Guidelines for the Management of

Heart Failure In Primary and

Secondary Care

Lead Dr Jane Fisher

Authors Dr Jane Fisher
Anita Walton
Policy Version No 2
Policy Application East Kent Hospitals Trust and Eastern and Coastal Kent
Primary Care Trust.
Policy status Guidance
Approving Body Clinical Audit & Effectiveness Committee
Date Approved 8th February 2007
Review March 2008
Distribution Email to all Medical (including Renal) and HCOOP
Directorates
Email to all GP’s and Community Matrons

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 Guidelines for the Management of Heart Failure in Primary and
Secondary Care

Contents Page

Page 3: Mission Statement

Service Provision
Page 4: Referral and Discharge Criteria
Page 5: Diagnosis
Page 6: Management of Heart Failure
Page 8: Drug Therapy
Page 11: Oxygen Therapy
Page 12: Education and Support
Page 13: Guidelines for Referral to Specialist Palliative Care
Page 14: Audit
Future Plans
Page 15: References
Page 16: Appendix I: Heart Failure Nursing Service Referral
Flowchart
Page 17: Appendix II: Planned Heart Failure Service Model
Page 18: Medicines Management Supplement
Page 19: Instructions
Page 20: Practical Guidance on the use of Loop Diuretics
Page 22: Practical Guidance on the use of Ace Inhibitors
Page 25: Practical Guidance on the use of Beta Blockers
Page 28: Practical Guidance on the use of Spironolactone
Page 30: Practical Guidance on the use of Digoxin
Page 32: Referral and Treatment Plan Form

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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:

¾ Following an acute admission to hospital, medical teams / ward

staff will make a referral to the Heart Failure Nurse Specialist
(HFNS), immediately following diagnosis using the referral and
treatment plan form (see page 32). The treatment plan element
of the form – signed by a medical practitioner - is the legal
framework required by a non prescribing HFNS in order to
titrate medication. Other aspects of care that the HFNS will be
involved in are: appropriate blood chemistry monitoring, health
education, lifestyle advice and support.
¾ Consultants and GPSI`s can make a direct referral using the same
form and/or a referral letter from clinic.
¾ GP`s can refer patients with established diagnosis using the form
and/or a letter
¾ Tertiary Care referrals.
¾ Referrals will also be considered from Community Matrons,
Cardiac Rehabilitation Nurses and other specialist nurses where
there is GP agreement.

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 form should be faxed to 01304 210834. Telephone referrals to

01304 222338 (answer phone) should be followed by a fax within
twenty - four hours. Early inpatient referrals would improve
chances of a pre discharge visit by the HF Nurse. Where medical
teams are unsure as to the future management of their patient with
heart failure they should refer to the cardiologist in the usual way.
Patients will be followed up by home visits or clinic appointments to
up titrate medications and provide education and support. It should
be clear that this is not an emergency response service. We will aim
to contact all new referrals within ten working days. Healthcare
professionals are welcome to contact the HFNS for advice and/or
education concerning heart failure patients.

Discharge from Secondary Care

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.

Discharge from the Heart Failure Service

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.

Patients will be discharged if they are unwilling to be treated or are non

compliant with treatment despite all efforts.

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Diagnosis

A careful and detailed history should be taken and a clinical

examination should be performed for all patients with suspected
heart failure. These should be combined with investigations to
confirm the presence of heart failure in order to make a complete
diagnosis.

Before referral, healthcare professionals should seek to exclude a

diagnosis of heart failure by carrying out a twelve lead ECG, Chest X-
Ray and/or BNP (B natriuretic peptide) when available. If ECG, Chest X-
Ray and BNP are normal, then a diagnosis of heart failure is unlikely.

Patients must have the following investigations carried out to evaluate

aggravating factors: blood tests (urea, creatinine, electrolytes, full blood
count, thyroid function, liver function, fasting lipids and fasting glucose).
Urinalysis and peak flow/spirometry are desirable wherever possible.

A Transthoracic Doppler 2D echocardiographic (echo) examination

should be performed in order to exclude valve disease, assess systolic and
diastolic function of the left ventricle and to detect intracardiac shunts.
Right heart failure and raised pulmonary pressures also need to be
identified.

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.

Monitoring of weight change is always important and unstable patients,

such as those admitted to hospital, should have daily weights performed.

Management of heart failure should be seen as a shared responsibility

between the patient and the healthcare professional.

Heart failure care should be delivered by a multi-disciplinary team with

an integrated approach across the healthcare community. All patient
information should be communicated between healthcare professionals,
patients and carers. Changes to drug therapy made by the prescribing
HFNS will be communicated to the GP by fax or telephone call within
two working days

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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

NB: Please refer also to the Medicines Management Supplement at the

end of these guidelines.

Diuretics should be routinely used for patients with symptomatic heart

failure and titrated according to need and adjusted after initiation of
subsequent heart failure therapies. Blood chemistry should be monitored.
The management of early signs of acute decompensation should be with
the titration of loop diuretics. Patients should be informed that timing of
administration can be flexible (up to 1700 hours) as this can aid
compliance.

Down titration of loop diuretics should be considered in patients who are

stable and where evidence based medication is considered to be optimal.
This should be done in stages, reducing doses gradually and slowly using
daily weights to assess fluid status.

Thiazide diuretics (Bendroflumethiazide) and metolazone may be used as

an alternative to loop diuretics in patients with less severe heart failure or
in addition to loop diuretics in patients with very severe heart failure.
This combination should be used with caution and usually following
specialist consultation. Unlike loop diuretics, thiazides and metolazone
are long acting and the adjustment of timing of dosing is not as
advantageous as for loop diuretics.

An Isosorbide Dinitrate/Hydralazine combination may be used in patients

with heart failure who are intolerant of ACE Inhibitors or Angiotensin
Receptor Blockers due to renal failure. These patients should be referred
for specialist advice. This combination has also been shown to be
effective in Afro-Caribbean patients.

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.

Combined ACE Inhibitor /ARB therapy could be considered in patients

intolerant to beta-blockers, if they have severe symptoms and repeated
admissions into hospital. This would only be initiated by a consultant
with an interest in heart failure and this combination should not be used
with Spironolactone.

Heart failure patients who remain symptomatic despite optimal therapy

i.e. loop diuretics, ace inhibitors and beta-blockers, should be prescribed
Spironolactone. Alternative therapy should be considered where there is
intolerance and specialist advice sought with regard to the use of
Eplerenone. There is at present insufficient evidence to know whether
adding Spironolactone to ARB`s in patients who are intolerant of ACE
Inhibitors is beneficial or harmful.

Patients taking Spironolactone should have their blood potassium and

creatinine levels monitored for signs of hyperkalaemia and/or
deteriorating renal function. Spironolactone can interfere with the
Digoxin assay. Caution should also be exercised when prescribing to
diabetic patients.

Patients who have refractory symptoms of heart failure despite optimal

therapy, or who have atrial fibrillation (AF) with any degree of heart
failure should be prescribed digoxin.

Anticoagulation is indicated for patients with the combination of heart

failure and atrial fibrillation. This should also be considered for heart
failure patients with a history of thromboembolism, left ventricular
aneurysm or intracardiac thrombus.

Patients with heart failure caused by coronary artery disease should be

treated with a statin. The role of statins for other patients in heart failure
is currently being debated.

Gout in heart failure may have an atypical presentation and can be

exacerbated by the use of diuretics. It should however always be treated,
and colchicine may be useful for the treatment of an acute attack.
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Allopurinol can reduce the risk of further attacks but should not be started
at the time of an acute attack..

Drugs which can worsen heart failure:

Non–Steroidal Anti Inflammatory Drugs (NSAID). Try

paracetamol/opiates instead.

Calcium Channel Blockers. However, Amlodipine can be considered

for the treatment of co-existent hypertension and/or angina if other
medication is found to be insufficient as it is the least likely to precipitate
heart failure. Verapamil and Diltiazem should be avoided, especially
with Beta-Blockers.

COX 2 Inhibitors.

Tricyclic Antidepressants.

Doxazosin is associated with an increase in heart failure when used to

treat hypertension.

Corticosteroids.

Effervescent tablets (e.g. soluble Co-Codamol due to the high salt

content).

Glitazones.

Antacids with a high sodium content (e.g. Gaviscon). Algicon or Topal

is recommended.

Some herbal remedies and liquorice.

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Oxygen Therapy

At present there are no clear guidelines for the prescription of oxygen in

heart failure.

However, oxygen may be indicated when the patient is hypoxic PaO2

<8.0 or oxygen saturations drop by more than 5% on exercise and
recovery takes longer than ten minutes.

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.

Oxygen may be recommended in palliative care to relieve distressing

symptoms.

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

Patients should be given lifestyle advice and healthcare professionals

should encourage them to make healthy lifestyle choices. Lifestyle
advice should include: fluid intake, smoking cessation, alcohol, dietary
advice particularly with reference to salt and fluid intake, sexual activity,
vaccinations (flu and pneumococcal) exercise, air travel and education
about the rationale for medications, side effects and timing in order to
encourage compliance.

Patients will be educated in self-care strategies such as daily weights and

diuretic dose adjustment, including early recognition of when to call for
help. Also, the benefits of improved activity levels, to which end patients
with heart failure will be able to access the cardiac rehabilitation service
or the exercise referral scheme wherever appropriate.

Ongoing support will be provided by the HFNS through follow up

appointments at home and in clinic or through advice by telephone.
During this contact there may often be a need to impart unwelcome news
to patients and carers.

In order to facilitate the communication process patients will have hand

held records to record current drug therapy, appointment times, their own
weight and copies of letters regarding their care.

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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 under the care of the cardiology consultants/heart failure nurse

specialists and/or have a diagnosis of heart failure with appropriate
investigations.

Patients should be aware of the diagnosis of heart failure and have an

insight into the irreversible and progressive nature of their disease, and so
accepting a palliative approach.

Patients will usually have advanced heart failure NYHA IV (or III at
discretion of health care team).

Patients will have an anticipated life expectancy of less than 12 months.

Repeated admissions to hospital with symptomatic heart failure will be a

feature, e.g. 3 admissions to hospital within the last 12 months with
symptoms of heart failure.

Patients will be experiencing physical, psychological and/or social

symptoms despite optimal tolerated therapy (+/- deterioration in renal
function).

Specialist palliative care input may come in a number of ways:

1. Telephone advice for specific symptom management problems.

2. One off assessment/input from specialist palliative care at home,
either in the home or as an outpatient at the hospice.
3. One off assessment/input in the secondary setting, usually on the
wards.
4. Ongoing support from the heart failure team, supplemented by
additional specific services from the hospice such as: day hospice,
complementary therapies or hospice admissions for carer respite.
5. Ongoing support from community palliative care services (regular
home visiting), with all other hospice services available. This
would be for patients who have particularly complex or multiple
symptoms (physical, psychological, social or spiritual) and when a
mutual decision has been taken against active, interventional
treatment.

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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.

Patients will be contacted to evaluate the Heart Failure Service using

discovery interviews and the results will be used in the planning of
further developments

Future Plans

Patients will be contacted to evaluate the Heart Failure Service using

discovery interviews and the results will be used in the planning of
further developments.

At least two patient representatives and one carer representative are

members of the East Kent Heart Failure Steering Group which is the local
monitoring and development group for the service.

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

European Society of Cardiology (ESC) (Update 2005): Task Force

Report. Guidelines for the Diagnosis and Treatment of Chronic Heart
Failure.

National Service Framework (NSF) for Coronary Heart Disease (CHD)

(2000) London. Dept of Health.

National Institute for Clinical Excellence (NICE) (2003) Chronic Heart

Failure: Management of chronic heart failure in adults in primary and
secondary care. London. NICE.

Review Date 1st March 2008

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

Heart Failure Service Referral Pathway

Patient with Heart

Failure

Referral to Heart Failure Service Fax Referral to

Essential Investigations 01304 210834 with
Echocardiogram ECG, Chest X-Ray, UECR, FBC, TFT individualised
(T4), Fasting Lipids, Fasting Glucose
Desirable Investigation
treatment plan
Urinalysis and Peak Flow / Spirometry and/or referral letter

GP may wish to
Contact from Heart Failure manage the
Nurse Specialist within 10 patient alone
working days under certain
circumstances

Follow up by home visit or clinic appointment for

optimisation of medication and monitoring if fluid status

Referral to Cardiac Referral to

Rehabilitation or Routine Palliative Care
exercise referral follow up or Team where
scheme where discharge appropriate
appropriate

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 Appendix II

East Kent Heart Failure Service Model (Planned)

HF suspected
Clinical examination
GP

and tests including

BNP
Primary Care

+ BNP - BNP
GP

Consider other
HF not diagnosis. Review
confirmed meds etc

GPSI led one stop

diagnostic shop
includes echo
GPSI
Primary Care

HF confirmed

Refer for further diagnostics to HF Nursing service to

GPSI

confirm aetiology, create care commence/continue

plan, continue pharmacological pharmacological and non
and non pharmacological pharmacological treatments
treatments See Diagram 2
Secondary Care Cardiologist

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).

The objectives of pharmacological treatment are to relieve symptoms, improve

exercise tolerance and quality of life, reduce hospital admissions and improve
survival. In order to achieve this, patients need to be prescribed the optimal dose of
the evidence based medicines at the appropriate intervals and with the relevant blood
chemistry monitoring. This process can be time consuming and complex

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.

References for all guidance notes

British National Formulary 2004

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

National Institute for Clinical Excellence (NICE) (2003) Management of Chronic

Heart Failure in Primary and Secondary Care .London. NICE

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 PRACTICAL GUIDANCE ON THE USE OF LOOP DIURETICS
IN PATIENTS WITH HEART FAILURE

In whom and when

Indications

• Potentially all patients with heart failure

• First line treatment in patients with NYHA Class I-IV, in conjunction with
at least one evidence based medicine for Heart Failure
• Deterioration in condition with one or more of the following clinical
symptoms and signs:
Increasing dyspnoea
A third heart sound
Raised Jugular Venous Pressure (JVP)
Ankle oedema
Basal crepitations
Associated weight gain

Exclusions

• Renal impairment with anuria

• Hypersensitivity to loop diuretics
• Known hepatic impairment
• Serum potassium <3.5mmol/l
• Serum sodium <130mmol/l
• Pregnancy and breastfeeding

Cautions

• Moderate renal impairment

• Co-administration of NSAIDs
• Postural hypotension
• Systolic blood pressure <90mmHg
• Urea or creatinine rising compared to the patients usual results
• Current Furosemide dose >80mg twice daily or Bumetanide dose >2mg
twice daily

Which loop diuretic and what dose

For the purposes of this service only two drugs have been selected

Starting dose Target dose

Furosemide 40mg once or twice daily 250-500mg daily

Bumetanide 1mg once or twice daily 5-10mg daily

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 How to use

• Start with a small dose

• Increase the dose at 3 day intervals (HFNS)
• Monitor lying and standing BP, pulse, weight, JVP, heart sounds, auscultation
of the chest and inspection of the ankles for oedema
• Review patients within one week of dose increase
• Monitor renal function
• HFNS will only up-titrate to a maximum of Furosemide 80 mg twice daily and
Bumetanide 2 mg twice daily
• When to stop up-titration / down titration – see “Problem solving”

Advice to patient

• Explain expected benefits, improve symptom control only

• Increase in dose may cause dizziness and leg cramps
• Report any experiences of dizziness on standing (indicating dehydration
and hypotension)
• Continue to weigh daily, aim for weight loss of <1kg per day. Report
weight loss in excess of this
• Report back if symptoms do not improve within 2-3 days
• Report any adverse effects
• 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, oedema, weight gain)

• If increasing congestion, increase diuretic dose and review

• Consider reducing beta-blocker dose if no response from diuretic dose
increase

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

Worsening renal function

• 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

In whom and when

Indications

• Potentially all patients with heart failure

• First line treatment in patients with NYHA Class I – IV.

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

• Known or suspected renovascular disease.

• Creatinine > 150 mmol/l
• Sodium < 130 mmol/l
• Patients on high doses of loop diuretic e.g. 80mg furosemide or above.
• Patients on potassium supplements or potassium sparing diuretics
• Patients on concurrent NSAID`s

Which ACE and what dose

For the purposes of this service only three drugs have been selected

Starting Dose Target dose (mg)

Lisinopril 2.5 mg once daily 30 – 35 mg once daily

Perindopril 2mg once daily 8 mg once daily
Ramipril 2.5 mg once daily 5mg twice daily or
10 mg once daily.

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

• If dizziness, light-headedness and/or confusion and a low blood pressure

consider discontinuing nitrates, calcium channel blockers* and other
vasodilators.
• If no signs / symptoms of congestion consider reducing diuretic dose.
• If these measures do not solve the problem seek specialist advice.

* Calcium channel blockers should be discontinued unless absolutely essential ( e.g.

for angina or hypertension).

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.

Worsening renal function

• Some rise in urea, creatinine and potassium is to be expected after initiation of

an ACE Inhibitor; if the increase is small and asymptomatic no action is
necessary.
• An increase in creatinine of up to 30% from the baseline is acceptable.
• An increase in potassium < 6mmol/l is acceptable.

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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

In whom and when

Indications

• 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

• Pregnancy and breastfeeding

• History of hypersensitivity to beta- blockers
• 2nd or 3rd degree heart block
• Asthma and Chronic Obstructive Pulmonary Disease
• Unstable heart failure
• Symptomatic hypotension,
• Bradycardia of <50 bpm
• Severe peripheral vascular disease (awaiting angioplasty or lower limb
revascularization or claudication distance of <25m).

Cautions

• Severe (NYHA Class IV) CHF

• Abnormal liver function
• Renal impairment (creatinine >150mmol/l)
• Systolic blood pressure of < 100mmHg
• 1st degree heart block
• Diabetes, symptoms of hypoglycaemia may be masked
• Myasthenia Gravis
• Phaeochromocytoma
• Co-administration with other hypertensives
• Co-administration with diltiazem and verapamil
• Co-administration with anti-arrhythmic agents, effects may be potentiated
• Co-administration with digoxin may increase digoxin levels

Which Beta-Blocker and what dose

Starting Dose Target Dose

• Bisoprolol 1.25 mg once daily 10 mg once daily

• Carvedilol 3.125 mg twice daily 25 – 50 mg twice daily*

*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)

• If increasing congestion, double dose of diuretic and / or halve dose of beta –

blocker (if increasing diuretic does not work).
• If marked fatigue (and/or bradycardia, see below) halve dose of beta-blocker
(rarely necessary).
• Review patient in 1 – 2 weeks; if not improved seek specialist advice.

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 • If serious deterioration, halve dose of beta-blocker or stop this treatment
(rarely necessary); seek specialist advice

Low heart rate

• If < 50 beats/min and worsening symptoms – halve dose beta-blocker or, if

severe deterioration, stop beta-blocker (rarely necessary).
• Consider need to continue treatment with other drugs that slow the heart (e.g.
digoxin, amiodarone, diltiazem) and discontinue if possible.
• Arrange ECG to exclude heart block
• Seek specialist advice

Asymptomatic low blood pressure

• Does not usually require any change in therapy

Symptomatic hypotension

• If low blood pressure causes dizziness, light-headedness or confusion,

consider discontinuing drugs such as nitrates, calcium channel blockers and
other vasodilators
• If no signs / symptoms of congestion consider reducing diuretic dose
• If these measures do not solve problem seek specialist advice

Note: beta-blockers should not be stopped suddenly unless absolutely necessary

(there is a risk of a ‘rebound’ increase in myocardial ischaemia / infarction and
arrhythmias); ideally specialist advice should be sought before treatment
discontinuation.

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PRACTICAL GUIDANCE ON THE USE OF SPIRONOLACTONE
IN PATIENTS WITH HEART FAILURE

In whom and when

Indications

• Potentially all patients with symptomatically moderate or severe chronic heart

failure.
• Second line therapy (after ACE inhibitors and beta-blockers) in patients with
continuing symptoms NYHA Class III – IV CHF.

Exclusions

• Pregnancy and breastfeeding

• Serum potassium > 5.5mmol/l
• Serum sodium < 130 mmol/l
• Addison’s disease
• Co-administration of Angiotensin II Receptor Blockers

Cautions / seek specialist advice

• Serum potassium >5.0mmol/l

• Serum creatinine >150mmol/l
• Hepatic impairment
• Porphyria

Which dose

Starting dose Target dose

25 mg once daily or on alternate days 25 – 50 mg once daily

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

• Explain expected benefits

• Treatment is given to improve symptoms, prevent worsening of heart failure
and to increase survival.
• Symptom improvement occurs within a few weeks to a few months of starting
treatment.
• Avoid NSAID`s not prescribed by a physician (self purchased ‘over the
counter’ treatment, e.g. ibuprofen).
• Temporarily stop Spironolactone if diarrhea and/or vomiting and contact
HFNS or doctor.
• One in six men may experience gynaecomastia but it is reversible.
• Provide product information leaflet.
• Read Heart Failure Information booklet provided.
• Patient held record updated.
• Date of next U&E`s check.

Problem solving
Worsening renal function / hyperkalaemia

• See “How to use”

• Major concern is hyperkalaemia (> 6.0 mmol/litre) though this was
uncommon in the RALES clinical trial; a potassium level at the higher end of
the normal range may be desirable in patients with heart failure, particularly if
taking digoxin.
• Some ‘low salt’ substitutes have a high potassium content
• Male patients may develop breast discomfort and / or gynaecomastia.
• It is important to avoid other potassium retaining drugs (e.g. potassium sparing
diuretics) and nephrotoxic agents (e.g. NSAIDs)

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 PRACTICAL GUIDANCE ON THE USE OF DIGOXIN IN
PATIENTS WITH HEART FAILURE

In whom and when

• 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

• Co-administration of Amiodarone, other antiarrhythmic agents and Calcium

Channel blockers.
• History of ventricular arrhythmias or paroxysmal atrial fibrillation.
• Pregnancy and breastfeeding
• Thyroid disease
• Serum potassium <4mmol/l
• Bradycardia <60 bpm

Dose

Dose in Males Dose in females and patients

weighing < 6o kg

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

• Explain expected benefits are for symptom control only

• Side effects are usually short lasting
• Report any adverse effects by contacting HFNS or doctor
• Date of digoxin level test and time.
• If taking warfarin the dose may be affected
• Provide product information leaflet.
• Read Heart Failure Information booklet provided.
• Patient held record updated.
• Date of next U & E`s check

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

REFERRAL AND TREATMENT PLAN

Patient Details
Name………………………………………………. GP Name…………………………………………..
Sex M / F DOB………………………….. Practice Name……………………………………...
NHS Number…………………………....................
Hospital Number………………………………….. Consultant…………………………………………
Address……………………………………………
………………………………………….................. WHH KCH QEH
…………………………………………..................
Post code………………………………………….. Ward……………………………………………….
Telephone Number………………………………...
Essential Investigations please send with referral
Echo / Angio evidence of confirmed heart failure
ECG
UECR, FBC, TFT, LFT, fasting lipids and fasting glucose
Chest X Ray results desirable
Symptom review Past medical history
Breathlessness YES / NO Previous MI YES / NO
Orthopnoea YES / NO History of angina YES / NO
Reduced exercise tolerance YES / NO Hypertension YES / NO
Peripheral oedema YES / NO Valvular Disease YES / NO
Paroxysmal nocturnal dyspnoea YES / NO Heart Murmur YES / NO
Fatigue / lethargy YES / NO Arrhythmias YES / NO
Other (please specify) Intervention / Cardiac surgery YES / NO
Diabetes YES / NO

Evidence Based Medicines Other current medications

Please state current drugs and doses. Document if any are
contraindicated and should not be commenced in the future.

Diuretic………………………………………….
ACEI/ARB………………………………………
Beta Blocker…………………………………….
Spironolactone………………………………….
Digoxin………………………………………….

Other relevant information and planned investigations

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.

Signed…………………………………………….. Print Name……………………………………………

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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