ACUTE HEART FAILURE

Symptoms and signs

• Breathlessness
• Swelling of feet and ankles
• Orthopnoea
• Paroxysmal nocturnal dyspnoea
• Wheeze
• Tachycardia
• Hypertension/hypotension
• Raised jugular venous pressure (JVP)
• Gallop rhythm
• Valvular heart disease – murmur
• Peripheral oedema
• Pulmonary oedema – crackles on chest auscultation
• Hepatic congestion – hepatomegaly, ascites

Differential diagnosis

• Chronic obstructive pulmonary disease (COPD)
• Acute severe asthma
• Pneumonia
• Pulmonary embolism
• Interstitial lung disease
• Anaemia
• Dependent oedema resulting from immobility
• Renal failure/nephrotic syndrome
• Cirrhosis

• Chest X-ray – other causes of SOBOE
• ECG – useful for rate, rhythm or dynamic ischaemic abnormalities
• FBC – exclude anaemia as a cause of symptoms
• U&E, LFT, Troponin I, TSH, glucose and fasting serum lipids
• If patient has dyspnoea at rest or severe pulmonary oedema, arterial blood gases (ABG)

BNP (measure before echocardiogram)

• Measure serum natriuretic peptides (BNP or NT-proBNP) before referral for echocardiography
• If BNP (ng/L) < 100, heart failure unlikely. Explore alternative diagnosis
• If 400 > BNP (ng/L) > 100, heart failure possible if other causes of clinical presentation excluded. Proceed to Echocardiogram
• If BNP (ng/l) >400, heart failure likely. Proceed to Echocardiogram

Echocardiogram

• Request inpatient echocardiogram unless echocardiogram performed in last 6 months and no new or worsening symptoms (or murmur) since last echo

Identify cause(s)/trigger factor for current decompensation

Primary cardiac causes of heart failure

• ACS
• Valve disease
• Arrhythmia – including AF
• Cardiomyopathy
• Significant pericardial disease
• Diastolic dysfunction
• Pulmonary hypertension/primary right heart failure

Heart failure secondary to co-morbidity

• COPD
• Pneumonia
• Sepsis
• Anaemia
• Hypertension
• Renal failure
• Endocrine abnormalities (e.g. thyroid disease)
• Nutritional deficiencies
• Hypoventilatory syndromes including obesity, sleep apnoea and neuromuscular problems

• Treat probable heart failure
• manage symptoms, fluid and co-morbidities
• contact heart failure specialist nurses

Symptoms

• Nurse patient in sitting position in bed/chair
• If hypoxic, see Oxygen therapy in acutely hypoxaemic patients guideline

• If patient has congestive symptoms unresponsive to their admission dose of diuretics, give the equivalent 24 hr total diuretic dose or higher (up to 2 times usual dose) of furosemide by either a slow IV injection (as single or multiple doses) or 24 hr infusion.
• choice of repeated/single or continuous 24 hr regimen does not affect clinical outcome.
• give IV dose no faster than 4 mg/min to reduce risk of ototoxicity
• If patient never has been on diuretics, consider furosemide 40–80 mg by slow IV injection
• if no response within 20 min, repeat similar dose by slow IV injection
• in patients with severe renal dysfunction (CKD4-5), consider giving up to 500 mg over 24 hr by IV infusion

Aim of fluid management

• Aim to achieve >0.5 kg weight loss daily
• If not achieved and patient remains congested, either increase 24 hr total furosemide by 40–80 mg IV (to a maximum of 240 mg over 24 hr) or add a low dose of thiazide diuretic (e.g. 1.25–5 mg metolazone) as one-off single dose
• metolazone can induce massive diuresis. Monitor patients carefully to prevent hypovolaemia or electrolyte disturbance
• Continue until JVP normal before changing to maintenance oral dose to maintain stable ‘dry’ weight

• Optimise treatment of non-cardiac conditions responsible for or contributing to heart failure
• If in new atrial fibrillation with rapid ventricular rate, add digoxin – see Digoxin guideline
• Contact heart failure specialist nurses for advice

Acute pulmonary oedema and cardiogenic shock

• Cardiogenic shock is defined as a BP falling to below 90 mmHg systolic with evidence of hypoxia, poor end organ perfusion including urine output below 0.5 mL/kg/hr
• Contact cardiology for help with:
• symptoms and cause
• whether patient is candidate for circulatory support (e.g. dobutamine), – see Dobutamine hydrochloride guideline, intra-aortic balloon pump (e.g. in patients suitable for revascularisation, who have reversible causes of heart failure or who are potential candidates for heart transplantation)

Specific treatments

• In specific situations (e.g. coronary ischaemia, severe aortic or mitral regurgitation, hypertension), consider IV glyceryl trinitrate (GTN). Initiate in a ward familiar with its monitoring and titration – see Glyceryl trinitrate guideline
• if GTN alone is not effective in lowering diastolic BP to <110 mmHg, consider alternatives – see Accelerated (malignant) hypertension guideline
• Do not routinely give opioids, but use with caution for specific indications such as pain or anxiety
• e.g. diamorphine 5 mg (1.25–2.5 mg in elderly or frail patients, or if serum creatinine >300 µmol/L) by slow IV injection (1 mg/min)
• Consider ventilation (invasive or non-invasive) if a person has cardiogenic pulmonary oedema with severe breathlessness and acidosis
• failure to respond to therapy
• a background of known significant lung disease
• reduced consciousness or physical exhaustion
• Treat cardiac arrhythmias aggressively – see Cardiac arrhythmias guideline
• Assess venous thromboembolism (VTE) risk and prescribe prophylactic low-molecular-weight heparin accordingly – see Prophylaxis against venous thromboembolism guideline

Refractory heart failure or probable heart failure with worsening renal function

• Remember that cause of persistent peripheral oedema, especially in the elderly, can be multi-factorial and does not always reflect fluid status
• If resistant to treatment, seek advice on further management from cardiology team

• Pulse, BP and respiratory rate 4-hrly until no longer dyspnoeic at rest
• if patient unwell or while titrating up vasoactive drugs (e.g. nitrates, inotropes), measure vital signs more frequently than 4-hrly
• Weight and fluid balance daily
• U&E – daily/alternate days
• more frequent U&E required when titrating up diuretic or ACEI, and in higher risk patients
• Chest X-ray – repeat after 3 or 4 days to assess response if patient presented with LVF or significant pleural effusion

• Could patient have intensive heart failure management as outpatient or at home? If so (or if you are not sure) contact Ambulatory Heart Failure clinic to discuss

Inclusion criteria

• Possible/probable heart failure syndrome with ‘fluid overload’
• Patient preference is OPD care
• Patient able to attend daily to Ambulatory Heart Failure clinic if required
• None of the exclusion criteria apply

Exclusion criteria

• Cardiac cause mandating hospitalisation – ACS, haemodynamically unstable arrhythmia present or suspected as cause for presentation, cardiogenic shock, acute pulmonary oedema, severe acute valvular heart disease
• Need for greater supplemental oxygen than usual
• Other co-morbidity mandating hospitalisation
• Social circumstances or frailty do not permit daily visits to Ambulatory Heart Failure clinic

General advice

• Reduce salt intake (no added salt, avoid salty food)
• Avoid excessive fluid intake
• Smoking cessation

Heart failure with preserved [LV] ejection fraction

• If echo is absolutely normal, reconsider the diagnosis of heart failure
• Continue fluid and co-morbidity management
• Do not use ACEI/Beta-blockers/MRA-aldosterone antagonists in management of this mechanism of heart failure
• Optimise co-morbidities (e.g. hypertension, angina, renal function, AF rate control and thromboprophylaxis, diabetes, sleep apnoea, anaemia, BMI)
• if corpulmonale, optimise oxygenation
• if pulmonary hypertension unrelated to pre-existing lung disease, discuss with cardiology registrar
• if a restrictive cardiomyopathy such as amyloidosis suspected as underlying cause, discuss with cardiology registrar

Heart failure with reduced [LV] ejection fraction

• Continue fluid and co-morbidity management
• Consider ACEI/ARB, beta-blockers, Mineralocorticoid Receptor Antagonist (MRA) and complex device therapy

ACE inhibitor/ARB (usually first line medication before beta-blockers)

• Contraindications to starting ACEI/ARB
• patient taking valsartan/sacubitril (Entresto^®), a neprilysin/ARB combination
• critical aortic stenosis
• renal function severely impaired (eGFR 20 mL/min/1.73m²)
• bilateral renal artery stenosis
• prior allergic reaction
• In all other cases, introduce ACE inhibitor (ACEI) as soon as renal function stable and blood pressure sufficient for systemic perfusion – see Introduction of an angiotensin-converting enzyme (ACE) inhibitor guideline
• Raise dosage empirically every 2 days to maximal tolerated by time of discharge.
• In patients with any of systolic BP <90 mmHg, eGFR <30 mL/min/1.73m², serum potassium >5.0 mmol/L, the very elderly and renal artery stenosis suspected (e.g. symptoms/signs of peripheral vascular disease), proceed more slowly and by smaller dose increments
• If ACEI not tolerated because of cough, substitute ARB such as candesartan. Confirm cough not caused by pulmonary congestion before changing to candesartan
• In patients unsuitable for ACEI/ARB or with ongoing symptoms despite optimal ACEI/ARB and beta-blocker, consider hydralazine (25 mg 8-hrly) and isosorbide mononitrate/dinitrate (10–20 mg 8-hrly)

Beta-blockers

• Continue beta-blockers in patients admitted taking beta-blockers
• reduce dose in patients considered for inotropes or with bradycardias and heart failure
• Increase or initiate beta-blocker once patient is euvolaemic with heart rate >65/min and systolic BP >95 mmHg: start with low dose (e.g. bisoprolol 1.25 mg daily)
• if beta-blocker initiated or increased, ensure patient remains stable over next 48 hr as inpatient or refer to Ambulatory Heart Failure clinic for 48 hr of monitoring as outpatient

MRA-Aldosterone antagonists (eplerenone or spironolactone)

• Consider starting at a dose of 12.5–25 mg daily if:
• serum creatinine <220 μmol/L
• serum potassium <5.0 mmol/L

Complex device therapy

• For suitable patients on optimal medical treatment with an EF <35%, contact cardiology registrar re complex device therapy

• Patients with intractable symptoms and signs, whose life expectancy is likely to be <12 months
• Patients with persistent dyspnoea, nausea, vomiting, pain or depression, who are unsuitable for prognostic interventions and may be in the palliative phase of heart failure for ≥12 months
• Patients who want advice about terminal care planning/hospice care
• Some patients in palliative phase of heart failure may still benefit from aggressive active cardiac interventions (e.g. IV diuretics, IV inotropes, palliative angioplasty)
• If likely to die of pump failure within 6–12 months, consider to be in end-stage heart failure – highlight to GP for inclusion on Gold Standards Framework registry on discharge

Criteria for discharge

• Free from central and peripheral congestion (e.g. JVP normal or normalising, third heart sound resolved)
• Heart failure symptoms minimised, maximally decongested
• Renal function stable

Preparation for discharge

• Mobilise once dyspnoea at rest subsides – prolonged bed rest is counterproductive
• Encourage patient to exercise as much as possible
• Ensure patients see heart failure nurse pre-discharge and given red amber green traffic light self management plan
• Ensure all patients referred to cardiac rehab service
• Ensure all patients referred to community heart failure nurses
• Stop dalteparin on day before discharge

Discharge letter should include

• Confirmation of diagnosis of heart failure and evidence of cardiac dysfunction and aetiology of cardiac dysfunction. If aetiology unknown, investigations to determine aetiology or statement that aetiology will not influence future management
• Cause of current deterioration and subsequent inpatient treatment
• Current and planned pharmacological treatment
• Relevant co-morbidities and management plans
• Request to monitor U&E at 1–2 weeks and then after 1 month
• Whether patient referred as an outpatient or seen as an inpatient by heart failure nurses, cardiologist or palliative care team
• If patient has LVSD – who will review after titration of medications by heart failure nurses (i.e. details of follow-up for community heart failure nurses)
• Plan of action should patient deteriorate during or after titration