Heart Failure – Chronic Management

FROM: National Heart Foundation of Australia and Cardiac Society of Australia andNew Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018 https://www.heartlungcirc.org/article/S1443-9506(18)31777-3/fulltext

Pharmacological Management of Chronic Heart Failure

Heart Failure With Reduced Left Ventricular Ejection Fraction (HFrEF)

Medications Recommended in All Patients:

1. Angiotensin-Converting Enzyme (ACE) Inhibitors:
   • Indication: All patients with HFrEF with LVEF ≤ 40%, unless contraindicated or not tolerated.
   • Benefits: Decrease mortality and hospitalization.
   • Examples: Enalapril, Lisinopril, Ramipril.
   • Dosing: Start at low doses, uptitrate every two weeks to target or maximum tolerated dose.
   • Monitoring: Blood pressure, renal function, potassium levels at 1–2 weeks after initiation and dose escalation, then every 6 months.
   • Precautions: Contraindicated with ARNIs within 36 hours due to the risk of angioedema.
   • Common Side Effects: Cough, hyperkalemia, renal impairment, hypotension.
   • Management of Side Effects: Switch to ARB if ACE inhibitor-induced cough; adjust dose if renal function declines significantly or hyperkalemia occurs.
2. Beta Blockers:
   • Indication: All patients with HFrEF with LVEF ≤ 40%, once clinically stable and euvolaemic.
   • Benefits: Decrease mortality and hospitalization.
   • Specific Agents: Bisoprolol, Carvedilol, Metoprolol (controlled/extended release), Nebivolol.
   • Dosing: Start at low doses, uptitrate every 2–4 weeks to target or maximum tolerated dose.
   • Monitoring: Heart rate, blood pressure, clinical evaluation of volume status at 1–2 weeks after initiation and dose escalation, then every 6 months.
   • Precautions: Ensure the patient is euvolaemic; contraindicated in patients with significant bradycardia or heart block.
   • Common Side Effects: Bradycardia, hypotension, worsening heart failure.
   • Management of Side Effects: Adjust or reduce dose if symptomatic bradycardia or hypotension occurs; consider increasing diuretic dose if congestion increases.
3. Mineralocorticoid Receptor Antagonists (MRAs):
   • Indication: All patients with HFrEF with LVEF ≤ 40%, unless contraindicated or not tolerated.
   • Benefits: Decrease mortality and hospitalization for heart failure.
   • Examples: Spironolactone, Eplerenone.
   • Dosing: Start with 25 mg daily, uptitrate to 50 mg daily as tolerated.
   • Monitoring: Renal function, potassium levels at 1–2 weeks after initiation and dose escalation, then every 4 weeks for 12 weeks, at 6 months, then every 6 months.
   • Precautions: Avoid in patients with severe renal impairment or hyperkalemia.
   • Common Side Effects: Hyperkalemia, renal impairment, gynecomastia (with spironolactone).
   • Management of Side Effects: Adjust dose if significant hyperkalemia or renal impairment occurs; switch to eplerenone if gynecomastia occurs.

Medications Recommended in Selected Patients:

1. Diuretics:
   • Indication: Patients with heart failure and clinical symptoms or signs of congestion.
   • Benefits: Improve symptoms and manage congestion.
   • Examples: Furosemide (20–40 mg daily), Bumetanide (0.5–1.0 mg daily).
   • Dosing: Start at low doses, adjust according to clinical response.
   • Monitoring: Volume status, renal function, electrolytes at 1–2 weeks after initiation, then every 6 months.
   • Common Side Effects: Electrolyte imbalance, renal impairment.
   • Management of Side Effects: Adjust dose based on volume status and electrolyte levels.
2. Angiotensin Receptor Blockers (ARBs):
   • Indication: Patients with HFrEF with LVEF ≤ 40% if ACE inhibitors are contraindicated or not tolerated.
   • Benefits: Decrease cardiovascular mortality and hospitalization.
   • Examples: Candesartan, Valsartan.
   • Dosing: Start at low doses, uptitrate every 2 weeks to target or maximum tolerated dose.
   • Monitoring: Blood pressure, renal function, potassium levels at 1–2 weeks after initiation and dose escalation, then every 6 months.
   • Common Side Effects: Hyperkalemia, renal impairment, hypotension.
   • Management of Side Effects: Adjust dose if significant hyperkalemia or renal impairment occurs.
3. Angiotensin Receptor Neprilysin Inhibitor (ARNI):
   • Indication: Patients with HFrEF with LVEF ≤ 40% despite maximally tolerated doses of ACE inhibitors or ARBs and beta blockers.
   • Benefits: Decrease mortality and hospitalization.
   • Example: Sacubitril-valsartan.
   • Dosing: Start at low or moderate doses, uptitrate every 2–4 weeks to target or maximum tolerated dose.
   • Monitoring: Blood pressure, renal function, potassium levels at 1–2 weeks after initiation and dose escalation, then every 6 months.
   • Precautions: Ensure ACE inhibitors are stopped at least 36 hours before starting ARNI.
   • Common Side Effects: Hypotension, hyperkalemia, renal impairment, angioedema.
   • Management of Side Effects: Adjust dose if significant hypotension, hyperkalemia, or renal impairment occurs.
4. Ivabradine:
   • Indication: Patients with HFrEF with LVEF ≤ 35% and sinus rate ≥ 70 bpm despite maximally tolerated doses of ACE inhibitors or ARBs and beta blockers.
   • Benefits: Decrease cardiovascular mortality and hospitalization.
   • Dosing: Start at 2.5–5.0 mg twice daily, uptitrate to 7.5 mg twice daily as tolerated.
   • Monitoring: Heart rate at 1–2 weeks after initiation and dose escalation, then every 6 months.
   • Common Side Effects: Bradycardia, visual disturbances (phosphenes).
   • Management of Side Effects: Adjust dose if symptomatic bradycardia occurs; cease if persistent or permanent atrial fibrillation develops.
5. Hydralazine Plus Nitrates:
   • Indication: Patients with HFrEF if ACE inhibitors and ARBs are contraindicated or not tolerated.
   • Benefits: Decrease mortality.
   • Dosing: Start with low doses (Hydralazine 25 mg three times daily, Isosorbide dinitrate 20 mg three times daily), uptitrate to target doses (Hydralazine 50–75 mg three times daily, Isosorbide dinitrate 60 mg three times daily).
   • Monitoring: Blood pressure at 1–2 weeks after initiation and dose escalation, then every 6 months.
   • Common Side Effects: Hypotension, headache.
   • Management of Side Effects: Adjust dose if significant hypotension occurs.
6. Digoxin:
   • Indication: Patients with HFrEF and moderate to severe symptoms despite maximally tolerated doses of ACE inhibitors or ARBs, beta blockers, and MRAs.
   • Benefits: Decrease hospitalization for heart failure.
   • Dosing: Start with low doses (≤0.125 mg daily).
   • Monitoring: Digoxin levels after 4 weeks (aim for 0.5–0.9 ng/mL), renal function.
   • Common Side Effects: Digoxin toxicity, renal impairment.
   • Management of Side Effects: Adjust dose based on renal function and digoxin levels.
7. Nutraceuticals:
   • Indication: Patients with persistent HFrEF despite best-practice treatment.
   • Example: N-3 polyunsaturated fatty acids.
   • Benefits: Modestly decrease mortality and cardiovascular hospitalization.
   • Dosing: 850–882 mg eicosapentaenoic acid and docosahexaenoic acid daily.
   • Monitoring: Standard follow-up as part of comprehensive heart failure management.

Heart Failure With Preserved Left Ventricular Ejection Fraction (HFpEF)

• Diuretics:
  • Indication: Manage congestion.
  • Preferred Agents: Loop diuretics (e.g., Furosemide).
  • Alternative: Thiazide diuretics if hypertensive.
  • Dosing: Adjust based on clinical response.
• Management of Comorbidities:
  • Conditions: Hypertension, ischemic heart disease, diabetes, atrial fibrillation.
  • Approach: Identify and actively manage.
• Neurohormonal Antagonists:
  • Indication: Often used to manage comorbidities.
  • Agent: Low-dose spironolactone.
  • Benefits: May decrease hospitalizations for heart failure.
• Specialized Care:
  • Indication: Infiltrative cardiomyopathies (e.g., cardiac amyloidosis).
  • Approach: Referral to specialized centers.

Non-Pharmacological Management of Heart Failure

Effective long-term management of heart failure involves non-pharmacological strategies to reduce hospitalisation and improve survival. These strategies help manage multiple comorbidities and polypharmacy, optimizing care across primary, hospital, and community settings.

Systems of Care to Reduce Rehospitalisation

• Rationale:
  • Systems of care (e.g., disease-management programs, telemonitoring, nurse practitioners, medication titration clinics) improve service delivery.
  • Studies show reduced mortality in collaborative care models (GP/general physician and cardiologist) compared to GP/general physician alone.
  • Dedicated heart failure units significantly reduce mortality and rehospitalisation.
  • Meta-analysis indicates heart failure care pathways reduce rehospitalisation and in-hospital mortality.
• Practice Advice:
  • Develop collaborative care models involving GPs, heart failure nurses, and specialist physicians.
  • Implement systems of care with a multidisciplinary heart failure specialist team and the patient’s GP.

Models of Care to Improve Evidence-Based Practice

• Two Main Models:
  1. Multidisciplinary Heart Failure Disease Management Programs and Telemonitoring:
     • Recommended for high-risk patients to decrease mortality and rehospitalisation.
     • Includes frequent home visits, telemonitoring, and telephone support.
     • Proven to significantly reduce mortality and rehospitalisation.
  2. Nurse-led Titration Clinics:
     • Recommended for patients with HFrEF to achieve maximum tolerated doses of key medications.
     • Effective in reducing rehospitalisation and mortality.
• Practice Advice:
  • Implement multidisciplinary heart failure programs with a specialist team.
  • Use telemonitoring and telephone support systems with comprehensive alert systems.
  • Focus on high-risk patients, especially those recently discharged from hospital.
  • Establish nurse-led medication titration clinics supported by cardiologists or specialist physicians.

Non-pharmacological Heart Failure Management and Multimorbidity

• Adjust management strategies based on patient values, preferences, and goals.
• Focus on education, multidisciplinary care, and individualized management plans.
• Consider frequent monitoring during periods of instability or medication optimization.

Frequency of Follow-up

• Early follow-up post-hospital discharge is crucial to identify potential issues and prevent early exacerbation of heart failure.
• Prospective studies suggest follow-up within 7–10 days post-discharge reduces rehospitalisation.
• Practice Advice:
  • Review patients within the first 7–14 days post-discharge.
  • Frequency of appointments should be guided by clinical stability.

Self-management

• Recommendation: Educate patients and carers about heart failure self-management to decrease hospitalisation and mortality.
• Key Components:
  • Medication adherence.
  • Symptom monitoring.
  • Collaboration with health professionals.
• Practice Advice:
  • Begin education soon after diagnosis, tailored to the patient’s health literacy.
  • Provide continuous education throughout the patient’s life.
  • Use resources from the National Heart Foundation of Australia.

Fluid Restriction and Daily Weighing

• Rationale: Volume management through fluid restriction and daily weighing helps manage congestion.
• Evidence: Mixed results on the effectiveness of fluid restriction; however, daily weighing is important for monitoring fluid accumulation.
• Practice Advice:
  • Consider fluid restriction (1.5 L/day) for patients with overt congestion.
  • Advise patients to see their GP if weight increases by 2 kg over 2 days.
  • Use a sliding scale of diuretics for competent patients.

Sodium Intake

• Current Advice: Apply the NHFA general population recommendation of <2 g/day sodium intake.
• Practice Advice: Refer to a dietitian for individualized low sodium diet strategies.

Exercise Training and Heart Failure

• Recommendation: Regular moderate-intensity exercise is recommended for stable chronic heart failure patients, particularly those with reduced LVEF, to improve physical function, quality of life, and reduce hospitalisation.
• Practice Advice:
  • Encourage continuous endurance training, with additional resistance training for muscle strength.
  • Tailor exercise programs to the patient’s clinical stability and response.