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Primary Care Guideline for Treatment of Chronic Heart Failure, Study notes of Management of Health Service

London School of Hygiene & Tropical Medicine (LSHTM)Management of Health Service

Initial Management. If symptoms are sufficiently severe, they warrant treatment while waiting for confirmation of diagnosis.

Typology: Study notes

2021/2022

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Primary Care Guideline for Treatment of Chronic Heart Failure
Initial Management
If symptoms are sufficiently severe, they warrant treatment while waiting for confirmation of diagnosis
Consider prescribing a loop diuretic1:
• Furosemide is the preferred choice of diuretic - usually given once daily in the morning but may be
given twice daily for additional diuresis, titrate the dose to control symptoms. Bumetanide may be
more effective in patients who are severely oedematous.
Management following diagnosis
Some patients have heart failure due to left ventricular systolic dysfunction (LVSD) which is associated with
a reduced left ventricular ejection fraction. Others have heart failure with a preserved ejection fraction
(HFpEF, also known as Diastolic Heart Failure). The majority of evidence on treatment is for heart failure due
to LVSD; therefore, for those with HFpEF management should be in consultation with a cardiologist. The
following recommendations are based around patients with LVSD.
• Remove Aggravating Factors: NSAIDs, steroids, tricyclics, glitazones, verapamil, diltiazem
• Identify/Exclude Treatable Causes: Hypertension, Valvular/Ischaemic Heart Disease
• Lifestyle Modification: Smoking, salt & fluid intake, exercise, alcohol
• Advice - Flu/Pneumococcal vaccine
Key Prescribing Points
• Aim for management of all patients with LVSD using triple therapy of an angiotensin converting enzyme
inhibitor (ACEI), beta-blocker therapy and a mineralocorticoid therapy (MRA).
• NICE2 recommends the addition of an MRA if patients still have symptoms after an ACEI and beta blocker,
however because of strong evidence3 that an MRA improve survival and reduce morbidity in patients with
heart failure with reduced ejection fraction and that these clinical benefits are observed in addition to
those of ACEI and beta-blockers, local cardiologists promote the use of all three agents to the target
dose. (see below)
• All medicines need to be introduced gradually, using clinical judgement when deciding which of an ACEI
or a beta blocker to introduce first.2
• Cough is common in heart failure and ACEI cause cough in some patients. The effect of ACEI on survival
is more certain than that of angiotensin receptor blockers4. Do not rule out ACEIs until certain that the
drug is causing the cough.
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Download Primary Care Guideline for Treatment of Chronic Heart Failure and more Study notes Management of Health Service in PDF only on Docsity!

Primary Care Guideline for Treatment of Chronic Heart Failure

Initial Management

If symptoms are sufficiently severe, they warrant treatment while waiting for confirmation of diagnosis Consider prescribing a loop diuretic 1 :

  • Furosemide is the preferred choice of diuretic - usually given once daily in the morning but may be given twice daily for additional diuresis, titrate the dose to control symptoms. Bumetanide may be more effective in patients who are severely oedematous.

Management following diagnosis

Some patients have heart failure due to left ventricular systolic dysfunction (LVSD) which is associated with a reduced left ventricular ejection fraction. Others have heart failure with a preserved ejection fraction (HFpEF, also known as Diastolic Heart Failure). The majority of evidence on treatment is for heart failure due to LVSD; therefore, for those with HFpEF management should be in consultation with a cardiologist. The following recommendations are based around patients with LVSD.

• Remove Aggravating Factors: NSAIDs, steroids, tricyclics, glitazones, verapamil, diltiazem

• Identify/Exclude Treatable Causes: Hypertension, Valvular/Ischaemic Heart Disease

  • Lifestyle Modification: Smoking, salt & fluid intake, exercise, alcohol
  • Advice - Flu/Pneumococcal vaccine

Key Prescribing Points

  • Aim for management of all patients with LVSD using triple therapy of an angiotensin converting enzyme inhibitor (ACEI), beta-blocker therapy and a mineralocorticoid therapy (MRA).
  • NICE^2 recommends the addition of an MRA if patients still have symptoms after an ACEI and beta blocker, however because of strong evidence 3 that an MRA improve survival and reduce morbidity in patients with heart failure with reduced ejection fraction and that these clinical benefits are observed in addition to those of ACEI and beta-blockers, local cardiologists promote the use of all three agents to the target dose. (see below)
  • All medicines need to be introduced gradually, using clinical judgement when deciding which of an ACEI or a beta blocker to introduce first. 2
  • Cough is common in heart failure and ACEI cause cough in some patients. The effect of ACEI on survival is more certain than that of angiotensin receptor blockers 4. Do not rule out ACEIs until certain that the drug is causing the cough.
  • Do not withhold beta blockers solely because of age or the presence of chronic obstructive pulmonary disease, interstitial pulmonary disease peripheral vascular disease, erectile dysfunction or diabetes mellitus. 2
  • If there are symptoms of postural hypotension from taking all the medication in the morning, consider giving ACEI in the evening5,6.

ACE Inhibitors

Licensed ACEI Starting dose Target dose

Ramipril (preferred) 2.5mg once daily Note the BNF 7 recommends a 1.25mg starting dose but NICE CKS 8 recommends 2.5mg which is supported by local cardiologists with clinical discretion to start at a lower dose in patients at higher risk of hypotension

5mg twice daily or 10mg once daily 7

Perindopril erbumine*^ 2mg once daily 4mg once daily 7

*Perindopril erbumine is an alternative ACEI that could be considered to reduce the number of dose titrations needed but it is approximately four times^7 as expensive as ramipril so should not be used routinely. How to use^8 Full information available at CKS Managing ACE Inhibitors

  • Measure renal function, serum electrolytes and blood pressure before prescribing an ACE-inhibitor
  • Seek specialist advice where the patient is on a high dose (e.g. furosemide 80 mg) of a loop diuretic
  • Recheck renal function, serum electrolytes, and blood pressure 1-2 weeks after starting treatment.
  • Earlier monitoring (after 5–7 days) may be required for people: o With existing CKD stage 3 or higher. o Aged 60 years or over. o With relevant comorbidities such as diabetes mellitus or peripheral arterial disease. o Taking a combination of an ACE-inhibitor plus a diuretic or an aldosterone antagonist.
  • Titrate dose upwards e.g. 2 weekly intervals doubling the dose each time, aiming for target dose (see above) or, failing that, the highest tolerated dose and maintain indefinitely unless adverse effects occur
  • Monitor renal function and blood pressure after each dose titration and then once stable measure monthly for 3 months then every 6 months
  • Cough — if the cough is intolerable (for example it prevents the person from sleeping) and other causes have been ruled out, consider switching to an angiotensin-II receptor antagonist.(AIIRA).
  • Abnormal results: some increase in creatinine and potassium levels is expected after starting or increasing the dose of an ACEI. See Appendix One for further information on managing abnormal results

Advice to patient^8

  • Explain expected benefits
  • Advise about possible first dose hypotension
  • Treatment is given to improve symptoms, to prevent worsening of heart failure and to increase survival
  • Symptoms improve within a few weeks to a few months
  • Advise patients to report principal adverse effects (i.e. dizziness/symptomatic hypotension, cough)
  • Diarrhoea and vomiting: patients should be advised that if they develop diarrhoea and vomiting while taking an ACE-inhibitor, they should maintain their fluid intake and stop the ACE-inhibitor for 1–2 days until they recover.
  • The aim is to avoid dehydration, hypotension and acute renal failure, and should not cause a sudden deterioration in heart failure. If symptoms persist beyond 2 days, they should see a GP and have their renal function checked.

Specific Patient Groups

Patients in AF with heart failure

  • Heart rate control best achieved with a beta-blocker, but digoxin may be added if rate control is inadequate or beta-blocker not tolerated. Seek specialist advice before initiating 1

Appendix One: Managing Abnormal ACEI Results 8

References:

  1. Clinical Knowledge Summaries (CKS). Chronic heart failure. Version 1.0. Newcastle upon Tyne: CKS; 2009.
  2. NICE NG 106 Chronic heart failure in adults: diagnosis and management. Accessed via https://www.nice.org.uk/guidance/ng106/resources/chronic-heart-failure-in-adults-diagnosis-and-management- pdf-
  3. Zannad F, Gattis Stough W, Rossignol P et al 2012; Mineralocorticoid receptor antagonists for heart failure with reduced ejection fraction: integrating evidence into clinical practice. Eur Heart J. 33:2782–2795.
  4. Dézsi CA. Differences in the clinical effects of angiotensin-converting enzyme inhibitors and Angiotensin receptor blockers: a critical review of the evidence. Am J Cardiovasc Drugs. 2014;14(3):167-173. Accessed via https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033811/
  5. NHS Website Medicines; Ramipril. Accessed via https://www.nhs.uk/medicines/ramipril/
  6. NHS Website Medicines; Lisinopril. Accessed via https://www.nhs.uk/medicines/lisinopril/
  7. BNF online. Accessed via https://bnf.nice.org.uk/
  8. CKS Heart Failure – Chronic, prescribing information; Managing angiotensin converting enzyme inhibitors. January 2017. Accessed via https://cks.nice.org.uk/topics/heart-failure-chronic/prescribing- information/managing-ace-inhibitors/
  9. CKS Heart Failure – Chronic, prescribing information; Managing beta blockers. January 2017 Accessed via https://cks.nice.org.uk/topics/heart-failure-chronic/prescribing-information/managing-beta-blockers/
  10. SIGN clinical guideline. Management of chronic heart failure 2016. Accessed at https://www.sign.ac.uk/assets/sign147.pdf
  11. Electronic Medicines Compendium. Accessed at: https://www.medicines.org.uk/emc/
  12. NICE TA679. Dapagliflozin for treating chronic heart failure with reduced ejection fraction. Accessed via https://www.nice.org.uk/guidance/ta
  13. NICE TA388 Sacubitril valsartan for treating symptomatic chronic heart failure with reduced ejection fraction. Accessed via https://www.nice.org.uk/guidance/ta388/resources/sacubitril-valsartan-for-treating-symptomatic- 14. chronic-heart-failure-with-reduced-ejection-fraction-pdf- H&W MPC Approved Date: April 2021 Review Date: April 2024

Serum creatinine and estimated glomerular filtration rate (eGFR)

  • If the serum creatinine level increases by more than 20% or the eGFR falls by more than 15%, remeasure the renal function withing 2 weeks.

Creatinine or eGFR increase Action required Creatinine less than 30% No further action required Creatinine 30-50% increase or to over 200micromol/L or eGFR less than 30 mL/min/1.73 m 2

Clinical review of volume status and temporary dose reduction, or withdrawal of diuretic or ACEI Creatinine more than 50% increase or to over 256micromol/L or eGFR 20-25 mL/min/1.73 m 2

Dose reduction or withdrawal of diuretic and/ or stopping ACEI and consider specialist referral Creatinine more than 100% increase or to over 310micromol/L or eGFR less than 20mL/min/1.73 m 2

Stop ACEI and seek specialist advice

  • If the eGFR decreases by 25% or more, or the creatinine level increases by 30% or more investigate other causes of deteriorating renal function, such as volume depletion. Stop or reduce the dose of the following drugs (where appropriate) if the person is taking them: o Nephrotoxic drugs (such as non-steroidal anti-inflammatory drugs). o Vasodilators (such as calcium-channel blockers, nitrates). o Potassium supplements or potassium-sparing diuretics. o Diuretics (consider dose reduction if the person is hypovolaemic).
  • If the decrease in eGFR or increase in creatinine level continue despite these measures stop the ACEI or

reduce to a previously tolerated dose and recheck the levels.

  • Consider the possibility of renal artery stenosis in patients with significant decline in the eGFR and refer for

specialist assessment.

Serum potassium

Serum potassium increase Action required Levels up to 5.5mmol/L No further action required Levels of 5.5-6.0mmol/L Stop ACEI and seek specialist advice Levels of over 6.0mmol/L Stop all medication that can increase potassium including the ACEI and seek urgent specialist advice

  • If elevated levels persist, review any medicines that may increase potassium (e.g. spironolactone, NSAIDs

and nephrotoxic drugs)

Serum sodium

  • Seek specialist advice if the serum sodium falls to under 132mmol/L