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Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006

Executive summary

Chronic heart failure (CHF) is a complex clinical syndrome with typical symptoms (e.g. dyspnoea, fatigue) that can occur at rest or on effort, and is characterised by objective evidence of an underlying structural abnormality or cardiac dysfunction that impairs the ability of the ventricle to fi ll with or eject blood (particularly during physical activity).

Common causes of CHF are ischaemic heart disease (present in over 50% of new cases), hypertension (about two-thirds of cases) and idiopathic dilated cardiomyopathy (around 5-10% of cases).

Diagnosis is based on clinical features, chest x-ray and objective measurement of ventricular function (e.g. echocardiography). Plasma levels of B-type natriuretic peptide may have a role in diagnosis, primarily as a test for exclusion. Diagnosis may be strengthened by improvement in symptoms in response to treatment.

Management involves prevention, early detection, slowing of disease progression, relief of symptoms, minimisation of exacerbations, and prolongation of survival. Key therapeutic approaches or considerations include:

• non-pharmacological strategies, including physical activity, diet and risk-factor modifi cation
• angiotensin-converting enzyme inhibitors (ACEIs) that prevent disease progression and prolong survival in all grades of CHF severity
• beta-blockers that prolong survival when added to ACEIs in symptomatic patients
• diuretics that provide symptom relief and restoration or maintenance of euvolaemia; often aided by daily self-recording of body weight and adjustments of diuretic dosage
• aldosterone receptor antagonists (aldosterone antagonists), angiotensin II receptor antagonists and digoxin, which may be useful in selected patients
• biventricular pacing, which may have a role in New York Heart Association Class III or IV patients with wide QRS complexes in improving physical activity tolerance and quality of life, as well as reducing mortality
• implantable cardioverter defi brillators, which have been shown to reduce the risk of sudden cardiac death in patients with CHF and severe systolic dysfunction of the left ventricle
• surgical approaches in highly selected patients that may include myocardial revascularisation, insertion of devices and cardiac transplantation
• post-discharge multidisciplinary management programs and palliative care strategies
• drugs to avoid include anti-arrhythmic agents (apart from beta-blockers and amiodarone), non-dihydropyridine calcium-channel antagonists (in systolic CHF), tricyclic antidepressants, non-steroidal anti-infl ammatory drugs and COX-2 inhibitors, thiazolidinediones and tumour necrosis factor antagonists

CHF is often accompanied by important comorbid conditions that require specific intervention. These include concomitant ischaemic heart disease, valvular disease, arrhythmia, arthritis, gout, renal dysfunction, anaemia, diabetes and sleep apnoea.

Heart failure with preserved systolic function (HFPSF), or diastolic heart failure, is common and may account for up to 40% of patients with CHF. Definitive diagnosis is diffi cult and treatment is empirical. Angiotensin II receptor antagonists and beta-blockers have not demonstrated suffi cient benefit to warrant these agents being considered mandatory therapy in this setting.

Ideally, specialist opinion should be obtained for all patients with CHF, in view of the severity, the symptomatic limitation, the prognosis and the complex nature of the condition and its management. Specialist care has been shown to improve outcomes, reduce hospitalisation and improve symptoms in patients with heart failure (Level IIB). See Section 13 on post-discharge management programs.

At a minimum, such as for patients who are geographically isolated, specialist opinion should be sought:

• when the diagnosis is in question
• when there is a question regarding management issues
• when the patient is being considered for revascularisation (percutaneous or surgical)
• when the patient is being considered for a pacemaker, defi brillator or resynchronisation device
• when the patient is being considered for heart or heart/lung transplantation
• at the request of the local medical officer to help guide management and clarify prognosis
• in patients under 65 years of age.

The treatment of acute decompensated heart failure is complex and involves appropriate use of oxygen and pharmacological therapies including morphine, diuretics and nitrates, as well as non-invasive mechanical therapies such as continuous positive airway pressure (CPAP) via mask, or bilevel non-invasive positive-pressure (BiPAP) ventilation. Patients with advanced decompensation may require inotropic support, assisted ventilation, intra-aortic balloon counterpulsation and, in extreme cases, ventricular assist devices.

Last Modified: 26 June 2007
Authorised By: Quality care