Clinical Knowledge Summaries CKS Heart failure - chronic Management in primary care of: oChronic heart failure with left ventricular systolic dysfunction on echocardiography. oHeart failure symptoms with preserved left ventricular ejection fraction. oComorbidities. Educational slides based on the CKS topic Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Key learning points and objectives To be able to: oOutline which drug treatments should be offered to people with LVSD, and in what sequence. oExplain the benefits of drug treatments for HF. oDescribe how to initiate and titrate drug treatment. oDescribe when an AIIRA may be prescribed in preference to an ACE inhibitor. oDistinguish between beta-blockers which are licensed for HF and which are not. oDescribe how HF with preserved ejection fraction should be managed. oOutline how common morbidities such as angina should be managed. oRecognise the role of the GP and the role of the specialist and how they relate.

Overview of management Management of heart failure involves: oOn going liaison with the secondary care specialist. oInitial drug treatment is usually with: Diuretics, ACE inhibitors and a beta-blocker. oTreatments usually started by a specialist; may include: Aldosterone antagonists, digoxin, hydralazine plus a nitrate or ivabradine, dual therapy with an AIIRA with an ACE inhibitor. oManaging co-morbidities (e.g. angina). oLifestyle advice and rehabilitation. oImplantable cardiovertor defibrillators. oDiscussion of end of life issues and planning.

Left ventricular systolic dysfunction on echocardiography Based on the CKS topic Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Which drug treatments to offer To relieve symptoms of fluid overload: oPrescribe a diuretic (e.g. furosemide). oTitrate the dose up or down according to symptoms. oReview the dose and adjust as necessary after introducing other drug treatments for heart failure. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Which drug treatments to offer To reduce morbidity and mortality prescribe: oAn angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker. oAn angiotensin-II receptor antagonist (AIIRA) may be considered if the person develops intolerable side effects to the ACE inhibitor. Introduce one drug at a time. Add the second drug once the person is stable on the first drug. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Which angiotensin-II system drug ACE inhibitor (first-line). AIIRA (only if intolerable side effect to an ACE). Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Which drug to start first? Use clinical judgement when deciding which drug to start first. For example, the preferred initial treatment might be: oA beta-blocker, if the person has angina. oAn ACE inhibitor, if the person has diabetes. oAn ACE inhibitor, if the person still has signs of fluid overload (beta-blocker may make the symptoms of heart failure worse). Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Which beta-blocker? Bisoprolol, carvedilol, and nebivolol are recommended as: oNICE recommends that a beta-blocker which is licensed for treating heart failure should be prescribed. oBisoprolol, carvedilol, and nebivolol are the only beta-blockers licensed for treating heart failure. oAlthough some evidence indicates that metoprolol reduces mortality, it is not licensed for use in heart failure. Switch to bisoprolol, carvedilol, or nebivolol if already taking a different beta-blocker (e.g. for angina or hypertension). Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

If prescribing an ACE inhibitor first Prescribe a low dose and titrate upwards until: oThe target dose, or oThe highest tolerated dose is reached. Monitor renal function and serum electrolytes: o Before starting treatment. o 1–2 weeks after starting treatment, and o After each dose increase. Do not increase the dose further if there is: o Worsening renal function. o Hyperkalaemia. Seek specialist advice before starting treatment if already taking 80 mg furosemide or more. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

If prescribing an ACE inhibitor first Once stable, add a beta-blocker, unless contraindicated (e.g. asthma, heart block), or intolerant of beta-blockers. Start at a low dose and titrate slowly upwards until: oThe target dose, or oThe highest tolerated dose is reached. After each dose increase monitor: oHeart rate oBlood pressure, and oStability of the clinical status. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

When to follow up Follow up regularly to assess any need for changes and to detect possible drug adverse effects. Follow up: oEvery few days to every 2 weeks if the clinical condition or medication has changed. oAt least every 6 months if the person's condition is stable. More frequent follow up required for: oSignificant comorbidity (e.g. angina, atrial fibrillation), or oIf the condition has deteriorated since the previous review. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

At follow up Assess and monitor: oPsychosocial needs (including depression). oFunctional capacity. oIntercurrent infection (e.g. respiratory tract infection). oFluid status (e.g. change in body weight). oCardiac rhythm (e.g. syncopal or presyncopal symptoms, pulse and heart rate). oBiochemistry. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Referral Refer to a specialist for the management of: o Severe HF (NYHA class IV - inability to carry on physical activity with out discomfort. Symptoms of cardiac failure are present even at rest). o HF that does not respond to treatment despite optimal treatment. o HF that can no longer be managed effectively in the home setting. Refer for specialist advice: oWomen who are planning a pregnancy or who are pregnant. Specialist advice may also be appropriate when managing people with HF and a comorbidity. For example: o If considering prescribing nicorandil in people with HF and angina. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Other management Assess and manage cardiovascular risk. Review current medicines that may affect heart failure: oNSAIDs (associated with fluid retention and renal toxicity). oCalcium-channel blockers (may cause fluid retention and have no mortality benefit). oAntiarrhythmics. Manage comorbidities (e.g. angina, diabetes). Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Summary LVSD Prescribe a diuretic to control symptoms. Start an ACE inhibitor and a beta-blocker. oStart with one drug add the second one after the person is stabilised on the first. Only use an AIIRA if intolerable side effect to an ACE inhibitor. Review and stop medicines that may affect heart failure (e.g. NSAIDs). Frequent follow up may be required: oEvery few days to every 2 weeks if the clinical condition or medication has changed. oAt least every 6 months if the person's condition is stable. Consider referral if, severe HF or: o HF that does not respond to optimal treatment. o HF that can no longer be managed effectively in the home setting. o Pregnant or women who want to become pregnant. o If there is a comorbidity.

Heart failure symptoms with preserved left ventricular ejection fraction. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing preserved ejection fraction (PEF) To relieve symptoms of fluid overload: oPrescribe a low- to medium-dose diuretic (e.g. up to 80 mg furosemide). Seek specialist advice if: oDiuretics do give sufficient relief of symptoms, and oAdditional drug treatments are being considered. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing PEF Ensure any comorbidities and precipitating factors are optimally managed, for example: oHypertension. oMyocardial ischaemia. oAtrial fibrillation. Monitor medical and psychosocial status regularly. Follow up and referral advice are the same as for LVEF. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Summary – HFPEF Prescribe a low- to medium-dose diuretic to relieve symptoms of fluid overload. If diuretics do not work and considering additional drugs seek specialist advice. Ensure any comorbidities and precipitating factors are optimally managed. Monitor medical and psychosocial status regularly. Follow up and referral advice are the same as for LVEF. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing comorbidities in heart failure Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing angina Consider referral for a specialist opinion on treatment, including revascularisation. Ensure that angina symptoms are well controlled, with optimum use of medical management. Ensure that fluid retention is well controlled with diuretics. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing angina Treatments recommended: oLow-dose aspirin – recommended for people with HF and angina. oBeta-blockers – recommended for people with HF and angina. oNitrates – good safety profile for use in HF. oCalcium-channel blockers are effective at controlling angina symptoms, but some may aggravate heart failure (e.g. verapamil and diltiazem). Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing angina Treatments not recommended: oVerapamil, diltiazem, and short-acting dihydropyridines – may aggravate heart failure oNicorandil – contraindicated in people with HF with low filling pressure. Seek specialist advice if considering prescribing nicorandil. oIvabradine – contraindicated in unstable or acute HF. May be considered by some specialists, but heart failure must be stable before it is initiated. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing asthma or COPD Beta-blockers : oContraindicated in people with a history of asthma or bronchospasm. oMay be used in stable COPD without reversibility: oPeople who have COPD without reversibility should be able to tolerate beta-blockers and are likely to benefit significantly from their use. oThese people are often undertreated when they develop heart failure and their outcomes are worse than the average person with heart failure. oBisoprolol or nebivolol are more cardioselective. oStart with a low dose and slowly titrate up. oIf symptoms worsen reduce the dose, or stop treatment. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing atrial fibrillation The onset of AF may lead to worsening of symptoms and poor prognosis. Consider referral for cardioversion, rhythm or rate control. If rate control is chosen: o A beta-blocker is usually chosen first-line. o Digoxin may be an alternative if a beta-blocker cannot be taken. Antithrombtic treatment is recommended. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing diabetes Maintain good glycaemic control – reduces thirst that can lead to excessive fluid intake. If using metformin, monitor renal function and review if: o Serum creatinine is > 130 micromol/L, or o eGFR < 45 mL/min/1.73 m 2. Do not prescribe a glitazone (contraindicated in HF). Cardioselective beta-blockers (e.g.bisoprolol or nebivolol) preferred. o Non-selective beta-blockers can mask warning signs of hypoglycaemia. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing gout Loop diuretics may precipitate or aggravate gout o Can cause an increase in uric acid levels. Avoid NSAIDs – colchicine is preferred. Consider systemic corticosteroids if NSAIDs and colchicine are contraindicated. Monitor renal function if using allopurinol to prevent recurrence. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing renal impairment Manage any reversible causes, for example: o Dehydration. Reduce dose or temporarily stop diuretic. o Deterioration caused by ACE inhibitor or AIIRA. Reduce the dose or temporarily stop the ACE inhibitor or AIIRA. o Coincident renal disease (e.g. diabetic nephropathy or renovascular disease). Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Managing renal impairment If taking an aldosterone antagonist: o Monitor serum potassium closely. o Aldosterone antagonists may cause significant hyperkalaemia if there is renal impairment. If taking digoxin: o Consider reducing the dose. o Monitor for signs and symptoms of toxicity (e.g. nausea, vomiting, blurred or yellow vision). o Consider checking serum digoxin levels if toxicity is suspected. o Renal impairment is associated with reduced digoxin clearance and toxicity. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.

Summary comorbidities Angina o Ensure that fluid retention is well controlled with diuretics. oEnsure symptoms are well controlled and consider - low-dose aspirin beta-blockers, nitrates and CCBs (but not diltiazem or verapamil). o Consider referral. Asthma/COPD o Avoid betablockers but they may be used in stable COPD without reversibility. o Bisoprolol or nebivolol are more cardioselective. AF o Consider referral for cardioversion, rhythm or rate control. o If rate control is chosen, a beta-blocker (first-line) or digoxin may be used. o Antithrombtic treatment is recommended.

Summary comorbidities Diabetes o Maintain good glycaemic control - reduces thirst that can lead to excessive fluid intake. o If using metformin, monitor renal function. o Glitazones contraindicated in HF. o Non-selective beta-blockers can mask warning signs of hypoglycaemia Gout o Loop diuretics may precipitate or aggravate gout. o Avoid NSAIDS – colchicine preferred, but can use systemic steroids. Renal impairment o Manage any reversible causes (e.g. dehydration). o If patient on an aldosterone antagonist - monitor serum potassium. o If taking digoxin – monitor for and advise the patient about the signs of toxicity (consider reducing the dose).

Summary - LVSD Prescribe a diuretic to control symptoms. Start an ACE inhibitor and a beta-blocker. oStart with one drug add the second one after the person is stabilised on the first. Only use an AIIRA if intolerable side effect to an ACE inhibitor. Review and stop medicines that may affect heart failure (e.g. NSAIDs). Frequent follow up may be required: oEvery few days to every 2 weeks if the clinical condition or medication has changed. oAt least every 6 months if the person's condition is stable. Consider referral if, severe HF or: o HF that does not respond to optimal treatment. o HF that can no longer be managed effectively in the home setting. o Pregnant or women who want to become pregnant. o If there is a comorbidity.

Summary – HFPEF Prescribe a low- to medium-dose diuretic to relieve symptoms of fluid overload. If diuretics do not work and considering additional drugs seek specialist advice. Ensure any comorbidities and precipitating factors are optimally managed. Monitor medical and psychosocial status regularly. Follow up and referral advice are the same as for LVEF. Based on the CKS topic; Heart failure - chronic (Nov 2010), and NICE guidance (2010); Management of chronic heart failure in adults in primary and secondary care.