Diagnosis and management

Heart failure - is a clinical syndrome of symptoms (e.g. Breathlessness, fatigue) and signs(e.g. Oedema, crepitations) resulting from structural and/or functional abnormalities of cardiac function which leads to reduced cardiac output or high filling pressures at rest or with stress.

HF-REF - (Heart Failure with Reduced Ejection Fraction= Left Ventricular Systolic Dysfunction) refers to HF symptoms and/or signs with Left Ventricular Ejection Fraction < 40%. There are multiple treatment options for this form of HF

HF-PEF - (Heart Failure with Preserved Ejection Fraction= Left Ventricular Diastolic Dysfunction) refers to the a clinical Syndrome of HF with a normal/near normal Left Ventricular Ejection Fraction. There is a very poor evidence base for intervention in this group of HF patients.

There are no diagnostic clinical symptoms or signs for HF but the following are more specific and should raise suspicion of the diagnosis and prompt consideration of investigation:

Symptoms: Breathlessness, Orthopnoea, Paroxysmal Nocturnal Dyspnoea, Reduced Exercise Tolerance, Fatigue, Tiredness, Ankle Swelling

Signs: Elevated JVP, Hepatojugular Reflux, Third Heart Sound, Laterally display apex, Cardiac murmur

General: FBC(anaemia), Urinalysis/ACR if urinalysis positive for protein and U&E (renal dysfunction), TSH (hypo and hyperthyroidism), Glucose or HbA1C (diabetes), CXR( non cardiac causes of breathlessness)

Specific
NT- proBNP This is a very specific and sensitive marker for HF but alone is NOT diagnostic. A raised level should prompt referral for ECHO.
(N.B. Patients who are already on treatment with HF medication ( diuretics, ACEI, ARB, BB, Spironolactone etc will have a reduced level of NT-proBNP and ECHO may still be indicated if clinician suspicion is high)). There is some evidence that higher levels should be treated more urgently due to the association with greater mortality.

ECG: The ECG is not very specific for HF but should be performed in all cases of confirmed HF as the findings (atrial fibrillation, prolonged QRS, signs of ischaemia) have implications for treatment.

ECHO: refer for ECHO if NT-proBNP raised ( or normal in a treated patient with raised clinical suspicion). If the initial NT-proBNP is >2000 then refer as URGENT as earlier treatment in confirmed HF may reduce mortality and morbidity.

• Assessment to tailor therapy is based largely on functional status as defined by the New York Heart Association class as follows:

• An assessment of aetiology should be undertaken at the time of diagnosis and is often apparent from the clinical history and ECHO (e.g. MI, AF, Valvular disease)
• Dependent on own level of confidence and severity of clinical presentation consider referral to the local Heart Failure Specialist nursing service for assessment and initial treatment/ treatment plan (SCI gateway referral).

Mood: patients with evidence of depression should be considered for referral for CBT (evidence of reduction in depression symptoms). If antidepressants used avoid tricyclics due to the pro arrhythmic potential and reduction in myocardial contractility.

Fluid Restriction: patients with frequent episodes of decompensation should have their fluid intake assessed and a tailored approach given to fluid restriction (seek advice from Cardiac Specialist Nurses if required)

Salt intake: aim for daily intake of <6g. Avoid ‘Lo’ salt due to potassium content.

Coenzyme Q10: insufficient evidence to recommend supplementation

Diet: avoid cranberry juice if on warfarin, avoid grapefruit juice if on Simvastatin,, avoid St John’s wort due to multiple interactions.

Daily weighing: all patients should be encouraged to weigh themselves daily ( on rising, before dressing, after voiding, before eating) and to report an increase of more than 1.5-2.0kgs in two days as a potential early side of fluid a acclumination.

Alcohol: avoid excess intake. In patients with Alcohol induced HF compete abstinence is advised (evidence of clinical improvement)

Exercise: regular low intensity physical activity can be encouraged in patients with stable symptoms.

HF-REF is associated with an increased risk of sudden cardiac death. This is further increased in the presence of a prolonged QRS and LBBB. The following table is a summary of SIGN recommendations for intervention with device therapy. All patients matching these criteria should be referred to the Cardiac Nursing Team for assessment and onward referral.

ICD = implantable cardioverter defibrillator; CRT-D = cardiac resynchronisation therapy with an implantable cardioverter defibrillator;  CRT-P = cardiac resynchronisation therapy with pacing

Patients with advanced heart failure with ongoing symptoms in spite of optimally-tolerated heart failure treatment should have access to a collaborative cardiology/ palliative approach to care. Liaison with the Cardiac Nursing team for specialist input is advised to include:

• Anticipatory Care Planning/ KIS.
• Rationalisation of Medication.
• Active heart failure management and symptom control.
• Management of heart failure related devices.
• Management of Dyspnoea
  • After optimising diet, fluid intake and standard management for heart failure, prescription of low dose opioids, titrated against effect, should be considered in patients with dyspnoea
  • There is no (identified) evidence of benefit of oxygen therapy at rest or when ambulatory in patients with heart failure

35-50% of patients with clinical HF have a normal Ejection Fraction. There is very little evidence of any interventions of prognostic benefit. Treatment should be focused on the probable aetiology ( e.g. hypertension, myocardial ischaemia, tachyarrhythmia), and symptom relief.