Patients who have had HF as defined above for some time are often said to have ‘Chronic Heart Failure’. A treated patient with symptoms and signs that have remained generally unchanged for at least 1 month is said to be ‘Stable chronic heart failure’
Diagnostic Criteria
The diagnosis of Chronic heart failure requires the following features:
- Symptoms of heart failure, typically breathlessness or fatigue, at rest or during exertion
- Objective evidence of cardiac dysfunction preferably by Echocardiography (Systolic and/or Diastolic)
- A clinical response to treatment is supportive but not sufficient for diagnosis
Hence diagnosis and management of CHF should be sought at referral centres where at least echocardiography assessment can be performed.
Treatment of Systolic Heart Failure (LVEF< 45–50%)
Goals of treatment
- Prevention of disease leading to cardiac dysfunction and heart failure eg hypertension, coronary artery disease, valve disease etc.
- To achieve maintenance or improvement in quality of life and improve survival
Non-pharmacological Treatment:
- Patient and family education
- Explain what Heart Failure (HF) is and why symptoms occur, cause of HF, how to recognize symptoms and what to do when they occur, daily self-weighing and what to do in case of weight gain
- Rationale of treatment, importance of adhering to drug & non-drug prescription Refrain from smoking
- Prognosis–explain morbidity and mortality
- Drug counseling–Effects, doses and times of administration, side effects and adverse effects
- Dietary and social habit
- Control sodium intake when necessary, avoid excessive fluid intake in severe HF Limit fluid intake to 1–1.5 L/day if fluid overloaded despite diuretic therapy
- Avoid excessive alcohol intake
- Regular exercise within limits of symptoms.
- Sexuality counselling regarding the risk of pregnancy and the use of oral contraceptives and phosphodiesterase-5 inhibitors are not recommended in advanced HF, if used nitrates should be avoided < 24–48hours of nitrate intakes
Medicines to avoid or to be used with caution
- NSAIDs & Coxibs
- Class I anti–arrhythmic
- Calcium antagonists
- Lithium
- Tricyclic antidepressants
- Corticosteroids
Pharmacological Treatment
Approach combination therapy
Diuretics
Loop diuretic
B: Furosemide 40–80mg (PO) twice a day orally
OR
S: Torsemide 5–20mg (PO) orally
AND
Mineralocorticoid (Aldosterone) Receptor Antagonists:
C: Spironolactone 25–50mg ounce a day orally
OR
S: Eplerenone 25–50mg ounce a day orally
Thiazide
A: Hydrochlorthiazide 12.5–25mg (PO) once a day
OR
S: Metolazone 0.1–10mg day
Angiotensin Receptor Inhibitors ACEI or Angiotensin Receptor Blockers (ARB)
B: Captopril 6.25–25mg three times a day orally
OR
C: Enalapril 5–20mg twice a day orally.
OR
S: Perindopril 8mg/daily orally
Angiotensin Receptor Blocker–ARB (*Don’t combine with ACEI contraindicated, Indicated in patient sensitive to ACEIs)
C: Losartan 50mg/daily
OR
C: Candesartan 4–16mg ounce a day orally.
Beta blocker (Carvedilol–improve Morbidity & Mortality in CHF).
C: Carvedilolol 6.25–25mg twice a day especially in heart failure with reduced systolic function
Note: Beta Blockers is contraindication to patients with Bronchial Asthma or Severe Pulmonary Disease Symptomatic bradycardia or hypotension
Add on therapy in patient in NYHA class III/IV.
Vasodilator agents: The combination of hydralazine/nitrate
C: Isosorbide mononitrate 10–20mg orally 12 hourly
OR
C: Hydralazine 25 mg 6–8 hourly. Maximum dose: 200 mg/day
Cardiac Glycosides–Digoxin, give with caution! has narrow therapeutic index see below under section of Cardiac Glycosides
C: Digoxin 0.125mg–0.25mg once a day orally
Note: Patients at high risk of digoxin toxicity are: Elderly, patients with poor renal function, hypokalaemia and low body weight
Consider Anti–thrombotic agents–Heparin &/or warfarin under special indications see below: Congestive Heart Failure with atrial fibrillation, previous thromboembolic events or a mobile LV thrombus Heparin for DVT prophylaxis for patients admitted to hospital, unless contraindicated
Anti–thrombotic agents.
Heparin &/or warfarin – firmly indicated on congestive heart hailure with atrial fibrillation, previous thromboembolic events or a mobile LV thrombus Heparin for DVT prophylaxis for patients admitted to hospital, unless contraindicated:
D: Heparin 5000 units (SC) 8 hourly
OR
D: Warfarin oral 5 mg daily.
Monitor INR to therapeutic range, i.e. between 2.0–2.5
Thiamine Supplement: Consider in all unexplained heart failure
Referral
Ideally all patients with CHF should be managed in dedicated HF clinics/units with devoted HF expert staffs (nurses & doctors).
The following category of patients should be referred for specialized care
- Severe HF class III/IV
- HF of unknown origin
- Relative contraindication: asymptomatic bradycardia and/or low blood pressure
- Intolerance to low doses
- Previous use of ß –blockers and discontinuation because of symptoms
- Bronchial asthma or severe pulmonary disease
