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Guidelines for the Management of Heart Failure in Primary and
Secondary Care
Contents Page
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Guidelines for the Management of Heart Failure in Primary and
Secondary Care
Mission Statement
The aims of the Heart Failure Service are to enhance patient quality
of life by providing ongoing education and support, reduce
inappropriate admission and readmission, to improve prognosis and
prescribing rates to this patient group.
Service Provision
Patients will access the heart failure service in one of the following ways:
At present there is no provision for sick/annual leave cover for the HFNS
team.
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Referral and Discharge Criteria
Referrals
The medical team should generally only discharge heart failure patients
from hospital when their clinical condition is stable and when there is a
treatment plan. The timing of the discharge should take into account
patient and carer needs and wishes, along with the level of care and
support that can be provided in the community.
The primary care team, the patient and carer (if any) must be aware of the
treatment plan. Follow up of patients will be at home initially and later at
Heart Failure Clinics, where the patient will be seen either by the
consultant running the clinic, a GP with Specialist Interest (GPSI) or the
HFNS as appropriate.
When the patient has achieved optimal drug therapy and their condition is
felt to be stable the HFNS will discharge back to the GP who should
continue the regime and review the patient at regular intervals. Patients
can refer themselves back to the heart failure service at any time or when
the GP feels it appropriate.
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Diagnosis
The echo examination may also identify patients suitable for bi-
ventricular pacing and others who should be considered for Implantable
Cardioverting Defibrillator (ICD), if they also fulfill other criteria.
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Management of Heart Failure
NB: For drug therapy please see page 7 and the Medicines
Management Supplement at the end of these guidelines
Ideally, a specialist should assess all patients with heart failure at least
once after the diagnosis is made or suspected. As part of a multi-
disciplinary approach this can take the form of a review of the notes.
All patients with chronic heart failure should have their clinical status
monitored at regular intervals. This should include assessment of
functional capacity, fluid status, cardiac rhythm (minimum of examining
the pulse), nutritional and cognitive status. Medication should also be
reviewed including any changes, possible side effects and compliance.
Serum urea, electrolytes, creatinine and eGFR (estimated Glomerular
Filtration Rate) should be measured appropriately. This is a minimum
standard and the monitoring interval can be short (days to 2 weeks) if the
clinical condition or medication regime has changed. It is required at least
six monthly in stable patients with proven heart failure and should take
place in the most appropriate setting at that time i.e. primary care or
secondary care.
When the HFNS service arranges or conducts blood tests it will be their
responsibility to check the results and act accordingly. GP’s will be
copied in to all blood results ordered by the HFNS. Where creatinine
increases to more than 30% over the baseline or EGFR falls by 15%, the
HFNS will refer back to the consultant / GP for review of the individual
clinical management plan and possible renal referral according to renal
guidelines.
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The palliative needs of patients and carers should be identified, assessed
and managed with access to professionals with palliative care skills
within the multi-disciplinary team.
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Drug Therapy
All patients with heart failure due to left ventricular systolic dysfunction
(LVSD) should be considered for treatment with an ACE Inhibitor, which
should be initiated at the appropriate dose and titrated upwards at suitable
intervals e.g. two weekly, until the optimal dose tolerated or the target
dose is achieved. If ACE Inhibitors are not tolerated (e.g. due to severe
cough) consider Angiotensin II Receptor Blocker (ARB) as an
alternative. Candersartan at present is the only ARB licensed for use in
chronic heart failure. Blood chemistry should be measured after
initiation and at each ACE Inhibitor / ARB dose increment regardless of
whether the patient is in hospital or at home.
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In all patients with left ventricular impairment, beta-blockers licensed for
use in heart failure should be initiated after diuretic and before or after
ACE Inhibitor therapy (regardless of whether or not symptoms persist).
Beta-Blockers should be introduced and titrated slowly with assessment
of heart rate, blood pressure and clinical status after each titration. The
Beta-Blockers licensed for use in heart failure are Bisoprolol and
Carvedilol. They may also be appropriate in right heart failure.
COX 2 Inhibitors.
Tricyclic Antidepressants.
Corticosteroids.
Glitazones.
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Oxygen Therapy
Cylinders will be used in patients where short burst oxygen is used for
less than two hours in a twenty four hour period. Where long term
oxygen therapy (LTOT) is indicated concentrators will be supplied and
re-assessment of need will take place within the first six weeks. In both
cases the HFNS will use the HOOF form to order from Allied
Respiratory.
In some cases fan therapy may be helpful to heart failure patients and
should be considered as an alternative.
Referrals to the heart failure service from secondary care for possible
discharge oxygen should be planned well in advance. The service should
not be used to alleviate the bed situation as it does not have the resources
to respond to emergency call outs.
Where COPD exists with heart failure, assessment will be with input
from the specialist respiratory team. Advanced oxygen assessment is
beyond the skills of the HFNS.
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Education and Support
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Guidelines for Referral to Specialist Palliative Care
Pilgrims Hospices in East Kent
Patients will be considered for referral if they meet the following criteria:
Patients will usually have advanced heart failure NYHA IV (or III at
discretion of health care team).
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Audit
NICE Guidelines provide technical detail on the criteria for audit. The
denominators include discharge planning, patient and carer
understanding, frequency of monitoring, numbers of patients on ace
inhibitors and beta blockers, echocardiography and the disease registers
in GP practices. The heart failure patient database will be developed and
used to inform future planning.
Future Plans
The service also benefits from five people affected by heart failure who
have agreed to be available for focus group work when deemed necessary
and appropriate by the Steering Group. The focus group activity will be
carried out to assist with service developments and to gain a fuller
understanding of the patients’ perspective.
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References
These guidelines reflect the complex nature of heart failure and the
care required. They should be read in conjunction with the attached
Medicines Management Supplement, the National Institute for
Clinical Excellence (NICE) Guidelines for Chronic heart failure
(2003) and the European Society of Cardiology guidelines for the
Treatment of Chronic Heart Failure (Update 2005).
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Appendix I
GP may wish to
Contact from Heart Failure manage the
Nurse Specialist within 10 patient alone
working days under certain
circumstances
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Appendix II
HF suspected
Clinical examination
GP
+ BNP - BNP
GP
Consider other
HF not diagnosis. Review
confirmed meds etc
HF confirmed
Cardiology MDT:
Outpatients: Patients NOT
Further referred to
investigations cardiologist
which may to have notes
include reviewed by
mechanical MDT
devices, surgery
or
transplantation
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MEDICINES
MANAGEMENT
SUPPLEMENT
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MEDICINES MANAGEMENT SUPPLEMENT
This is the practical guidance for health professionals on the use of evidence-based
medicines in heart failure. It provides the legal framework required by the non
prescribing HFNS to alter drug dosages within the limits of a treatment plan.
Guidance notes for each drug group are contained within this supplement and are
based on NICE guidance (2003).
If the patient condition exceeds the limits of the guidance notes or the treatment plan
needs to be reviewed due to a change in the patient condition, the HFNS will return to
the original referrer.
Guidelines for the diagnosis and treatment of chronic heart failure (Update 2005) The
Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European
Society of Cardiology: European Heart Journal 18/5/2005
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PRACTICAL GUIDANCE ON THE USE OF LOOP DIURETICS
IN PATIENTS WITH HEART FAILURE
Exclusions
Cautions
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How to use
Advice to patient
Problem solving
Hypotension
• Postural hypotension may indicate dehydration (check for thirst), review signs
and symptoms and consider reducing dose by Furosemide 40mg daily or
Bumetanide 1mg daily
• If hypotension causes dizziness, light-headedness, or confusion, consider
discontinuing or reducing other medication after discussion with specialist
• If urea >12mmol/l or increased by >50% from the baseline and/ or creatinine >
180mmol/l or increased by 50% from the baseline, specialist advice should be
sought with regard to reducing the dose
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PRACTICAL GUIDANCE ON THE USE OF ACE INHIBITORS IN
PATIENTS WITH HEART FAILURE
Exclusions
• Pregnancy
• History of hypersensitivity to ACE Inhibitors including angiodema
• Known or suspected aortic stenosis or outflow tract obstruction
• Symptomatic hypotension, systolic blood pressure less than 90 mmhg
• Potassium > 5.5 mmols /l
Cautions
How to Use
• Start with a low dose
• Double the dose at not less than 2 weekly intervals.
• Aim for target dose or failing that the highest tolerated dose (optimal).
• Remember that some ACE inhibitor is better than no ACE inhibitor.
• Monitor blood chemistry and blood pressure following each up titration.
• When to stop up – titration / down titration – see “Problem Solving”
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Advice to patient
• Explain expected benefits.
• Treatment is given to improve symptoms, to prevent worsening of HF and to
increase survival
• Symptoms improve within a few weeks to a few months.
• Advise patients to report principle adverse effects (i.e. dizziness, symptomatic
hypotension, cough )
• First dose can cause a fall in blood pressure, advise to sit or lie down for 2 – 4
hours if this occurs.
• Consider stopping NSAIDs.
• Provide product information leaflet.
• Read Heart Failure Information booklet provided.
• Patient held record updated.
• Date of next U&E`s check.
Problem solving
Asymptomatic low blood pressure does not usually require any change in therapy
Symptomatic Hypotension
Cough
• Cough is common in patients with heart failure, many of whom have smoking
related lung disease.
• Cough is also a symptom of pulmonary oedema which should be excluded
when a new or worsening cough develops.
• ACE Inhibitor induced cough rarely requires treatment discontinuation.
• If the patient develops a troublesome dry cough which interferes with sleep
and is likely to be caused by an ACE Inhibitor, consider substituting an
Angiotensin Receptor Blocker (ARB ) for the ACE Inhibitor.
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• If urea, creatinine or potassium do rise excessively consider stopping
concomitant nephrotoxic drugs e.g. NSAID`s, non-essential vasodilators (e.g.
calcium antagonists, nitrates), potassium supplements / retaining agents and, if
no signs of congestion reducing the dose of diuretic.
• If greater rises in creatinine or potassium than those outlined above persist
despite adjustment of concomitant medications the dose of the ACE Inhibitor
should be halved and blood chemistry rechecked. If there is still an
unsatisfactory response specialist advice should be sought.
• If potassium rises > 6mmol/l or creatinine increases by more than 100% or to
above 350 mmol/l the dose of ACE Inhibitor should be stopped and specialist
advice sought.
• Blood chemistry should be monitored closely until potassium and creatinine
concentrations are stable.
Note: It is very rarely necessary to stop and ACE Inhibitor and clinical deterioration is
likely if treatment is withdrawn, ideally specialist advice should be sought before
discontinuation.
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PRACTICAL GUIDANCE ON THE USE OF BETA BLOCKERS
IN PATIENTS WITH HEART FAILURE
• Potentially all patients with stable mild to moderate chronic heart failure;
patients with severe chronic heart failure should be referred for specialist
advice.
• First line treatment in patients with NYHA Class I – IV.
Exclusions
Cautions
*Carvedilol; maximum dose 25mg twice daily if severe heart failure. For patients
with mild to moderate heart failure maximum dose 50 mg twice daily if weight
more than 85 kg – otherwise maximum dose 25 mg twice daily.
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How to Use
• Start with a low dose
• Double the dose at not less than two weekly intervals
• Aim for target dose or failing that the highest tolerated dose (optimal)
• Remember that some beta-blocker is better than no beta-blocker
• Monitor heart rate, blood pressure, clinical status (symptoms, signs –
especially signs of congestion/deterioration, body weight)
• Check blood chemistry 1-2 weeks after initiation, after each titration and 1-2
weeks after final dose titration.
• When to stop up-titration / down titration – see “Problem Solving”
Advice to patient
• First dose can cause fall in blood pressure. Patients should be advised to sit or
lie down for 2 – 4 hours.
• May experience a wheeze, inform staff if occurs
• Cold extremities
• Patients with diabetes, particularly those on insulin should be advised that
symptoms of hypoglycaemia may be masked
• Explain expected benefits
• Emphasize that treatment given as much to prevent worsening of CHF as to
improve symptoms; beta-blockers also increase survival
• If symptomatic improvement occurs, this may develop slowly (3-6 months or
longer).
• Temporary symptomatic deterioration may occur (estimated 20 – 30% of
cases) during initiation / up-titration phase
• Advise patient to report deterioration ( see ‘Problem Solving’) and that
deterioration (tiredness, fatigue, breathlessness) can usually be easily managed
by adjustment of other medication; patients should be advised not to stop beta-
blocker therapy without consulting their physician.
• Patients should be encouraged to weigh themselves daily (after waking, before
dressing, after voiding, before eating) and to consult their doctor if they have
persistent weight gain.
• Provide product information leaflet.
• Read Heart Failure Information booklet provided.
• Patient held record updated.
• Date of next U&E`s check.
Problem solving
Worsening symptoms / signs (e.g. increasing dyspnoea, fatigue, oedema, weight
gain)
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• If serious deterioration, halve dose of beta-blocker or stop this treatment
(rarely necessary); seek specialist advice
Symptomatic hypotension
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PRACTICAL GUIDANCE ON THE USE OF SPIRONOLACTONE
IN PATIENTS WITH HEART FAILURE
Exclusions
Which dose
How to use
• Start at 25 mg once daily
• Check blood chemistry at 1, 4, 8 and 12 weeks; 6, 9 and 12 months; 6 monthly
thereafter
• If serum potassium rises to between 5.5 and 5.9 mmol/l or creatinine rises to
200 mmols/l the dose should be reduced to 12.5 mgs daily and blood
chemistry monitored closely
• If potassium rises to greater than 5.9 mmol/L or creatinine rises to 200
mmols/l, stop Spironolactone and refer back to the consultant. Urgent ECG
should be performed and reviewed by a doctor.
• If patients do not fit criteria for dose increase medical advice would be
obtained and documented in notes.
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Advice to patients
Problem solving
Worsening renal function / hyperkalaemia
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PRACTICAL GUIDANCE ON THE USE OF DIGOXIN IN
PATIENTS WITH HEART FAILURE
• Atrial fibrillation
• Severe refractory symptoms of heart failure – NYHA III – IV, despite
treatment with an ACE inhibitor, a diuretic, and a beta-blocker.
Exclusions
• Hypersensitivity to digoxin
• 2nd and 3rd degree heart block
• Supraventricular arrhythmias caused by Wolff-Parkinson-White syndrome
Cautions
Dose
125 mcg once daily for at 62.5 mcg once daily for at least 2 weeks
least 2 weeks
Increase to 250 mcg once daily if Increase to 125 mcg once daily if
therapeutic dose not achieved or therapeutic dose not achieved or atrial
atrial fibrillation not controlled fibrillation not controlled
How to use
• Dose increases can be made at two week intervals to the maximum dose, as
above
• Digoxin levels will be checked one week after initiation or dose increase, the
sample must be taken at least six hours after dose. Serum levels should be 0.8
– 2.0 mcg/l
• Dose should be halved in patients taking Amiodarone
• Serum creatinine levels should be within normal range
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Advice to patient
Problem solving
• The main side effects usually associated with excessive dose include:
anorexia, nausea, vomiting and diarrhea.
• Should these side effects be experienced then digoxin levels should be taken
six hours after dose as above.
• In bradycardia record ECG and monitor Digoxin level, reduce dose or seek
advice
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HEART FAILURE NURSING SERVICE
Diuretic………………………………………….
ACEI/ARB………………………………………
Beta Blocker…………………………………….
Spironolactone………………………………….
Digoxin………………………………………….
This form must be signed by a medical practitioner as it fulfils the legal requirement for non-
prescribing heart failure nurse specialists to optimise medications.
Contact details…………………………………………..
Please fax this form to the Heart Failure Team on 01304 210834. If you wish to
discuss the referral please telephone 01304 222338. Please consider in-patient
referrals at the earliest opportunity to try and ensure a pre-discharge visit.
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