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Quick reference guide for health professionals

Diagnosis and management of


chronic heart failure
Updated October 2011

This quick reference guide is derived from the National Heart Foundation of Australia
and Cardiac Society of Australia and New Zealand Guidelines for the prevention,
detection and management of chronic heart failure in Australia. Updated October 2011.

The recommendations are not prescriptive. Clinical Check for, and treat, iron deficiency in people
judgement and individual patient circumstances will with CHF to improve their symptoms, exercise
determine the most appropriate care. tolerance and quality of life.
Please refer to the updated full guidelines for more Educate people with CHF about lifestyle
information about positive trials that warranted changes (e.g. increase physical activity
an update to the 2006 chronic heart failure (CHF) levels, reduce salt intake and manage
guidelines. weight). Help them make these changes,
and routinely include psychosocial
assessment in their management plan.
Key messages Educate people with CHF about CHF symptoms
and how to manage fluid load.
Optimal management of CHF improves quality
of life, reduces hospitalisation rates and prolongs Avoid prescribing drugs that exacerbate CHF
survival for people with this condition. (see page nine).

Echocardiography is the single most useful Use a multidisciplinary care approach for
test in the evaluation of heart failure, and is people with CHF consider Chronic Disease
necessary to confirm the diagnosis. Management (CDM) Medicare items.

Plasma B-natriuretic peptide (BNP) Prescribe angiotensin-converting enzyme


measurements may be useful in excluding CHF. inhibitors (ACEI) at effective doses for people
with all grades of systolic heart failure, and titrate
Try to distinguish systolic heart failure from heart
to the highest recommended dose tolerated.
failure with preserved systolic function (diastolic
heart failure) to guide management and help
determine prognosis.

Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 1
Angiotensin II receptor antagonists (ARA) may
be used as alternatives in people who cannot Definitions Who is at risk? When to suspect CHF
tolerate ACEIs. ARAs should also be considered Most symptoms of CHF are non-specific. Consider
Chronic heart failure CHF is a disabling and potentially fatal condition investigating for possible CHF in:
for reducing morbidity and mortality in people
affecting an estimated 1.52% of Australians. It
with systolic CHF who remain symptomatic A complex clinical syndrome that is people with unexplained fatigue, dyspnoea or
is one of the most common reasons for hospital
despite receiving ACEIs, although aldosterone frequently, but not exclusively, characterised symptoms of fluid overload, with or without risk
admission and GP consultations in the elderly.
antagonists would be preferred in this setting. by an underlying structural abnormality or factors
Prevalence is rising, but a significant proportion of
cardiac dysfunction that impairs the ability
For people with stabilised systolic heart failure people with CHF remain undiagnosed. people with risk factors, including previous
of the left ventricle (LV) to fill with or eject
who remain symptomatic despite appropriate myocardial infarction (MI) or hypertension
blood, particularly during physical activity. Systolic heart failure is mainly due to coronary heart
doses of an ACEI, prescribe beta-blockers that (particularly in the elderly).
Symptoms of CHF (e.g. dyspnoea and fatigue) disease (CHD). HFPSF is more common in women
have been shown to improve outcome in heart
can occur at rest or during physical activity and the elderly, and is mainly due to hypertension,
failure (e.g. bisoprolol, carvedilol, extended- History, examination and
(see Table 1 on page four). age-related fibrosis and hypertrophy, CHD and
release metoprolol or nebivolol). Titrate to the
highest recommended dose tolerated.
diabetes. investigations
Systolic heart failure
Prescribe diuretics, digoxin and nitrates for A weakened ability of the heart to contract. Symptoms that are relatively specific to CHF (e.g.
people already using ACEIs and beta-blockers to The most common form of CHF. Diagnosis of CHF orthopnoea, paroxysmal nocturnal dyspnoea or
ankle oedema) occur in more advanced disease
manage symptoms as indicated.
Heart failure with preserved systolic and do not help early diagnosis.
Consider prescribing fish oils for people with function (HFPSF) Causes of CHF
symptomatic systolic HF after ACEIs and beta- Exertional dyspnoea is usually present and may
Also known as diastolic heart failure. Common be slowly progressive. A dry, irritating cough
blockers.
Impaired filling of the LV of the heart in CHD (especially at night), dizziness or palpitations can
For people who have severe systolic heart failure response to a volume load, despite normal also suggest CHF.
Conditions that cause pressure overload (e.g.
(New York Heart Association (NYHA) Class ventricular contraction. Systolic heart failure hypertension, aortic stenosis) Examination should include assessment of vital
III-IV) despite appropriate doses of ACEIs and and HFPSF can occur together. The distinction
diuretics, consider prescribing spironolactone. Idiopathic dilated cardiomyopathy signs, cardiac auscultation (murmurs, S3 gallop)
between them is relevant to the therapeutic and checking for signs of fluid retention (e.g. raised
Consider prescribing eplerenone for people with approach (see Table 3 on page six). Less common jugular venous pressure, peripheral oedema, basal
systolic heart failure who still have mild (NYHA Volume overload (e.g. mitral valve regurgitation) inspiratory crepitations).
Class II) symptoms despite receiving standard
Physical examination is often normal, and clinical
therapies with ACEIs and beta-blockers. Gaps in current management Uncontrolled arrhythmias (e.g. atrial fibrillation
(AF)) diagnosis of CHF can be unreliable, especially in
Consider direct sinus node inhibition with Australian studies show that the care of people with older people and people who are obese or have
ivabradine for people with CHF who have CHF could be improved by: Thyroid dysfunction (e.g. hyperthyroidism,
concomitant pulmonary disease.
impaired systolic function, have had a recent hypothyroidism)
greater use of echocardiography currently Clinical assessment cant rule out a diagnosis of
heart failure hospitalisation and are in sinus Other systemic illness (e.g. amyloidosis,
under-used in diagnosis and ongoing assessment CHF. People with a low LV ejection fraction (LVEF)
rhythm with a heart rate > 70 bpm. sarcoidosis, scleroderma, haemochromatosis,
greater use of ACEIs currently under- may be asymptomatic. Absence of clinical signs of
Consider assessing people with CHF for cryoglobulinaemia)
prescribed and used at suboptimal doses fluid overload (e.g. clear lung fields) or a normal
biventricular pacemakers and implantable Idiopathic chest X-ray do not rule out the possibility of CHF.
defibrillators. greater use of beta-blockers currently under-
Early diagnosis of LV dysfunction is the goal, Objective assessment of ventricular function
prescribed and used at suboptimal doses
because optimal treatment can prevent or slow using echocardiogram is necessary when CHF
avoidance of drugs that may exacerbate CHF CHF progression. is suspected, because physical signs are often
inadvertent co-prescribing is common. normal in early CHF.
Diagnosis is based on clinical features, chest X-ray
(acute phase) and echocardiography (or plasma Further investigations in CHF aim to confirm the
BNP measurement if the echocardiogram cant be diagnosis, determine the mechanism (e.g. LV systolic
performed in a timely manner and the diagnosis is dysfunction, valvular heart disease), determine
not clear) (see Figure 1 on fold out panel). the cause (e.g. CHD), identify exacerbating and
precipitating factors (e.g. arrhythmias, ischaemia,
Other tests and response to treatment help confirm anaemia, pulmonary embolism, infection), guide
the diagnosis, determine prognosis and guide treatment and determine prognosis.
management (see Table 2 on page five).
Try to distinguish systolic heart failure from HFPSF
(see Table 3 on page six).

2 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 3
Everyone with suspected CHF should undergo The echocardiography report should help you Table 2. Investigations in CHF
an ECG, chest X-ray and echocardiogram, even if decide:
physical signs are normal (see Table 2 on page five). Investigations indicated in people with suspected CHF
if the persons symptoms and signs can be
Echocardiogram attributed to CHF Echocardiogram
Echocardiography is the single most useful
diagnostic test in the evaluation of people with the severity of CHF The most useful test.
suspected CHF. the probable cause of CHF (e.g. CHD, Provides objective assessment of cardiac structure and function, and confirms the diagnosis of systolic
The echocardiogram (structural assessment hypertension, valvular disease, myocardial LV dysfunction.
combined with Doppler flow studies) provides damage)
ECG
information on LV and right ventricular size, volume an appropriate management plan. Can add or confirm information about the cause of CHF (e.g. MI).
and wall thickness; ventricular systolic and diastolic
function; and valvular structure and function. Changes on ECG are not specific to heart failure, so an abnormal ECG does not replace
echocardiography.

Table 1. New York Heart Association (NYHA) functional classification of CHF symptoms Chest X-ray
Specific abnormalities can rule out CHF as an explanation for the persons symptoms and signs.
NYHA I No symptoms, even during moderate-intensity physical activity.
Cardiomegaly, pulmonary venous changes and interstitial oedema of lung fields support the diagnosis
NHYA II Reduced physical capacity for moderate-intensity physical activity (e.g. breathlessness of CHF.
when climbing stairs). Normal chest X-ray does not exclude CHF.
NHYA III Severely reduced physical capacity for low-intensity physical activity (e.g. breathlessness Full blood count, plasma urea, creatinine and electrolytes
except when at rest).
Include these in diagnostic investigation and repeat every six months in people with stable CHF.
NHYA IV Symptomatic at rest. Mild anaemia is common in CHF and worsens prognosis. Severe anaemia is occasionally a cause. All
anaemia warrants full investigation.

Other investigations

Thyroid function tests are indicated when thyroid dysfunction is considered as a possible cause of
CHF (e.g. older people with AF and no pre-existing CHD).
Liver function tests are abnormal if congestive hepatomegaly and/or cardiac cirrhosis are present.
Plasma BNP may be helpful to improve diagnostic accuracy in people with recent-onset dyspnoea by
ruling out CHF.
Stress testing may be indicated to exclude ischaemia as a cause of CHF if exertional dyspnoea is not
explained by resting echocardiography. The test protocol should be determined in consultation with a
cardiologist, if possible.
Coronary angiography (as indicated by stress test and to assess for myocardial revascularisation)
should be considered in people with CHF with a history of exertional angina or suspected ischaemic
LV dysfunction.
Invasive haemodynamic testing is occasionally useful when the diagnosis of CHF is in doubt, or to
confirm HFPSF.
Endomyocardial biopsy is rarely indicated (e.g. with dilated cardiomyopathy or recent onset, or
when CHD has been excluded by angiography).
Spirometry is useful in excluding respiratory disease (e.g. chronic obstructive pulmonary disease
(COPD), asthma).

4 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 5
Table 3. Systolic heart failure and HFPSF
Management of CHF increasing frailty and debilitation
language barrier
Systolic heart failure HFPSF

Diagnosis Echocardiography: Echocardiography: impaired LV relaxation and/or


Management goals lower socioeconomic status.

Clinical signs impaired LV contractile evidence of raised filling pressure and normal LV The goals of therapy are to:
Routinely instigate
and symptoms of function (LVEF < 40%). function (LVEF > 40%).
CHF (e.g. history,
prevent CHF in people at risk non-pharmacological
Exclude myocardial ischaemia and valvular disease.
symptoms, signs, detect asymptomatic LV dysfunction early treatment in people with CHF
chest X-ray). Cardiac catheterisation or echocardiography may
relieve symptoms and improve quality of life Strong evidence supports the routine instigation
indicate diastolic dysfunction.
of non-pharmacological measures as a central
slow disease progress and prolong survival
component of CHF management.
improve physical activity tolerance
reduce hospital admissions. Educate people with CHF about
self-management
Prevent CHF in people at risk Teach people with CHF to monitor and control their
Relevance to Strong evidence supports Occurs in 40% of people with CHF.
management standard treatments (see Prescribe an ACEI in people with asymptomatic fluid balance.
Recognised as a significant clinical entity, but systolic LV dysfunction as tolerated (see Figure 2
Table 4 on page 10). Limit dietary sodium to less than 2 g/day,
remains difficult to diagnose. on fold out panel), and consider preventive ACEI
Prognosis worsens and fluid intake to < 2 L/day (1.5 L for severe
Manage underlying cause (e.g. strict control of therapy in people most at risk (e.g. with a history CHF), although this will depend on individual
as functional class of MI or other cardiovascular disease).
blood pressure (BP) and blood glucose). Use ACEIs circumstances. Limit caffeine to 12 drinks per
progresses.
or angiotensin II receptor blockers (ARB) to prevent Prescribe one or more antihypertensive agents day.
LV hypertrophy. to prevent CHF in people with hypertension. Use the persons weight after correction of
Initiate treatment with a beta-blocker early fluid overload as a benchmark. Explain that
after MI, whether or not the person has systolic steady weight gain over days may indicate fluid
ventricular dysfunction. retention. Instruct people to weigh themselves
each morning (after urinating and before
Manage lipid abnormalities using statin therapy
dressing and breakfast), and to contact a doctor
according to Heart Foundation guidelines.
or specialist heart failure nurse immediately if
there is a 2 kg gain or loss over 48 hours.
Identify high-risk people for extra care
Explain symptoms of dyspnoea, oedema and
Up to two-thirds of CHF-related hospital admissions
bloating, and advise people to report these
could be avoided by improved adherence to
symptoms if detected.
therapy, adequate access to medical and social
support for people with CHF and their carers, and Some people can learn to self-adjust diuretics
appropriate response to acute exacerbations or (e.g. double the dose if there is evidence of
signs of deterioration. retention).

The most practical indicator of increased risk Advise people with CHF about healthy lifestyle and
of premature morbidity and mortality, or of prevention strategies.
readmission to hospital, is the presence of two or Minimise alcohol intake: should not exceed one
more of the following: to two standard drinks per day. Patients who
age > 65 years have alcohol-related cardiomyopathy should not
consume alcohol to help slow their diseases
severe symptoms limiting activities of daily living
progression.
LVEF < 30%
Quit smoking.
living alone or remotely from specialist cardiac
Vaccinate against influenza and pneumococcal
services
disease.
depression
Bed rest when clinically unstable or during an
significant renal dysfunction acute exacerbation.

6 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 7
For more information and advice about self- Systolic heart failure: initiate Consider Chronic Disease Avoid drugs that exacerbate CHF
management, refer people with CHF to the
pharmacological treatment to prolong Management (CDM) Medicare items Anti-arrhythmic agents (other than beta-blockers
Heart Foundations Health Information Service,
phone 1300 36 27 87 (local call cost) or email survival People with CHF who need multidisciplinary care and amiodarone)
health@heartfoundation.com.au. Prescribe an ACEI* for people with systolic heart may benefit from: Non-dihydropyridine calcium-channel blockers
failure (LVEF < 40%), whether symptoms are mild, a GP Management Plan (Item 721) and (e.g. verapamil, diltiazem)
Refer people with CHF to a physical moderate or severe. Titrate to recommended dose subsequent review (Item 725) Tricyclic antidepressants
activity specialist for maximum benefit, as tolerated. An ARA is an
Team Care Arrangements coordinated by the GP
alternative in people who are unable to tolerate Non-steroidal anti-inflammatory drugs (including
Regular physical activity reduces symptoms and ACEIs. (Item 723) and subsequent review (Item 727). COX-2 inhibitors)
increases functional capacity in people with CHF.
Prescribe a loop diuretic to manage symptoms An effective multidisciplinary team might include Clozapine
It is also recommended to correct physical de-
of fluid overload. In people with systolic LV an exercise physiologist and a dietitian.
conditioning. Thiazolidinediones (e.g. pioglitazone,
dysfunction, diuretics should never be used as rosiglitazone)
People with CHF should be referred to a physical monotherapy, but should always be combined with HFPSF: manage risk of progression
activity specialist for a specially designed physical an ACEI*. Corticosteroids (e.g. glucocorticoids,
There is limited clinical evidence to guide the
activity program, if available. The benefits are mineralocorticoids)
Beta-blockers* (carvedilol, bisoprolol, extended- management of HFPSF. Aims are to:
greater for middle-aged people with systolic heart
release metoprolol, nebivolol) are recommended Tumour necrosis factor antagonists
failure. manage the underlying cause (strict BP control
for people with systolic heart failure, in addition in hypertension, strict glycaemic and low BP Dronedarone (associated with increased
For more information, see the Physical activity to ACEI* at an effective dose. Titrate to the highest targets in diabetes) mortality in people with NYHA Class IV
recommendations for people with cardiovascular recommended dose tolerated. CHF or NYHA Class II-III CHF with a recent
disease 2006. prevent LV hypertrophy (initiate ACEI or ARA
Spironolactone* is recommended for people with decompensation requiring hospitalisation, and is
therapy* as for systolic heart failure).
systolic heart failure with severe symptoms (NYHA contraindicated in such people)
Access multidisciplinary CHF
Class III-IV), despite an appropriate dose of ACEIs* Manage related and coexisting Trastuzumab (associated with the development
programs where available and diuretics. Eplerenone should be considered
conditions of reduced LVEF and heart failure. It is
Most people with CHF need complex management in people with systolic heart failure who still have contraindicated in people with symptomatic
due to increased age, comorbidities, polypharmacy, mild (NYHA Class II) symptoms, despite receiving Use digoxin to control the ventricular rate of AF, heart failure or reduced LVEF (< 45%). Baseline
depression or reduced coping skills. standard therapies with ACEIs and beta-blockers. and beta-blockers if heart failure is stabilised. and periodic evaluation of cardiac status,
Amiodarone may also be considered to control AF including assessment of LVEF should occur)
Nurse-led multidisciplinary CHF programs are Use diuretics, digoxin and nitrates to manage
or ventricular fibrillation (VF). Follow guidelines for
available throughout Australia. They offer evidence- symptoms as indicated in people already receiving Tyrosine kinase inhibitors (e.g. sunitinib.
preventive use of warfarin in AF.
based pharmacological and non-pharmacological ACEIs and beta-blockers. Associated with hypertension, reduced LVEF and
therapy. Programs usually include personalised For people with CHD, prescribe low-dose aspirin heart failure. The riskbenefit profile needs to
Fish oils should be considered as a second-line
care; self-care education for people with CHF and and a statin to achieve recommended lipid targets be considered with these agents in people with
treatment for people with CHF who still have
their carers; counselling; intensive follow-up to (LDL-C < 2.0 mmol/L, HDL-C > 1.0 mmol/L and a history of symptomatic heart failure or cardiac
symptoms despite standard therapy with ACEIs,
detect problems early and prevent deterioration; TG < 2 mmol/L). Arrange assessment for coronary disease. Baseline and periodic evaluation of
ARBs and beta-blockers, if tolerated.
physical activity programs; and access to advice revascularisation as appropriate after initiation of LVEF should be considered, especially in the
and support. Direct sinus node inhibition with ivabradine should optimal drug therapy. presence of cardiac risk factors)
be considered for people with CHF who have
These programs can significantly reduce the risk of Achieve BP targets in people with hypertension Moxonidine (associated with increased
impaired systolic function and a recent heart failure
re-hospitalisation, improve quality of life, reduce using a combination of antihypertensive agents. mortality in people with heart failure and is
hospitalisation, and who are in sinus rhythm with a
healthcare costs and prolong survival. A dihydropyridine calcium-channel blocker contraindicated in such people)
heartbeat > 70 bpm.
(amlodipine or felodipine) may be added to ACEI
Treat for co-existing sleep apnoea Iron deficiency should be looked for and treated in and beta-blocker if required.
people with CHF to improve symptoms, exercise
Sleep disordered breathing commonly occurs with Cardiac surgery may benefit people with valvular
tolerance and quality of life.
CHF. Consider referring people with CHF to a sleep damage or symptomatic coronary disease.
clinician if there is excessive daytime drowsiness Table 4 on page 10 lists other main
or a history of snoring. Nasal continuous positive pharmacological management options.
airway pressure (CPAP) may be indicated.

* Unless contraindicated or not tolerated.


An anticoagulant that does not require INR control will be available for non-valve-related AF, but its role in comparison with
* Unless contraindicated or not tolerated. warfarin is not yet established in CHF-only populations.

8 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 9
Table 4. Pharmacological treatment for CHF

Agents Recommendations Prescribing notes Agents Recommendations Prescribing notes


ACEIs Mandatory in people with systolic LV Prescribe once daily at night. Digoxin Consider for relief of symptoms in Low dose (62.5 g/day). Adjust for
dysfunction. people with advanced CHF and people renal impairment or concomitant use of
Titrate over 34 weeks to highest
with AF. amiodarone.
Prolong survival, improve symptoms recommended dose tolerated. Monitor
and reduce hospitalisation in potassium and renal function. Improves exercise capacity and Monitor clinical effect and toxicity
symptomatic people. reduces risk of hospitalisation. (routine blood level monitoring no
longer recommended).
Loop diuretics Use to manage symptoms of fluid Titrate according to fluid balance,
overload in addition to ACEI. judged by bodyweight change and Direct sinus node Consider in people with CHF who
symptoms. inhibition with have impaired systolic function and a
Improve exercise tolerance, cardiac
ivabradine recent heart failure hospitalisation, and
function and symptoms of fluid With appropriate training, people with
who are in sinus rhythm where their
overload. CHF can adjust their own dose.
heartbeat remains 70 bpm, despite
Beta-blockers Recommended in all grades of systolic Start when symptoms improve and are efforts to maximise dose of background
CHF in combination with an ACEI. stable for 1 week. Start at low dose beta blockade.
and titrate slowly to recommended
Prolong survival and normalise LV Nitrates Recommended in angina prophylaxis. Start with a low dose and increase to
dose if tolerated. Warn people of
function (e.g. carvedilol, bisoprolol, target over 12 weeks.
possibility of transient tiredness. Reserve hydralazinenitrate
extended-release metoprolol,
combination for people who
nebivolol). Use with caution in people with
cant take ACEIs or ARAs.
reversible broncho-constriction
(asthma). Fish oil Consider as second-line agent
(n-3 polyunsaturated in people with CHF who remain
ARAs Alternative to ACEIs in people who Not recommended in preference to
fatty acids) symptomatic despite receiving standard
cant tolerate ACEIs (e.g. cough). ACEIs.
therapies with ACEIs and beta-blockers.
Spironolactone Recommended for people with systolic Not recommended if glomerular
Iron Consider in people with CHF who are
CHF with severe symptoms (NYHA filtration rate (GFR) < 30 mL/min.
iron deficient.
Class III-IV), despite appropriate doses
Monitor potassium and renal function
of ACEIs and diuretics.
regularly, especially in the elderly.

Eplerenone Recommended early post-MI for Not recommended if GFR < 30 mL/min.
people with LV systolic dysfunction
Monitor potassium and renal function
and symptoms of heart failure.
regularly, especially in the elderly.
Recommended in people with systolic
heart failure who still have mild (NYHA
Class II) symptoms despite receiving
standard therapies with ACEIs and
beta-blockers.

10 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 11
Some common causes of In people in whom implantation of an ICD is
planned to reduce the risk of sudden death,
When to refer people Living every day with my heart failure
Aboriginal and Torres Strait Islander patient and
deterioration in people with
previously stable CHF
it is reasonable to also consider cardiac
resynchronisation therapy (CRT) to reduce risk of
with CHF carer booklet, with action plan, available in print
only.
Ischaemia death and heart failure events if the LVEF is 30% Referral to specialist care has been shown to For general information and to order a print
and the QRS duration is 150 ms (left bundle improve outcomes, reduce hospitalisation and
Arrhythmias (most commonly AF) copy of the Heart Foundation resources, call our
branch block morphology), with associated mild improve symptoms in people with CHF. Health Information Service on 1300 36 27 87 or
Valvular dysfunction symptoms (NYHA Class II), despite optimal medical
GPs are ideally placed to coordinate ongoing email health@heartfoundation.com.au.
therapy.
Poor compliance with medicines (e.g. cessation care for people with CHF.
of diuretics) LV assist devices are used mainly as temporary
Referral to a specialist may be warranted when:
bridges to cardiac transplantation or recovery after
Unrestricted salt and water intake
heart surgery. the diagnosis is uncertain
Use of medicines that worsen CHF
complex management (including co-
Infections Manage advanced and end-stage CHF morbidities) is needed
Renal failure The use of positive inotropes for short-term acute decompensation occurs
improvement of cardiac pumping action is reserved
Anaemia for people not responding to other treatments. help is needed to clarify the prognosis
Pulmonary embolus Levosimendan or dobutamine may be of benefit in revascularisation, implantation of devices or
people with advanced CHF. In people who cant be heart and/or lung transplantation are being
Thyroid dysfunction
weaned off continuous inpatient infusion, consider considered
continuous ambulatory infusion at home.
Devices the person is young (e.g. < 65 years of age).
Both continuous positive airway pressure (CPAP)
Biventricular pacing is emerging as a safe and
and bi-level positive airway pressure (BiPAP)
effective treatment to improve symptoms and
haemodynamics in people with CHF. It should
ventilation reduce the need for invasive ventilation More information
in people with acute pulmonary oedema.
be considered (with or without an implantable
Palliative care should be considered for people who Guidelines for the prevention, detection
cardioverter defibrillator (ICD)) in people with all of
are likely to die within 12 months and have poor and management of chronic heart failure
the following:
quality of life on standard therapy aimed to prolong in Australia. Updated October 2011 The
NYHA functional class IIIIV on treatment (see full evidence-based review from which this
life. Strong predictors of death within months
Table 1 on page four) quick reference guide is derived. Provides
include advanced age, recurrent hospitalisation for
decompensated heart failure or related diagnosis, detailed information on the prevention,
heart failure with LVEF 35%
NYHA class IV symptoms, severe renal impairment, diagnosis and management of CHF,
QRS interval duration 120 ms including levels of evidence and grades of
cardiac cachexia, low plasma sodium concentration
sinus rhythm. and refractory hypotension that necessitates recommendations. Available in print and
withdrawal of medical therapy. online at www.heartfoundation.org.au.
ICD implantation should be considered in people
with CHF who meet any of the following criteria: It may be useful to consider the formulation 2011 Update to Guidelines for the
of advanced care directives and referral to prevention, detection and management
history of cardiac arrest due to VF or ventricular of chronic heart failure in Australia,
tachycardia (VT) specialist palliative care services where symptom
management is challenging. 2006 A Medical Journal of Australia article,
spontaneous sustained VT in association with available online at www.mja.com.au.
structural CHD Multidisciplinary care for people with chronic
LVEF 30% when stabilised post MI or heart failure. Principles and recommendations
revascularisation for best practice Available in print and online at
www.heartfoundation.org.au.
NYHA functional class II-III, LVEF 35%.
Living well with chronic heart failure Patient
and carer booklet with action plan insert.
Available in print only. Information sheet
summary available in print and online at
www.heartfoundation.org.au.

12 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 13
Notes Notes

14 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 Heart Foundation Quick reference guide Chronic heart failure. Updated October 2011 15
Figure 4.1
Diagnostic algorithm for CHF
Figure 1 Diagnostic algorithm for CHF

Suspected CHF
Shortness of breath
Fatigue
Oedema

Clinical history
Physical examination
Please fold out for diagnosis Initial investigations

and treatment algorithms Pulse rate and rhythm


Symptoms of CHF Blood pressur e
Dyspnoea Elevated JVP
Orthopnoea Cardiomegaly
PND Cardiac murmurs
Fatigue Lung crepitations
Oedema Hepatomegaly
Palpitations/Syncope Oedema

Past cardiovascular
disease ECG
Angina/MI Chest X-ray
Hypertension Other blood tests: full blood
Diabetes count, electrolytes, renal
Murmur/Valvular disease function, liver function,
Cardiomyopathy thyroid function
Alcohol/Tobacco use Consider BNP or
Medicines N-terminal proBNP test

Clinical diagnosis or suspicion of CHF

Echocardiogram

Structural diagnosis Pathophysiological diagnosis


E.g. myopathic, valvular Systolic dysfunction (LVEF < 40%)
Diastolic dysfunction (LVEF > 40%)

Consider specialist referral Proceed to treatment guidelines


for further investigation

BNP = B-type natriuretic peptide. MI = myocardial infarction.


JVP = jugular venous pressure. PND = paroxysmal nocturnal dyspnoea.
LVEF = left ventricular ejection fraction.
Figur e 7.1 Figure 7.2
Pharmacological treatment of asymptomatic LV dysfunction Pharmacological treatment of systolic heart failure
(LVEF <40%) (NYHA Class I) (LVEF <40%) (NYHA Class II III)
Figure 2 Pharmacological treatment of asymptomatic LV dysfunction (LVEF < 40%) (NYHA Class I) Figure 3 Pharmacological treatment of systolic heart failure (LVEF < 40%) (NYHA Class II/III)

Asymptomatic LV dysfunction Mildmoderate symptomatic CHF


(NYHA Class I) (NYHA Class IIIII)

Correct/Prevent acute Pharmacological Non-pharmacological


precipitants management management
Non-pharmacological Pharmacological management Disease-specific treatment
Non-compliance Multidisciplinary care
management ACEI e.g. CHD aspirin,
Acute ischaemia/infarction Exercise/Conditioning program
Exercise/Conditioning program Beta-blocker beta-blocker, statin
Arrhythmia* Low salt diet
Risk-factor modification e.g. Hypertension second
Fluid management
smoking/alcohol cessation, diet agent if needed

Fluid overload

Yes No

Diuretic ACEI
+
ACEI

Persistent oedema Improved Add beta-blocker**

Add spironolactone Add beta-blocker**


(Class III)
+/- digoxin
+/- angiotensin II
receptor antagonists

Improved

Add beta-blocker**

*
Patients in AF should be anticoagulated with a target INR of 2.03.0. Amiodarone may be used to control AF rate or
attempt cardioversion. Electrical cardioversion may be considered after 4 weeks if still in AF. Digoxin will slow resting
AF rate.

Multidisciplinary care (pre-discharge and home review by a community care nurse, pharmacist and allied health
personnel) with education regarding prognosis, compliance, exercise and rehabilitation, lifestyle modification, vaccinations
and self-monitoring.

The most commonly prescribed first-choice diuretic is a loop diuretic e.g. frusemide; however there is no evidence that
loop diuretics are more effective or safer than thiazides.

If ACEI intolerant, use angiotensin II receptor antagonists instead.
**
Once the patient is stable, prescribe beta-blockers that have been shown to improve outcomes in heart failure: carvedilol
(beta-1, beta-2 and alpha-1 antagonist), bisoprolol (beta-1 selective antagonist), metoprolol extended release (beta-1
selective antagonist) or nebivolol (selective beta-1 receptor antagonist).
For heart health information
1300 36 27 87
www.heartfoundation.org.au

Suggested citation:
National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand. Quick reference guide. Diagnosis and
management of chronic heart failure. Updated October 2011.
2011 National Heart Foundation of Australia ABN 98 008 419 761
ISBN: 978-1-921748-70-7
PRO-124 IPM 9/11
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professionals. The statements and recommendations it contains are, unless labelled as expert opinion, based on independent
review of the available evidence. Interpretation of this document by those without appropriate medical and/or clinical training is not
recommended, other than at the request of, or in consultation with, a relevant health professional.
While care has been taken in preparing the content of this material, the Heart Foundation and its employees cannot accept any
liability, including for any loss or damage, resulting from the reliance on the content, or for its accuracy, currency and completeness.
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