Guideline: Chronic Heart Failure SIGN Guideline (Feb 2007) Presented by Dr Tom Gamble

Heart Failure – Some Facts Heart failure is a syndrome and not a single pathological process. The syndrome of heart failure is common and readily recognised: the patient complains of symptoms of breathlessness and exhaustion at rest or with less than the normal degree of exertion the functional reserve of the heart is grossly reduced there are associated changes in many organ systems

BNP predictive of prognosis The incidence of heart failure is 20-30 per thousand per year with an overall prevalence of 1%. The prevalence in the over 80 age group is about 30%. Mild- 90% annual survival rate Severe – 50% annual survival BNP predictive of prognosis

Diagnosis History and examination: consider common alternative diagnoses: obesity hypoalbuminaemia chest disease (lung/diaphragm/chest wall/) renal or hepatic disease venous insufficiency in lower limbs PE drug induced ankle swelling (Ca channel blockers) drug induced fluid retention (NSAIDs) depression/anxiety disorders severe anaemia/thyroid disease

Diagnosis 2 Investigations: FBC; fasting blood glucose; U&Es; urinalysis; TFTs; CXR. ECG and/or natriuretic peptide Both normal? Heart failure unlikely 1 or more abnormal: echocardiography.

Management-Behavioral Reduce alcohol consumption Smoking cessation advice Regular low intesity physical activity when stable Diet (salt intake <6g/day) Daily weight (report increase of >1.5kg)

Management- Drugs ACE inhibitor Beta blocker when condition stable unless contra-indicated ARB if not tolerant of ACEi Consider diuretics for patients with dyspnoea or oedema If symptomatic consider addition of candesartan to ACEi and B-blocker For moderate to severe heart failure consider spironolactone (eplerenone alternative) Consider digoxin if still symptomatic after optimum therapy

Palliative Care Focus on symptom relief and discontinuation of non-essential treaments Opportunity to discuss issues of sudden death and living with uncertainty After optimisation of diet/fluid intake and drugs, consider opiods if dyspnoeic

NICE (2003) Broach sexual activity Vaccinations (influenza/pneumococcus) Titrate up ACEi and beta-blocker ARBs not licensed for heart failure at time of NICE Specialist consideration of isosorbide and hydralazine if ACEi not tolerated