID, reconsider or discontinue calcium channel blocker or other aggrevating drugs  Address BP control and lifestyle changes

Treat with: ACE inhibitor Beta-blocker (under hospital supervision)

Atrial fibrillation  Digoxin  Warfarin  Aim for excellent rate control 5mmol/l)

Persisting sodium and water retention  Spironolactone and/or  Increase dose of loop diuretic e.g. oral frusemide 80mg/d maximum and/or  Digoxin  Consider referral

Heart failure

Prevalence and natural history Chronic heart failure is a clinical syndrome characterised by breathlessness, tiredness and fluid retention most commonly caused by left ventricular systolic dysfunction. It mainly affects people over 70 years of age. Most cases are due to coronary heart disease or hypertension and most of these cases are due to dysfunction in the left ventricle during systole. Some heart failure occurs with normal systolic function (see below). Left ventricular systolic dysfunction affects 5% at age 65-74 years and 10% at 75-84 years. Only half the people with ventricular dysfunction are symptomatic. Annual mortality approaches 10% in mild cases (50% in five years). In severe cases annual mortality is 60% or more. Although optimal treatment may reduce deaths by up to a half, mortality remains high. Quality and expectation of life in patients with severe heart failure is comparable to that of more malignant terminal cancers. Severe heart failure is often a profoundly distressing terminal illness where the emphasis should be on quality of life and palliative care as well as optimal treatment.

New York Heart Association (NYHA) classification of heart failure symptoms Class I Asymptomatic Ordinary physical activity does not cause undue fatigue, dyspnoea or palpitation. Class II Mild heart failure* Patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation,dyspnoea or angina pectoris Class III Moderate heart failure* Although comfortable at rest, marked limitation of physical activity Class IV Severe heart failure* Symptoms at rest. Inability to carry on any physical activity without discomfort. *Severity applies to the symptoms not necessarily to prognosis

3

Heart failure without left ventricular dysfunction Approximately a quarter of patients with symptoms of heart failure have near normal systolic ventricular function. This has been termed ‘diastolic heart failure’ to indicate they may have abnormalities of ventricular filling during diastole. This area is one of current controversy, but a recent study found that most of these people have other causes for their breathlessness, usually obesity, lung disease or myocardial ischaemia (BMJ 2000;321:215-219). These guidelines do not cover this group of patients.

Diagnosis of heart failure due to left ventricular dysfunction Inability to eject blood from the left ventricle is the major cause of heart failure. In healthy people the mean ejection fraction is 50-60%. In people with mild heart failure, the ejection fraction is 40-50%, in moderate failure 30-40% and in severe heart failure the ejection fraction is less than 30%. (In echocardiography, ejection fraction is not the only measure of left ventricular function and is taken together with other indicators to give an estimate of function.) The predictive power of diagnostic tests in general practice is low because the prevalence of heart failure is low. General practitioners correctly diagnose 70-80% of people who have severe dysfunction. However, in people with mild dysfunction only a third are identified. Furthermore 30% of milder cases of heart failure are incorrectly diagnosed and are due to other causes. Isolated clinical signs are poor predictors and are often not present. In combination they are more reliable and an abnormal apical impulse is the best clinical predictor. Past medical history of myocardial infarction, angina or hypertension will be present in most patients with left ventricular dysfunction and the condition is five times more common in men and particularly prevalent over 80 years of age. ECG is abnormal in most cases. A normal ECG should prompt reconsideration of the diagnosis. However, a normal ECG doesn’t always exclude heart failure and further investigation will be required.

(continued on page 5)

4

Summary guidelines

Algorithm for assessment of suspected heart failure in primary care

Clinical assessment, CXR, ECG or patient history suggest heart failure

NO

Echocardiography* shows moderate or severe left ventricular dysfunction?

YES

Heart failure Lifestyle advice Stop aggravating drugs Start ACE inhibitor treat other risk factors

NOT AVAILABLE YES

Documented previous myocardial infarction?

YES

Probability of heart failure high – Are you confident of diagnosis?

NO, INCONCLUSIVE OR NOT KNOWN

ECG abnormal? (abnormal – Q waves, left bundle branch block)

YES

NO

NO, INCONCLUSIVE OR NOT KNOWN

Chest x-ray showing pulmonary congestion or cardiomegaly?

YES

NO, INCONCLUSIVE OR NOT KNOWN

Heart failure unlikely

NO

Remaining unexplained symptoms of heart failure?

YES

Refer for further investigation

*Note: Echocardiography should ideally be carried out in all patients with suspected heart failure. However, constraints on both patients and services make this difficult to achieve in the short term.

Heart failure

Chest X-ray. Cardiomegaly (cardiothoracic ratio > 0.5 or 50%) will be present in half the cases with impaired systolic function. Chest X-ray will be normal in half the cases of left ventricular dysfunction.

Drugs which worsen heart failure B

If CXR and ECG are both normal, heart failure is unlikely. The combination of positive past medical history and clinical signs is a good predictor of more severe heart failure. The combination of a displaced apex beat, prior MI and breathlessness has a sensitivity of over 90% and a false positive rate of 20% or less. Echocardiography. Echocardiography determines left ventricular size, shape, wall thickness, function and ejection fraction and assessment of valves. Fewer than 30% of patients with heart failure in the UK undergo echocardiography. Ideally all patients with suspected heart failure should have echocardiography, particularly if there is a murmur, diagnostic uncertainty or failure to respond to medication. In practice most patients do not receive an echocardiogram and local service provision for access to echocardiography remains variable and less than optimal. See appendix 2 for local arrangements.

NSAIDs. Non-steroidal anti-inflammatory drugs are associated with double the risk of admission with heart failure and should be avoided.

A Calcium channel blockers (CCBs). Nifedipine and other CCBs may exacerbate heart failure and should be avoided. Amlodipine and possibly felodipine may be less likely to exacerbate heart failure – while some clinicians feel these should be avoided in heart failure where at all possible, others feel they may be beneficial. C

Tricyclic antidepressants and corticosteroids.

A Doxazosin is associated with an increase in heart failure when used to treat hypertension. It should be avoided. C

Metformin

Drug treatment to prevent heart failure

Blood tests: FBC, biochemical profile (electrolytes, creatinine, liver enzymes, cholesterol, blood glucose), thyroid function tests and urinary protein.

A Anti-hypertensive treatment reduces heart failure.

Prevention and non-drug treatment of heart failure

C

People who have had a stroke or have CHD in whom aspirin 75mg is recommended, should continue with aspirin if they have heart failure.

A Smoking. Discuss strategies for cessation including specialist clinics and nicotine replacement.

C

In the absence of CHD or stroke, aspirin is not recommended in patients with heart failure.

A Increased physical activity should be encouraged and may improve function. C

Salt should not be added and high salt foods avoided.

C

Obese patients should be offered dietary advice.

C

Alcohol is acceptable in small amounts but contraindicated where it may be a cause.

C

Medication management may be improved by dosette boxes and community pharmacist or nurse supervision.

B

Outreach by trained nurses may reduce death and readmission after discharge from in-patient admission with heart failure.

B

Pneumococcal vaccine. Once-only pneumococcal immunisation and annual influenza immunisation.

5

A ACE inhibitors after myocardial infarction reduce heart failure.

6

Summary guidelines

Treatment of heart failure A Diuretic. Patients with signs of sodium and water retention, i.e. peripheral oedema, pulmonary oedema or an elevated jugular venous pressure, should receive diuretic therapy. Breathless patients may obtain symptomatic relief. Dose of frusemide should not exceed 80 mg. The combination of a loop diuretic with bendrofluazide or metolazone may be required in severe cases. Monitoring of potassium and renal function is mandatory and should be under hospital supervision. Metolazone is used intermittently rather than on a daily basis.

bisoprolol and metoprolol. There is no evidence to suggest one long acting ACE is better or worse than another. Local pharmaceutical advisors should be consulted for locally preferred options as both costs and evidence are rapidly changing. What is more important is that the chosen ACE inhibitor is given in the optimal dosage for heart failure (see BNF for optimal dosages). A Spironolactone. Spironolatone 25mg should be added in patients already treated with diuretics, an ACE inhibitor and/or digoxin, who are in NYHA classes III and IV. Careful monitoring of blood chemistry is mandatory as a high potassium and substantial increases in creatinine can be a problem, particularly in the elderly. A Digoxin

A ACE inhibitor. All patients with all grades of heart failure (including asymptomatic left ventricular dysfunction) should be considered for treatment with an ACE inhibitor. They reduce mortality and admission by 35%. Although ACE inhibitors are started at low dosage, dosage needs to be increased to the equivalent of that used in trials. Local hospital or primary care formularies/pharmaceutical advisors should be consulted for the locally preferred ACE inhibitor and the recommended target dose. (See BNF for dosage). A minority of patients will be intolerant of an ACE inhibitor, usually due to persistent cough, and should be considered for treatment with an angiotensin II receptor antagonist. A Beta-blocker. A beta-blocker should be added in patients already treated with diuretics and/or digoxin and an ACE inhibitor, who are clinically stable and without contraindications (COPD, asthma). They reduce mortality by 30%. They should be started with specialist supervision. As experience and confidence grows in their use, detailed treatment protocols will be developed to support their wider usage in the community (sic. ACE inhibitors). A useful reference for starting beta-blockers is Farrell HM, Foody JM, Krumholz HM. Beta-blockers in heart failure. Clinical applications. JAMA 2002;287:890-897.

Which ACE inhibitor or beta-blocker? For ACE inhibitors once daily long acting preparations are preferred. The strength of trial evidence, cost and licensing regulations will determine which of the various preparations should be used. Similar considerations apply to betablockers although trial evidence exists for carvedilol,

Should be given to all patients with atrial fibrillation and heart failure who need control of the ventricular rate (< 100 beats/min).  Even in the absence of atrial fibrillation, digoxin may

benefit patients with moderately severe or severely symptomatic (NYHA Class III or IV) heart failure who remain symptomatic despite diuretic and ACE inhibitor therapy and beta-blocker; have had more than one hospital admission for heart failure; or have very poor left ventricular systolic function or persisting cardiomegaly (cardiothoracic ratio > 0.55).  It is important to recognise that digoxin is an adjunct, not

an alternative to an ACE inhibitor. However in patients unable to tolerate ACE inhibitors or angiotensin II receptor antagonists, digoxin should be used  Digoxin toxicity needs to be considered, particularly in

the elderly or where there is renal impairment. C

Statin. Patients under 75 years with heart failure caused by coronary artery disease should be treated with a statin (if serum cholesterol ≥ 5mmol/l). At the time of writing there is no trial evidence at older ages, though some local clinicians believe it to be beneficial and current trials due to report soon are likely to confirm this.

Aspirin: is only recommended in heart failure where there is some other indication such as stroke, myocardial infarction or angina.

Heart failure

Algorithm for of the use of ACE inhibitors

Confirmed left ventricular systolic dysfunction

Check creatinine, urea and electrolytes

Specialist advice required before starting ACE inhibitor If any of the following:  Creatine > 150micromol/l*  Sodium 150micromol/l* or potassium to 5.5mmol/l)

 If no adverse effects aim for target dose (or highest dose tolerated) of ACE inhibitor  Titrate in incremental steps to target dose

Specialist referral

Step 3 Review patient after 1 month If cough consider angiotensin II inhibitor Refer for renal dysfunction

 Check blood chemistry (potassium, urea, creatine)  Check for adverse effects e.g. symptomatic hypotension, renal dysfunction/hyperkalaemia, intolerable cough

7

8

Summary guidelines

Atrial fibrillation Atrial fibrillation affects 10% in mild cases rising to 50% of people in more severe heart failure. Failure of rate control is an important cause of deterioration in symptoms.  Is atrial fibrillation the cause or consequence of heart failure?  Could the patient have mitral stenosis?  Could the patient have thyrotoxicosis?  Is alcohol a factor? A Digoxin should be used to control an excessive ventricular rate in patients with atrial fibrillation and heart failure. Poor rate control is fairly common even with digoxin and other measures are often necessary to control heart rate. Such rate control may be crucial. A Amiodarone is relatively ineffective in controlling the rate. Amiodarone has a major impact on pharmacokinetics increasing INR and serum digoxin. Warfarin dosage should be initially halved and digoxin dosage reduced. Fifteen per cent of patients develop thyrotoxicosis or hypothyroidism, similar proportions develop corneal depositions, photosensitvity and lung damage. Twenty-five per cent of patients on amiodarone in one trial were admitted to hospital or had the drug withdrawn as a result of adverse effects. Close monitoring under specialist supervision is required if this drug is used. A Warfarin: Aim for a target INR of 2.5 (range 2.0-3.0). See also east London summary atrial fibrillation guidelines, 2002 Clinical Effectiveness Group.

Myocardial infarction and angina Half the patients with heart failure have had a myocardial infarction or have angina. A Smoking cessation reduces infarction and mortality. A Statins (if serum cholesterol 5mmol/l or more) and beta -blockers reduce recurrent infarction, and beta blockers improve mortality in heart failure. There is currently no evidence on the benefits of statins in people over 75 years of age. Aspirin. Low dose aspirin is recommended although there are no trials specifically in heart failure.

A Nitrates relieve symptoms and have no effect on either mortality or heart failure symptoms (except in combination with hydralazine in heart failure). A Calcium channel blockers. Nifedipine, nisoldipine and diltiazem may worsen heart failure and should not be used. B

Amlodipine and felodipine may be less hazardous in heart failure, although ankle oedema is a frequent side effect and may exacerbate existing oedema. There is a lack of consensus as to whether the benefits of treatment in heart failure outweigh the risks. Some clinicians avoid them and others continue to use them.

Palliation (not included in SIGN guidelines) Despite optimal anti-failure treatment, heart failure may be a terminal and distressing illness and palliative care is appropriate. The relief of discomfort – both physical and psychological – is a prime aim of care. Where patients remain distressed despite optimal treatment consider referral to palliative care teams. Morphine may relieve discomfort from pain or breathlessness. SSRIs may improve depression. Cachexia may require calorie and vitamin supplementation.  The prognosis should be discussed where appropriate with carers and patients.  Benefits counselling for constant attendance, mobility and other benefits.  Respite care, arrangements for contacting GPs out of hours and 24 hour advice.  Local palliative care teams may prove very helpful.  A very informative reference on palliative care in heart failure is Ward C. The need for palliative care in the management of heart failure. Heart 2002;87:294-298.

Heart failure

Annual review

Audit criteria – age 65 years and over

People with heart failure should be reviewed at least annually and more frequently in more severe cases. Review should include

1. Prevalence of heart failure in people over 65 years of age

History History of deterioration / well being: extent of breathlessness, weight gain, fatigue, oedema, exertional chest or leg pain. NYHA grade? Clinical examination Weight, blood pressure, pulse rate and rhythm, examine heart, lungs and legs. Investigations  Urea and electrolytes 

Serum cholesterol if on a statin



Blood glucose



Digoxin level if unexplained deterioration.

Check medication Type, content, adherence and adverse effects. Patient and carer information Information including signs deterioration, common medication and who to contact with a problem. Lifestyle advice (see appendix 3).

Non-response to treatment 

Check mechanical factors not present such as valve disease.



Ensure optimal therapy: adequate ACE dosage; ? on spironolactone 25mg; ? on beta-blocker.



Exacerbating factors: alcohol; check NSAIDs have been stopped; digoxin toxicity; infection.



Non-adherence: involve carer, community pharmacist, district nurse; consider dosette boxes.



Rate control: may be poor. Rate may be normal at rest but too fast on exertion. Refer for 24 hour tape if suspected.



Social support: adequate benefits, carer information, social services support.



Palliative care: adequate palliative care and / or opiate for intractable breathlessness, pain or distress?

9

2. Proportion with a prescription for ACE inhibitor in preceding 12 months 3. Proportion with a documented blood pressure reading within preceding 12 months 4. Proportion with blood pressure