Heart Failure Pathway - Management of Systolic Heart Failure
Management of Heart Failure - loss of LV function (LVEF < 40%)
Principles of diuretic treatment:
- Use loop diuretic - frusemide.
- Patient weighs themselves daily.
- Give diuretic at a dose that achieves a weight loss of 0.5 to 1kg per day until clinical euvolaemia - establish the patient's dry or euvolaemic weight.
- If patient weight increases by > 2kg in 1-2 days then increase frusemide by 20mg per day for each kg of weight gainconsider short term thiazide diuretic use in decompensated patients who do not respond to loop diuretic dose increase.
- Improvement if there is weight loss the next day
- If no weight loss then review by Dr/Nurse
- Consider short term thiazide diuretic use in decompensated patients who do not respond to loop diuretic dose increase.
Principles of ACEI treatment:
- Start at a low dose and increase every 2 weeks until a dose reached that is equivalent to the dose used in clinical trials or maximum that is tolerated by the patient.
- Check creatinine and electrolytes after each dose change.
- If ACEI not tolerated then substitute with an angiotensin II receptor blocker.
Principles of Beta-Blocker treatment:
- Start beta-blocker when fluid overload corrected - use carvediol, (note: carvedilol has complex beta and alpha blockade actions and may have some theoretical advantages in CHF over other beta-blockers), metoprolol CR, bisoprolol (note: bisoprolol is more beta-1-selective than metoprolol and may have theoretical benefit in patients with asthma, peripheral vascular disease, postural hypotension, fatigue and nightmares).
- Start at a low dose and increase gradually until a dose reached that is equivalent to the dose used in clinical trials - carvediol 25mg bd / metoprolol CR 190 mg.
- Include older patients and patients with peripheral vascular disease, diabetes mellitus, erect ile dysfunction, interstitial lung disease and COPD without reversibility.
Disease specific treatment:
- Hypertension - maximise the dose of the beta-blocker and ACE inhibitor before considering other medications eg. amlodipine or felodipine.
- Coronary heart disease - consider aspirin 75-150mg daily, amolodipine or felodipine, nitrates.
- Atrial fibrillation - see Atrial Fibrillation pathway.
- Hyperlipidaemia - consider low fat diet and medication.
- Digoxin and spironolactone in Class 3 and 4 heart failure in addition to other medications.
- Avoid spironolactone in elderly or patients with renal impairment.
- Exercise program.
- Smoking cessation and minimal alcohol.
- Low sodium diet - no added salt.
- Fluid management:
- < 1500ml daily
- reduce to < 1000ml daily in severe or decompensated cases
Correct or prevent precipitating factors:
- Consider respiratory conditions - pulmonary emboli, sleep apnoea, lower respiratory infection.
- Consider medications that aggravate heart failure - diltiazem, verapamil, NSAID, clozapine, metformin, corticosteroids, glitazones, antiarrhythmic drugs, tricyclic antidepressants.
- Implanted devices - biventricular pacing, ICD.
- Heart transplantation.
Last updated : Friday, February 03, 2017
Next review date : Saturday, February 03,2018
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