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

2. 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

3. BNP predictive of prognosis
The incidence of heart failure is 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

4. 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

5. 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.

6. 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)

7. 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

8. 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

9. 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