1. Indication:  Suspected Heart Failure With abnormal ECG or Intermediate BNP (100-400) BNP:  Asymptomatic Murmur  Asymptomatic Cardiomegaly On CXR Direct Access Echo RSCH

2. Footnote: Please do not use open access Echo but refer directly to consultant for: 1.Pts with symptoms and signs of CHF or very high BNP 2.Pts with symtomatic heart murmurs 3.Known heart failure with previous echo 4.Other cardiac problems Direct Access Echo RSCH

3. Drug therapy in CHF Diuretics ACE inhibitors B - blockers Spironolactone (Class III & IV patients) Angiotensin II receptor blockers (Alternative to ACE I) Hydralazine & ISDN (ACE I/ARB intolerance or in renal failure or in Afro- Carribeans as in the AHeFT trial) Digoxin if still symptomatic or in AF

4. Dose of ACE Inhibitors in CHF Enalapril2.5 mg od10-20 mg bd Lisinopril2.5 mg od20-40 mg od Perindopril2 mg od4 mg od Ramipril1.25-2.5 mg od10 mg od Initial Dose*Optimal Dose * If there are signs of dehydration, stop diuretics for 24 hrs before initial dose of ACE inhibitor

5. Summary of Drug Treatment of CHF CHF Confirmed ACE Inhibitors (or ARBs) Oedema Diuretics + Consider Spironolactone in Class III/IV pts No congestion Beta-blockers AF Digoxin + Warfarin Angina ISMN / Amlodipine

6. Conclusions BNP will help exclude heart failure ECG also useful in excluding CHF - can use this for triage Intermediate BNP levels can be found in CHF/IHD/ACS, treated CHF with non- cardiac cause of dyspnoea or non-CHF with non-cardiac cause of dyspnoea including PE and pneumonia Echocardiography for definitive diagnosis BNP and open access echocardiography now available for primary care in Guildford