SECONDARY CARE HEART FAILURE SERVICE GUIDELINES (2011)

WALSALL HOSPITALS NHS TRUST SECONDARY CARE HEART FAILURE SERVICE GUIDELINES (2011) The Heart Failure Service is provided by nurses and doctors who specialise in heart failure. Their role is to provide a systematic approach to the management of patients presenting to the Acute Hospital Trust with a confirmed clinical diagnosis of left ventricular systolic dysfunction (LVSD). The Heart Failure Nurse Specialists (HFNS) educate, advise, support and counsel patients with heart failure and their relatives. Nursing staff in the service work closely with their colleagues in Primary Care to improve the management of patients with chronic heart failure, to reduce unnecessary hospital re-admission and to provide seamless care between primary and secondary care. Inpatients are seen by the Cardiologist or Staff Grade and one of the HFNS. The Heart Failure Service is supported by an administrator. The Heart Failure Team members (secondary care) are: Clinical Lead: Staff Grade in Cardiology: HFNS (full-time): Cardiac Nurse (part-time): Cardiac Rehab Nurse Specialist (in absence of HFNS): Administrator: Dr J Gupta, Consultant Cardiologist Tina Fletcher Tina Larcombe Harry Madhar Sarah Page The service operates during office hours Monday to Friday and the Heart Failure Nurse Specialists can be contacted on the following numbers: Extension 7860 Bleep 8106 Extension 6406 or fax 6633 (administrator) Extension 7240 and fax 6738 (when no-one available on 7860) The role of the HFNS is to potentially see all patients who are given a diagnosis of LVSD. All of these patients need to have an echocardiogram unless they have had one recently. Patients will be seen by the HFNS following their echocardiogram and given an assessment if the echocardiogram proves that they have systolic dysfunction. An echocardiogram MUST state mild / moderate / severe or significant systolic dysfunction or have comments about the LV having poor contractility (varying degrees) in order to fit the criteria. If the patient does not have LVSD but you feel that the Heart Failure Team would benefit from knowing about them then please make a referral to the Cardiologists. The Heart Failure Nurse Specialists are available to educate and advise the nursing team. Please find a list of common questions and answers below: 1. What is the purpose of the Heart Failure Team? To assess all patients with left ventricular systolic dysfunction (LVSD) To encourage use of the inpatient heart failure treatment guidelines (based on NSF 2000 and NICE 2003) to help: o o o o Initiate and optimise medical treatment (if required) To provide health education/promotion for patients and carers Reduce length of stay Prevent re-admissions 2. Who attends the Heart Failure Clinic? Patients who are suitable for starting betablockers or are for future titration Patients with worsening heart failure (urgent slots) 3. Who will see the Community Cardiac Nurses? PLEASE REFER TO COMMUNITY PATHWAY 1

4. Who decides and makes the referrals to the Clinic and Community Team? The Heart Failure Team and the Cardiac Rehabilitation Nurse Specialist/Post MI Clinic decide which patients are suitable for the Clinic and Community Team, and organise all of the appointments 5. How can you help the Heart Failure Team to maintain a high level of service? Refer all patients with LVSD to the team (including re-admissions even if they have been admitted for other reasons) Ensure all patients have strict daily weights Ensure all patients have regular U&E checks Titrate their ACE inhibitor while an in-patient if possible This document includes the patient journey through the Open Access Systolic Insufficiency Service (OASIS), as an inpatient, and through the Heart Failure Clinic. The Community Pathway will be discussed separately. CONTENTS Topic Page Introduction 4 OASIS 4 Out of hospital referrals 5 In-hospital referrals 5 Inpatient assessment 5 Discharge information 7 Referral to Heart Failure Clinic 9 Support 11 Nurse-led Heart Failure Clinic 12 Medicines 12 - ACE Inhibitor 14 - A2 16 - Betablocker 18 - Diuretic 19 - Spironolactone 20 - Metolazone 21 - Eplerenone 22 - Digoxin 23 - Hydralazine and Isosorbide Dinitrate 25 Lifestyle advice 28 Inpatient Heart Failure Guidelines 29 Walsall Cardiac Rehabilitation Trust Heart Failure Protocol 33 Tests and Investigations 35 - Transoesophageal echocardiography 35 - Stress echocardiography 35 - Exercise testing 35 - Ambulatory ECG monitoring 35 Further management in chronic heart failure 36 - CRT 36 - ICD 36 - Cardiac transplantation 37 - Coronary revascularisation 37 - AF 37 - Elderly 37 Major co-morbidities that impact on the management of heart failure 38 End of Life (EOL) 39 Criteria for using Palliative Care Guidelines 40 Heart Failure Advanced Care Plan 41 References 43 2

1. Introduction This guideline outlines the Heart Failure Service for patients going through the OASIS service, as an inpatient, and through the Heart Failure Clinic. The service cares for patients following a confirmed diagnosis of LVSD. All cardiac nurses are responsible for implementing the heart failure guidelines as produced by NICE. The HFNS implements a management plan of care for each hospital admission. The discharged patient is then followed up by four Community Cardiac Nurses (CCN), as deemed appropriate by the community cardiac pathway. 2. OASIS 2.1 GPs refer patients to the OASIS service using an OASIS referral form if they suspect heart failure symptoms and meet at least one of the following criteria: BNP > 400 (GPs can now request this blood test - cut-off level being reviewed) Atrial fibrillation Murmur Valvular problems Abnormal ECG 2.2 The patient receives an appointment for the OASIS clinic and an echocardiogram is performed. 2.3 An echocardiography technician reviews the scan and writes a simplified report which is sent to the GP, with details of whether the patient has been referred to the Heart Failure Clinic (if patient has left ventricular systolic dysfunction), Cardiology Clinic (if there are other cardiac problems) or back to the GP, depending on the findings of the scan. 3. Out of hospital referrals are accepted from healthcare professionals for patients with proven systolic heart failure for optimising treatment, further investigation or counselling. These patients are often brought to the nurse-led Heart Failure Clinic, which is held weekly. 4. Referral (in hospital) 4.1 Patients with symptoms and signs of heart failure should have some objective evidence of ventricular dysfunction (X-Ray, Consistent ECG, Raised NT-pro BNP) can be requested to have an echo (similar to the OASIS). Though heart failure with preserved or relatively preserved LV dysfunction is common we would at present seek to confine the Service to confirmed LV systolic dysfunction (where there is good evidence based treatment). We will in the future develop the service to address this other group of patients. In the meantime the referral should be addressed to General Cardiology who will attempt to contribute to further evaluation and treatment. 4.2 Patients known to have heart failure with LV systolic dysfunction may be referred from Integrated Assessment Unit (IAU) directly to the HFNS during her daily visit. Other areas of the hospital can make such direct referrals to the HFNS by phone if systolic heart failure has been confirmed. (Extension 7860 - message left on answerphone if HFNS 3

not available. Alternatively, a member of the team can be contacted via bleep number 8106.) 4.3 If heart failure is associated with preserved LV function then they should not be referred directly to the HFNS. Cardiologists would be happy to take such referrals. 5. Inpatient assessment 5.1 All patients diagnosed with heart failure on echocardiogram will be seen by a member of the Heart Failure Team. 5.2 A hospital inpatient will be formally introduced by a member of the Heart Failure Team and given an introduction sheet (appendix I) explaining the service and an outline of objectives for the interview. It gives an opportunity for the patient to have a relative/friend participate in the interview. An appointment time may be given. 5.3 Information and advice will be given on: Diagnosis and treatment Explanation of heart failure Coping with/adjusting to a chronic disease Prognosis Healthy eating Smoking cessation Safe alcohol levels Daily weights Occupation Sick notes if applicable Employment Retention Officer Holidays Driving Exercise Sexual advice Psychological assessment including Hospital Anxiety/Depression scale (HADS) Management of further symptoms and importance of calling for emergency help Follow-up investigations and clinic appointments Contact details of HFNS and CCN Other agencies/support network A CD will be offered to reinforce advice 5.4 Information will be given on an individual basis and tailored to suit each patient. Facilities will be made available for a key family member to be present if requested. However, if this is not convenient, arrangements will be made to speak at a later stage. 5.5 Baseline bloods are checked (FBC, U&Es, LFTs, BS, TFTs and lipid profile) and repeated when necessary. 5.6 Each patient is given a heart failure pack with contact details to refer to if necessary. 5.7 All patients are made aware of when to seek help and who to call. 5.8 All patients are encouraged to weigh themselves daily and report to the doctor/cardiac nurse if their weight goes up by 3lb or 1kg over three days (they are made aware of what the implications of this may be). They are advised to telephone the HFNS or CCN when there is a problem. 5.9 All patients will have already had an echocardiogram. Repeat tests are only required if there has been a significant change in clinical condition 4

5.10 An outline of the information and advice will be entered in the medical notes with the date, time and signature of the nurse who has carried out the assessment. 5.11 All cardiac nurses ensure heart failure patients are prescribed the Gold Standard medication, provided there are no contra-indications, according to National Service Framework (NSF) guidelines, i.e. ACE inhibitor, betablocker, diuretic if fluid overloaded and Spironolactone if appropriate. 5.12 The HFNS will hold a paper record of the information gathered from the assessment. This will be entered onto the computer database via the FUSION system by the HFNS or CHD Administrator. 5.13 Appropriate referrals will be made if required. This may include referrals to any of the multi-disciplinary team. Such referrals may include social services, occupational therapy, dietician, diabetic team, smoking cessation, physiotherapy or clinical psychologist. 5.14 Patients will usually be reviewed on the weekly heart failure ward round with either the Cardiologist or Staff Grade. The HFNS will review the patients on other days and this may be on a daily basis if they are unstable or less frequently if they are stable. 5.15 The HFNS will review medications and biochemistry and assess symptoms/daily weights at each visit. 5.16 The HFNS will either prescribe appropriate treatments or make recommendations based on NICE/NSF guidelines. 5.17 The HFNS will order appropriate blood tests or other tests where required. 6. Discharge information 6.1 All patients will be reviewed prior to discharge and given information regarding their follow-up. This will include: An appointment for the Heart Failure Clinic is made if they are appropriate for betablocker titration or require further titration or discussion on other investigations or treatment. If the patient lives in the Walsall borough a referral will be made to the Community Cardiac Nurse. Potential unstable patients will have a referral to both the Heart Failure Clinic and the CCN. If the patient is stable and booked for Heart Failure Clinic they will receive a one week follow-up telephone call from the HFNS. Out of area patients (OOA) will either receive a nurse-led Heart Failure Clinic appointment (runs weekly on Thursday afternoon) or will be referred to the Heart Failure Service in their area. Some patients will receive no follow-up if they are asymptomatic but are given contact details so they can ring the Heart Failure Service if they have any concerns or questions. A pathology form is given to each patient on discharge from hospital to have U&Es repeated if appropriate and the reason for this is explained to them. 5

6.2 These details are held on the FUSION database and in the appointments folder. The follow-up details will be included in the discharge letter which is filed in the medical notes. 6.3 Patients are informed that they will be contacted within seven working days of their discharge by the CCN or HFNS. Discharge information is faxed to the CCN on 01922 724126 either on the day of discharge or the next working day when this is not possible. A receipt for this fax is kept with the patient s paper record. An audit of faxed details is logged and faxed to the CCN at the end of every month. 6.4 If a patient is a smoker they are referred to the Smoking Cessation Service if they are in agreement with this. They are informed that a member of the Smoking Cessation Team will contact them. 6.5 All patients are given the contact details of the CCN and HFNS offices and are invited to ring them for any advice or further appointments. However, it will be made clear that this contact number should not be used to report symptoms of chest pain or acute shortness of breath. This information is given and reinforced. 6.6 A discharge summary letter generated from the FUSION database gives details of the patient s admission/discharge dates, the reason for admission, discharge medication and follow-up appointments. This is faxed to the CCN office and sent by courier post to their GP. A copy is filed in the patient s medical notes and another is kept with the paper record in the HFNS office. All written assessment details and correspondence is archived and stored according to Caldicott guidelines. 6.7 A monthly audit of heart failure patients can be extracted from the FUSION database. 7 Referral to Heart Failure Clinic The aim of the Heart Failure Clinic is to assess all patients with LVSD and to optimise their heart failure medications. On rare occasions patients without LVSD but who have symptomatic heart failure may be seen in the Heart Failure Clinic at the discretion of the Heart Failure Team but only when it is believed that this service may be of value to the patient. 7.1 The patient will make an average of five visits to the Heart Failure Clinic. 7.2 A new patient will be reviewed by the HFNS or CCN for health education and advice. Following this they will see the Cardiologist for assessment of initiation of betablockers or other medications. 7.3 If a Post MI patient is complicated with heart failure they may be referred to the Heart Failure Clinic rather than Post MI clinic to review medication and symptoms. 7.4 Patients attending for follow-up appointments will see the HFNS or CCN and then the Staff Grade. 7.5 If a patient attending for a follow-up appointment is stable they may only need to see the HFNS or CCN for medication titration. 7.6 The patient s GP will receive a letter after each visit stating any changes to medication. 7.7 Patients will receive follow-up every 2 weeks for possible further medication titration before being discharged. Where appropriate, patients may be referred for biventricular pacing (CRT) i.e. patients with NYHA III and IV heart failure. According to NICE, Cardiac Resynchronisation Therapy (CRT) with a pacing device (CRT-P) is recommended as a treatment option for people with heart failure who fulfil all the following criteria: 6

They are currently experiencing or have recently experienced New York Heart Association (NYHA) class III-IV symptoms. They are in sinus rhythm: - either with a QRS duration of 150 ms or longer estimated by standard electrocardiogram (ECG) - or with a QRS duration of 120-149 ms estimated by ECG and mechanical dyssynchrony that is confirmed by echocardiography They have a left ventricular ejection fraction of 35% or less They are receiving optimal pharmacological therapy. Cardiac resynchronisation therapy with a defibrillator device (CRT-D) may be considered for people who fulfil the criteria for implantation of a CRT-P device as previously detailed and who also separately fulfil the criteria for the use of an ICD device as recommended in NICE technology appraisal guidance 95. Likewise, patients with recurring cardiac pain may require referral for angiography or other revascularisation procedures. Patients with atrial fibrillation will be considered for anticoagulation and cardioversion or other appropriate treatments. CRITERIA FOR DISCHARGE: Stable heart failure symptoms, fully optimised medication, consideration for relevant referrals e.g. exercise rehabilitation, other consultants or tertiary centres. 7.8 When discharged from the Heart Failure Clinic patients living in the Walsall borough will be referred to the CCN, who will contact them two weeks after discharge and thereafter on an individualised basis according to the Community Pathway. 7.9 Patients discharged from the Heart Failure Clinic who live outside the Walsall borough will be offered further follow-up in the nurse-led Heart Failure Clinic or referral to the Heart Failure Service in their area. 7.10 Patients in NYHA I and II may be offered nurse-led Heart Failure Clinic follow-up if there condition is stable and they do not require a home visit. 7.11 Some patients will require further follow-up in the regular cardiology clinic. These would typically be patients with valvular problems or cardiological problems other than heart failure. Therefore, all patients discharged from the Heart Failure Clinic do not routinely require cardiology clinic follow-up. 7.12 A small number of patients will be offered a referral to Heart Care for exercise rehabilitation if appropriate. 7.13 New routine (NRT) Clinic appointments are made by the CHD Administrator only. 7.14 U&Es are checked every four weeks whilst attending the Heart Failure Clinic or more frequently if required. 7.15 Hb is checked every six months. A paper proforma is completed at each visit, which will be entered onto the FUSION database when LIVE. 7.16 Consider referral for Cardiac Rehabilitation (see appendix 1) 8. Support 8.1 All patients are encouraged to contact the HFNS or CCN for any help or advice. 7

8.2 Contact details of the HFNS and CCN are provided and family support group details are made available within the heart failure pack. 8.3 Patients may be given advice regarding exercise at home or referred to the community exercise team if appropriate. 8.4 Patients are made aware of the Heart Care Family Support Group, a patient-led group offering support and encouragement to anyone who has suffered heart problems. The group meets on the third Thursday of every month at Gorway Cricket Club. Regular guest speakers and events are organised. 8.5 Expert Patient Programme is offered and information regarding this is within their information pack. 9. Nurse-led Heart Failure Clinic 9.1 This is attended by: Patients discharged from hospital who live outside the Walsall area Patients discharged from the Heart Failure Clinic who live outside the Walsall area Patients who live outside the Walsall area who are referred to the service from other Consultants or have been through the OASIS service and also missed inpatients (for pre-assessment) 9.2 The nurse-led clinic runs weekly on Thursday afternoons alongside the cardiology clinic. If there are concerns about the patient the HFNS can discuss these with the Consultant, Staff Grade or Registrar. 9.3 Usually only patients in NYHA Classes I and II are seen. Patients in NYHA Class III will be seen if they live outside the Walsall area and no other follow-up is available. 9.4 Biochemistry is checked where necessary. Other tests and investigations are also requested where required. 9.5 A paper proforma is completed at each visit and will, in future, be entered onto the FUSION database when LIVE. 9.6 A letter is sent to the patient s GP after each visit. 10. Medicines Gold standard treatment according to NICE 2003 is recommended. Diuretics are given if there are any signs of fluid overload. ACE inhibitors are first line treatment and then Betablockers are considered unless contraindicated e.g. asthma. Efforts are made to distinguish true beta-blocker intolerance. Spironolactone is considered if severe heart failure (NYHA III or IV) or readmissions (1 st line aldosterone antagonist). Eplerenone is considered in post-mi heart failure or if Spironolactone causes gynaecomastia. Aspirin 75mg daily is given if there is underlying CHD. Simvastatin 40mg daily is considered if there is underlying CHD. 8

Anticoagulation is considered if there is either an underlying thrombus or atrial fibrillation. Calcium Antagonists are usually avoided in patients with LVSD, however Amlodipne can be considered in underlying hypertension. 10.1 ACE inhibitors (see over) 10.2 A2 receptor blockers (see over) 10.3 Betablockers (see over) 10.4 Diuretics (see over) 10.5 Spironolactone (see over) 10.6 Metolazone (see over) 10.7 Eplerenone (see over) 10.8 Digoxin (see over) 10.9 Hydralazine and nitrates (see over) Management for the use of ACE Inhibitors- Acute & Chronic Heart Failure (confirmed LVSD) Ramipril is often preferred because of familiarity and relative ease in titration to target dose. Indications for Use: Confirmed LVSD on echocardiogram. Aims for Treatment: Relieve heart failure symptoms; improve prognosis. Exclusion Criteria: Hypersensitivity to ACE inhibitors including angioedema. Known or suspected reno-vascular disease, aortic stenosis, symptomatic hypotension, deteriorating or severe impairment of renal function and acute renal failure (creatinine >200umol/l and or potassium >5.5mmol/l ). Contra-indicated in pregnancy. Cautions: Initiate with care in patients receiving diuretics and or potassium supplements, risk of hypotension with first dose, peripheral vascular disease, stop NSAIDS. Double the dose at no less than two week intervals. 9

ACE inhibitor- Initiation/ Titration Initiation Increments Target Ramipril 1.25mg od 2.5mg then 5mg od 10mg od Lisinopril 2.5mg od 5mg then 10mg/20mg od 30-35mg od Enalapril 2.5mg od 5mg then 10mg od 20mg od Adverse Effects Advise patients to observe for any side effects following Ace Inhibitor initiation. Most commonly dry cough and dizziness may be noticed but frequently settle down. Symptomatic hypotension. If patients do have hypotension and dizziness look at other drugs e.g. calcium channel blockers withdraw if not required. 10

Monitoring Guidance Blood biochemistry should be checked pre-initiation of ACE. Patient s blood pressure, blood biochemistry, and symptoms should be reviewed within 2 weeks of initiation, following each titration and when target has been reached. Once the titration is complete blood biochemistry should be reviewed at 6 monthly intervals long term. Symptomatic hypotension can occur, particularly after the first dose. Advice can be offered to patients with regard to this and frequently a change in medication administration times varying them from other treatments will alleviate the problem. An intolerant cough may necessitate changing to an Angiotensin 2 receptor blocker. A small rise in biochemistry can be expected following initiation of an ace. However an increase in creatinine greater than 50% above baseline, or greater than 200umol/litre, and or an increase in potassium above 5.9mmol/ litre advice should be sought. Worsening renal function: Some rise in creatinine and K+ and fall in egfr is to be expected after initiation of an ACE inhibitor; if this change is small and asymptomatic no action is necessary Where egfr is simply reported as >60 ml/min/1.73m2 significant reductions in renal function may be inferred from a rise in serum creatinine concentration of >20%. If the fall in egfr after starting ACEI/ARB therapy or reaching the end of a dose titration of ACE and ARB is less than 25% of baseline e GFR should be rechecked in 4-6 weeks. If the fall in egfr remains less than 25% compared to baseline the ACEI/ARB dose does not need modifying If the fall in egfr exceeds 25% compared to baseline and the blood pressure is in the recommended range the dose of ACEI/ARB should be halved and other agents added to maintain blood pressure control, if required. If K+ rises excessively or e GFR falls excessively consider stopping concomitant nephrotoxic drugs (e.g. NSAIDs), non-essential vasodilators (e.g. calcium antagonists, nitrates), K+ supplements/retaining agents (triamterene) An increase in K+ to 5.9 mmol/litre is acceptable Blood electrolytes should be monitored closely until K+ and e GFR concentrations are stable 11

Management for the use of A2 Receptor Blockers- Acute & Chronic Heart Failure (confirmed LVSD) Indications for Use: Remain second-line for confirmed LVSD if ACE inhibitors have produced cough (note: despite theoretical absence of kinin promoting effects and therefore reduced chances of angioedema it is best to avoid prescribing A2RBs in documented angioedema Aims for Treatment: Relieve heart failure symptoms; improve longevity and exercise tolerance; to reduce the incidence of acute exacerbations. Exclusion Criteria: Hypersensitivity to A2 receptor blockers/ ACE inhibitors including angio-oedema. Symptomatic hypotension, hyperkalaemia, hepatic impairment, deteriorating or severe impairment of renal function and acute renal failure (creatinine >200umol/l and or potassium >5.5mmol/l ). Contra-indicated in pregnancy/lactation. Concomitant treatment with Lithium Cautions: Initiate with care in patients receiving diuretics and or potassium supplements or potassium sparing drugs, risk of hypotension with first dose, stop NSAIDS. Candesartan/Valsartan/ Losartan initiation and titration: Initiation Increments Target Candesartan 4mg od 8mg od 16mg od 32mg od Valsartan 20mg bd 40mg bd 80mg bd Losartan 25mg od 50mg od 100mg od Adverse Effects Advise patients to observe for any side effects following A2 Receptor blocker initiation. Most commonly hypotension, rashes, GI disturbances, headaches, fatigue,back pains, hyponatraemia, hyperkalaemia, epistaxis, thrombocytopenia, diarrhoea,neutropenia. Angio-oedema(discontinue) 12

Monitoring Guidance Blood biochemistry should be checked pre-initiation of A2 receptor blocker. Patient s blood pressure, blood biochemistry and symptoms should be reviewed within 1 week of initiation, following each titration and when target has been reached. Thereafter every 4 weeks for 3 months, then every 3 months for 1 year thereafter every 6 months. Symptomatic hypotension can occur, particularly after the first dose. Advice can be offered to patients with regard to this and frequently a change in medication administration times varying them from other treatments will alleviate the problem. A deterioration in renal biochemistry can be expected following initiation of an A2 receptor blocker (as in an ACE inhibitor). However, an increase in creatinine greater than 50% above baseline, or greater than 200umol/litre, and/or an increase in potassium above 5.9mmol/ litre advice should be sought. Worsening renal function: Some rise in creatinine and K+ and fall in egfr is to be expected after initiation of an ACE inhibitor; if this change is small and asymptomatic no action is necessary Where egfr is simply reported as >60 ml/min/1.73m2 significant reductions in renal function may be inferred from a rise in serum creatinine concentration of >20%. If the fall in egfr after starting ACEI/ARB therapy or reaching the end of a dose titration of ACE and ARB is less than 25% of baseline e GFR should be rechecked in 4-6 weeks. If the fall in egfr remains less than 25% compared to baseline the ACEI/ARB dose does not need modifying If the fall in egfr exceeds 25% compared to baseline and the blood pressure is in the recommended range the dose of ACEI/ARB should be halved and other agents added to maintain blood pressure control, if required. If K+ rises excessively or e GFR falls excessively consider stopping concomitant nephrotoxic drugs (e.g. NSAIDs), non-essential vasodilators (e.g. calcium antagonists, nitrates), K+ supplements/retaining agents (triamterene) An increase in K+ to 5.9 mmol/litre is acceptable Blood electrolytes should be monitored closely until K+ and e GFR concentrations are stable 13

Management for the use of Beta-blockers - Chronic Heart Failure (confirmed LVSD) Indications for Use: Confirmed LVSD on echocardiogram meeting the following criteria: Clinically stable for 2-4 weeks pre-initiation. Heart rate > 58bpm and resting BP>100 systolic, >60 diastolic. Aims for Treatment: Reduce mortality in any grade of stable heart failure. Exclusion Criteria: History of asthma or bronchospasm, acute or decompensating heart failure, prinz-metal angina, marked bradycardia, hypotension, sick-sinus syndrome, 2 nd or 3 rd degree AV block, severe peripheral arterial disease. Cautions: Initiation with caution in COPD, avoid abrupt withdrawal, portal hypertension, diabetes, myasthenia gravis, history of hypersensitivity, pregnancy, breast feeding, may reduce response to Adrenaline. Bisoprolol / Carvedilol/ Nebivolol- Initiation/ Titration Initiation Increments Target First line choice Bisoprolol 1.25mg od 2.5mg od, 3.75mg od, 5mg od, 7.5mg od 10mg daily Carvedilol 3.125mg bd to 6.25mg bd 25mg daily (with food) followed by 12.5mg bd (body weight <85kg) 50mg daily (body weight >85kg) Nebivolol 1.25mg od 2.5mg od, 3.75mg od, 5mg od, 7.5mg od 10mg OD (dose increments should be at least 2 weeks) Adverse Effects: Excessive bradycardia- heart rate < 50bpm. If symptomatic consider reducing dose or stopping treatment immediately. If asymptomatic revert to lower dose tolerated. Review medication and consider reducing or stopping other rate controlling drugs. Perform a 12 lead ECG to exclude heart block / sick sinus syndrome. Review within one week and reduce dose further if HR still below 50bpm (seek medical advice if necessary). Symptomatic Hypotension. Consider over-diuresis and whether a reduction in dosage of diuretic may improve matters- check renal function. Consider reducing or stopping other hypotensive causing drugs. Consider temporary reduction in ace inhibitor. If unresolved decrease or stop beta blocker. Worsening Heart failure symptoms Dyspnoea, weight gain, peripheral oedema Usually can be corrected by a temporary increase in diuretic- improvement should be seen in 2-3 days. If no improvement within 1 week consider reducing or stopping beta-blocker. BETABLOCKERS SHOULD NOT BE STOPPED ABRUPTLY UNLESS ABSOLUTELY NECESSARY. Monitoring Guidance Titration can be done over weeks / months according to patients response- aim to optimise on maximum tolerated dose. All symptoms including blood pressure, heart rate and heart failure status should be closely monitored and reviewed pre and post dose change. Renal function should be checked at least every four weeks, or two weekly if symptoms deteriorate, and two weeks following final dose increment. 14

Management for the use of Diuretics - Acute & Chronic Heart Failure (confirmed LVSD) Indications for Use: Evidence of pulmonary oedema, dyspnoea, raised jugular venous pressure (JVP), ascites and generalised oedema. Aims for Treatment: To achieve patients dry weight using the lowest therapeutic dose, whilst also optimising symptom control. Diuretic regimes can be flexible and negotiated to suit patient s needs in order to encourage concordance. Exclusion Criteria: Pre-comatose states associated with liver cirrhosis, renal failure with anuria. Signs of Clinical Deterioration: Daily weight increase >3Ib/1kg above dry weight, sustained over 2-3days. Increasing dyspnoea/ and or peripheral oedema. Dosing procedure as below. Furosemide(oral) Current Dose- Increase to 40mg od - 80mg od 80mg od - 120mg od 120mg - 160mg od Doses may be split between morning and lunchtime particularly at higher doses. For inpatients: if necessary give Frusemide IV 80mg bd or 250mg infusion / 24 hours. Cautions: Hypersensitivity, hypotension, hypovolaemia, hypo-proteinuria, hepatic and renal impairment, hepat-renal syndrome, prostatic enlargement, pregnancy and breast-feeding. Stable Heart Failure Symptoms: Daily weight<3ib/1kg below dry weight over 2-3 days or more. No signs of increasing dyspnoea or peripheral oedema. Down titration may be undertaken using a similar approach as when up titrating (Step-by-step). This may be indicated as above or if patients show signs of thirst, dizziness or of feeling washed out. Similarly if renal function starts to reflect a decline, down titration may be considered. Bumetanide (oral) Current Dose- Increase to 1mg od- 2mg od 2mg od- 3mg od 3mg od- 4mg od 4mg od- 5mg od. Additional Information Morning doses of diuretics can be postponed if patient is leaving the house. However doses are best not taken after 4pm to avoid passing urine during the night. Extra vigilance needs to be taken during periods of warm/ hot weather. If patients develop diarrhoea and vomiting there may be a risk of dehydration. Potential for non-specific symptoms occurring in the elderly patient; confusion, urinary incontinence, impaired mobility- falls. Monitoring Guidance Patient s symptoms should be reviewed within one week of any diuretic changes. Blood biochemistry should also be checked at this time and thereafter at regular intervals. Management for the use of Spironolactone- Acute & Chronic Heart Failure (confirmed LVSD) 15

Indications for Use: 1. Systolic heart failure with NYHA 3 or worse symptoms with diuretics and ACE Inhibitors. Beta blockers are usually coadministered (even though the evidence for spironolactone came from a trial before beta-blockers were used in heart failure) 2. Eplerenone is useful in post MI patients with signs/symptoms of HF with preserved renal function and electrolytes Aims for Treatment: Relieve heart failure symptoms; to reduce the incidence of acute exacerbations and mortality. Exclusion Criteria: Hypersensitivity to Spironolactone or excipients. Symptomatic hypotension, Addison s disease, hyperkalaemia, hyponatraemia, porphyria, hepatic impairment, deteriorating or severe impairment of renal function and acute renal failure (creatinine >200umol/l and or potassium >5.5mmol/l ). Contra-indicated in pregnancy/lactation Cautions: Initiate with care in patients receiving diuretics, Cyclosporin, Tacrolimus, Lithium, hormone antagonists (trilostane, aminoglutethimide). Stop potassium supplements, risk of hypotension with first dose, stop NSAIDS. Care with Aspirin. Dosage: Spironolactone 12.5mg can be initiated although 25mg is the usual dose and can be up-titrated to 50mg daily. Eplerenone is started at 25mg, up-titrated to 50 mg daily Adverse Effects Advise patients to observe for any side effects following initiation. Most commonly dizziness may be noticed but frequently settle down. Symptomatic hypotension. Gynaecomastia (consider reducing dose or change to Eplerenone) Hyperkalaemia (discontinue) Hyponatraemia (discontinue) Confusion Monitoring Guidance Blood biochemistry should be checked pre-initiation of Spironolactone. Patient s blood pressure, blood biochemistry and symptoms should be reviewed within 1 week of initiation. Thereafter every 4 weeks for 3 months, then every 3 months for 1 year thereafter every 6 months. Symptomatic hypotension can occur, particularly after the first dose. Advice can be offered to patients with regard to this and frequently a change in medication administration times varying them from other treatments will alleviate the problem. A small rise in biochemistry can be expected following initiation of an ACE. If potassium rises between 5.5 5.9 or creatinine rises to 200 or above reduce the dose to 25mg alternate days and close monitoring (according to NICE 2003). If potassium rises to 6.0 or above or creatinine rises to 200 or above then STOP SPIRONOLACTONE AND SEEK ADVICE. Patients must be aware of stopping the drug if developing acute episode of vomiting and or diarrhoea, due to the risk of dehydration. Worsening renal function: Check, electrolytes and e GFR at: 1, 4, 8 and 12 weeks; 6, 9 and 12 months; 6 monthly thereafter. If K+ rises to between 5.5 and 5.9 mmol/litre or e GFR falls to < 35 ml/min/1.73m reduce dose to 25 mg on alternate days and monitor blood chemistry closely If K+ rises to 6.0 mmol/litre or egfr < 35ml/min/1.73m stop Spironolactone and seek specialist advice Management for the use of Metolazone - Acute & Chronic Heart Failure (confirmed LVSD) 16

Indications for Use: Severe/ deteriorating heart failure. As an adjunct with loop diuretics for patients with persistent oedema /worsening symptoms. Aims for Treatment: To alleviate deteriorating heart failure symptoms. Exclusion Criteria: Refractory hypokalaemia, hyponatraemia, hypercalcaemia, severe renal and hepatic impairment, symptomatic hyperuricaemia, Addisons disease, porphyria. Cautions: Hypersensitivity, hypotension, hypovolaemia, hepatic and renal impairment, pregnancy and breast-feeding, may aggravate diabetes and gout, exacerbation of systemic lupus erythematosus. Potential risk of drug interactions- (check BNF). Clinical Indication for use: Evidence of fluid overload resistant to current medication regime e.g. pulmonary oedema, visible JVP, peripheral oedema. Metolazone Dosing Regime 2.5mg to max. 5mg daily or alternate days. Dose can be > 10mg daily following advice from consultant. Down Titration Reduce dose in 2.5mg increments according to individual patient response/ needs. Some patients may require maintenance doses on alternate days or once / twice weekly. Additional Information Should be used with extreme caution and close monitoring is required especially in the initial stages of use. Morning doses of diuretics can be postponed if patient is leaving the house. However doses are best not taken after 4pm to avoid passing urine during the night. Extra vigilance needs to be taken during periods of warm/ hot weather. If patients develop diahorroea and vomiting there may be a risk of dehydration. Potential for non-specific symptoms occurring in the elderly patient, confusion, urinary incontinence, impaired mobility- falls. Monitoring Guidance Patient s symptoms should be reviewed within 3-7 days. Blood biochemistry should also be checked at this time and thereafter at regular intervals. Management for the use of Eplerenone- Acute & Chronic Heart Failure (confirmed LVSD) 17

Indications for Use: Licensed for Post MI heart failure. Can also probably be used if spironolactone is producing gynaecomastia (in systolic HF) Aims for Treatment: Relieve heart failure symptoms; to reduce the incidence of acute exacerbations of heart failure and mortality. Exclusion Criteria: Generally similar to spironolactone. Contra-indicated in pregnancy. Cautions: Take care if on other diuretics or potassium supplements. Dosage: Initially 25mg daily 50mg daily if required. Adverse Effects Diarrhoea Impaired renal function Nausea Headache Hypotension Insomnia Dizziness Pyelonephritis Hyperkalaemia Hyponatraemia Postural hypotension Dehydration Arterial thrombosis Malaise Asthenia Back pain Dyslipidaemia Leg cramps Eosinophilia Sweating Pharyngitis Pruritis Azotaemia Monitoring Guidance Blood biochemistry should be checked pre-initiation of eplerenone. Patient s blood pressure, blood biochemistry and symptoms should be reviewed within 1 week of initiation. Thereafter every 4 weeks for 3 months, then every 3 months for 1 year thereafter every 6 months. Symptomatic hypotension can occur, particularly after the first dose. Advice can be offered to patients with regard to this and frequently a change in medication administration times varying them from other treatments will alleviate the problem. A small rise in biochemistry can be expected following initiation of an ACE. If potassium rises between 5.5 5.9 or creatinine rises to 200 or above reduce the dose to 25mg alternate days and close monitoring (according to NICE 2003). If potassium rises to 6.0 or above or creatinine rises to 200 or above then STOP EPLERENONE AND SEEK ADVICE. Patients must be aware of stopping the drug if developing acute episode of vomiting and or diarrhoea, due to the risk of dehydration. Management for the use of Digoxin - Acute & Chronic Heart Failure (confirmed LVSD) 18

Indications for Use: 1. Useful as initial therapy for heart failure complicated by fast atrial fibrillation. 2. Can be used (preferably in small doses of 62.5-125mcg/day) to supplement symptom control in heart failure with sinus rhythm already on diuretics, angiotensin pathway blockers and betablockers. Does not improve survival. Aims for Treatment: Improve heart failure symptoms. Exclusion Criteria: Intermittent CHB. 2 nd degree AV Block. SVT caused by WPW syndrome. HOCM Hypertrophic Obstructive Cardio Myopathy ( unless concomitant atrial fibrillation and heart failure but with caution) Cautions: Evidence of benefit must be weighed against the possibility of an increase in sudden deaths associated with digoxin. The risk of digoxin toxicity is increased in hypokalaemia. Recent Myocardial Infarction Sick Sinus Syndrome Thyroid Disease Reduced dose in the elderly and in Renal Impairment Avoid in hypokalaemia. Avoid rapid intravenous administration (nausea and the risk of arrhythmias) Pregnancy Initiation/ Titration Rapid digitalisation 1-1.5 mg in divided doses over 24hours Less urgent 250 500mcg daily (higher doses may be divided) Maintenance 62.5 250mcg daily ( prefer smaller doses) According to renal function and, in atrial fibrillation on heart rate response 125 250 mcg daily (lower dose may be more appropriate in elderly) In patients with mild heart failure a loading dose is not required and a satisfactory plasma- digoxin concentration can be achieved over a period of about a week, using a dose of digoxin 125-250mcg bd which is then reduced. Adverse Effects (usually associated with excessive dosage) Anorexia Nausea, vomiting, diarrhoea, abdominal pain Visual disturbances, headache, fatigue. Drowsiness, confusion, delirium, hallucinations, depression Arrhythmias, heart block Rash (rarely) Intestinal ischemia Gynaecomastia - (on long term dose) Thrombocytopenia 19

Monitoring Guidance. * Digoxin has a long half life and maintenance doses need to be only given once daily (although higher doses maybe divided to avoid nausea.) * Routine monitoring of serum digoxin concentrations is not recommended. A digoxin concentration measured within 8-12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non compliance. * The serum Digoxin concentration should be interpreted in the clinical context as toxicity may occur even when the concentration is within therapeutic range. * The risk of Digoxin toxicity is increased by hypokalaemia. * If bradycardia occurs Digoxin should be stopped. Referenced from British National Formulary. NICE Clinical Guideline 5 July 2003 Chronic Heart Failure. Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Scottish Intercollegiate Guidelines Network (Sign) February 2007 Management of Chronic Heart Failure. National Service Framework 2003 Developing Services for Heart Failure. 20

Management for the use of Hydralazine and Isosorbide Dinitrate- Acute & Chronic Heart Failure (confirmed LVSD) Indications for Use: Isosorbide Dinitrate and Hydralazine combination Specialist Initiation Only Confirmed LVSD on echocardiogram. An Isosorbide Dinitrate and Hydralazine combination may be used in patients with heart failure who are intolerant of Ace Inhibitors or Angiotensin II receptors Treatment of Left Ventricular Failure (although potent coronary vasodilators their principle benefit follows from a reduction in venous return which reduced the left ventricle work) Heart failure (with long acting nitrates) In Caucasian patients the main indicator for H_ISDN is intolerance of an Ace Inhibitor or ARB due to renal dysfunction or hypocalcaemia. African American patients with advanced heart failure due to LVSD should be considered for treatment with Hydralazine and Isosorbide Dinitrate in additional to standard therapy Aims for Treatment: Improve heart failure symptoms. Reduce symptoms. Exclusion Criteria: Isosorbide Dinitrate.= Hypersensitivity to Nitrates Hypotensive conditions and Hypovolaemia HOCM Aortic Stenosis Cardiac tamponade Constrictive Pericarditis Marked Anaemia Closed Angled Glaucoma Hydralazine = Idiopathic systemic lupus erythematosus Severe tachycardia High output heart failure, Myocardial insufficiency due to mechanical obstruction Cor pulmonale Dissecting aortic aneurysm porphyria Cautions: Isosorbide Dinitrate = Sever hepatic or renal impairment Hypothyroidism Malnutrition, hypothermia Head trauma, cerebral haemorrhage Recent history of myocardial infarction Hydralazine = Hepatic impairment Renal impairment Coronary Artery Disease (may provoke angina, avoid after myocardial infarction until stabilised) Cerebrovascular disease, occasional blood pressure reduction too rapidly even with low parenteral doses. Pregnancy, breast feeding, Interactions = may enhance hypotensive effect when given with~ ACE inhibitors, Adrenergic neurone blockers, Alcohol, Aldesleukin, Alpha blockers, Alprostadil, Amifostine, General anaesthetics, NSAIDs, Angiotensin-II receptor antagonists, MAOIs with other tricyclic-related antidepressants, Phenothiazines, Anxiolitics and hypnotics, Beta blockers, Calcium channel blockers, Clonidine, Corticosteroids, Diazoxide, diuretics, Levodopa, Methyldopa, Moxisylyte,Moxonidine, Baclofen, Tizanidine,Nicorandil, Nitrates, oestrogens, carbenoxolone,nitroprusside. 21

Dosage: The A-HeFT trial used in patients self-identified as of African descent a fixed dose combination of 37.5 mg of hydralazine hydrochloride and 20 mg of isosorbide dinitrate given 3 times a day: note this is short acting nitrate. Though isosorbide mononitrate is often used instead it may not be useful if a nitrate free interval of at least 12 hours is not allowed between doses (This may need to be longer for sustained release preparations) The dose of hydralazine is therefore 25-50 mg 3 times daily (max 225 mg daily) and ISDN 20-40 mg 3 times daily (max 120 mg daily) Adverse Effects Isosorbide Dinitrate Throbbing headache Flushing Dizziness Postural hypotension Tachycardia (but paradoxical bradycardia has occurred) Hydralazine - Tachycardia - Palpitations - Flushing - Hypotension - Fluid retention - Gastro intestinal disturbances - Headache - Dizziness - Systemic lupus erythematosus like syndrome after long term therapy with over 100mg daily ( or less in women and in slow acetylator individuals) - Rarely rashes - Fever - Peripheral neuritis - Polyneutitis - Paraesthesia - Arthralgia - Myalgia - Increased lacrimination - Nasal congestion - Dyspnoea - Agitation - Anxiety - Anorexia - Blood disorders (including leucopenia, thrombocytopenia, haemolytic anaemia) - Abnormal liver function - Jaundice - Raised plasma creatinine - Proteinuria - Haematuria 22

Monitoring Guidelines. Isosorbide Dinitrate is active sublingually and is a more stable preparation for those who require nitrates infrequently. It is also effective by mouth for prophylaxis although the effect is slower in onset, it may persist for several hours. Duration of action of up to 12 hours is claimed for modified release preparations. The activity of Isosorbide Dinitrate may depend on the production of active metabolites the most important one which is ISMN. Manufacturer advises tests for antinuclear factor and proteinuria every 6 months and check acetylator status before increasing the dose above 100mg Referenced from British National Formulary. NICE Clinical Guideline 5 July 2003 Chronic Heart Failure. Management of Chronic Heart Failure in Adults in Primary and Secondary Care. Scottish Intercollegiate Guidelines Network (Sign) February 2007 Management of Chronic Heart Failure. National Service Framework 2003 Developing Services for Heart Failure. 11. Lifestyle Advice 11.1 Referral to Heart Care is considered at discharge from the HF Clinic. All patients re encouraged to be as active as possible, however little they are able to manage. 11.2 Smokers are encouraged to stop and are referred to the smoking cessation service if they agree. 23

11.3 Alcohol induced LVSD patients are encouraged to abstain permanently from the consumption of alcohol. Other patients should be advised not to drink more than 1 unit of alcohol per day. 11.4 Sexual activity may need to be discussed and health professionals should not expect the patient to bring up the subject. 11.5 Annual vaccination against influenza should be offered to all patients with LVSD. Pneumococcal vaccination will be offered to all patients with LVSD (once only). 11.6 Air Travel - This will depend on symptoms and adequate insurance is essential. Will need approval from medical physician prior to booking/travel. 11.7 Driving - As long as the patient has no symptoms at the wheel they can continue to use a standard driving licence. Other licences may need reviewing. INPATIENT HEART FAILURE GUIDELINES (Jan 2009) ADMISSION WITH SUSPECTED HEART FAILURE SYMPTOMS (SOB, SOA, orthopnoea, fatigue) SIGNS (Tachycardia, JVP,?AF,?S3 gallop,? murmur, creps, oedema,? ascites)? Acute MI ECG ----------------- CCU + MI protocol CXR -----------------? alternative diagnosis U&E, Cr FBC, ESR TSH (Blood cultures if fever) Urinalysis/MSU ---------? microscopic haematuria Book ECHOCARDIOGRAM (unless no evidence of SBE and echo within last 12 months already shows LV dysfunction or ECG normal) 24

REFER TO HEART FAILURE NURSE EXT 7860/BLEEP 8106 IF ECHO CONFIRMS LV DYSFUNCTION If echo does not show LVSD but still fluid overloaded and need further help with management then refer to Cardiologist on call. DAY 0 (on admission) DAY 1 DAY 2 START FRUSEMIDE 80mg x 2 I.V./day to promote diuresis (subsequently adjust dose to achieve weight loss of 0.5-1.0kg/day) START DAILY WEIGHTS START DAILY U&E, Creatinine If K+ <4.0mmol/l, start K+ supplements START prophylactic dose LMW HEPARIN (if AF start full dose LMWH + start Warfarin (INR 2-3) and digoxin 0.25mg x 2 for 2 days then 0.25mg x 1 daily START RAMIPRIL 2.5mg nocte if K+ <5.2mmol/l, Cr <150microm/l, systolic BP >100? need SOCIAL SERVICE review to arrange care package on discharge Review weight loss/u&e, Cr If K+ >5mmol/l STOP K+ supplements? adjust FRUSEMIDE dose DAY 3 DAY 4 Review weight loss/u&e, Cr If K+ >5mmol/l STOP K+ supplements? adjust FRUSEMIDE dose Increase RAMIPRIL to 5mg nocte if K+ <5.2mmol/l, Cr <150microm/l, systolic BP >100 Review weight loss/u&e, Cr If K+ >5mmol/l STOP K+ supplements? adjust FRUSEMIDE dose (?change to ORAL if oedema clear) Add SPIRONOLACTONE 25mg/day, if K+ <5.2mmol/l, Cr <150microm/l (if SEVERE LVSD or readmission with HF) DAY 5 DAY 6 DAY 7 Review weight loss/u&e, Cr If K+ >5mmol/l STOP K+ supplements? adjust FRUSEMIDE dose (? Change to ORAL if oedema clear) Review weight loss/u&e, Cr If K+ >5mmol/l STOP K+ supplements? adjust FRUSEMIDE dose (? Change to ORAL if oedema clear) Increase RAMIPRIL to 10mg nocte if K+ <5.2mmol/l, Cr <150microm/l, systolic BP >100 Review weight loss/u&e, Cr If K+ >5mmol/l STOP K+ supplements IF patient: oedema free and weight stable on same dose of oral FRUSEMIDE for last 2 days on maximum tolerated dose of RAMIPRIL (target 10mg nocte) on SPIRONOLACTONE 25mg/day (if tolerated) K+ <5.2mmol/l and stable Na & Cr acceptable and stable Systolic BP >90mmHg & no postural symptoms DISCHARGE STOP K+ SUPPLEMENTS ON DISCHARGE UNLESS K+ <4mmol/l ENSURE SOCIAL SERVICE SUPPORT PACKAGE PLANNED WELL IN ADVANCE ARRANGE FOR U&E, Cr TO BE REPEATED AT 1 WEEK FROM DISCHARGE AND WRITE ON BIOCHEMISTRY FORM FOR A COPY OF RESULT TO GO TO GP (PUT GP ADDRESS ON FORM) PROBLEM CASES the above protocol is a guide to try and achieve early stabilization and discharge. Some patients may respond more slowly. The cause of heart failure should be identified in each case. 25