Chronic heart failure: management of chronic heart failure in adults in primary and secondary care (partial update) NICE guideline Apendix C The algorithms Draft for consultation, January 2010 Chronic heart failure: NICE guideline DRAFT (January 2010) Page 1 of 3
Diagnosis Chronic heart failure: NICE guideline DRAFT (January 2010) Page 2 of 3
Treating heart failure HF Diagnosed by specialist HF-PEF HF-LVSD Specialist opinion Symptomatic Treatment (diuretics) + Manage co-morbid ities (e.g. BP, DM, IHD, Inherited CM) Rehabilitation & Education Congestion and fluid retention: DIURETICS ARB TO BE ADDED only if intolerant of AA Still Symptomatic Still Symptomatic ACEI* + β Blockers* Aldosterone antagonists* Consider CRT-P/D (where appropriate) Consider digoxin (all) Consider Hydralazine +Nitrates (Black patient) ARB only if truly intolerant of ACEI Specialist opinion Consider ICD where appropriate *For practical recommendations on the use of ACEI, Beta blockers and aldosterone antagonists refer to Appendix J For practical recommendations on the use of ACE inhibitors, beta blockers and aldosterone antagonists refer to appendix D Chronic heart failure: NICE guideline DRAFT (January 2010) Page 3 of 3
Chronic heart failure: management of chronic heart failure in adults in primary and secondary care (partial update) NICE guideline appendix D Draft for consultation, January 2010 If you wish to comment on this version of the guideline, please be aware that all the supporting information and evidence is contained in the full version. Chronic heart failure: NICE guideline DRAFT (January 2010) Page 1 of 5
Appendix D: Practical recommendations Background The course of heart failure patients is characterised by periods of clinical deterioration and potential need for changes to pharmacological therapy to be made. It is essential to maintain patients on therapy proven to reduce the risks of hospitalisation and improve the chances of survival. The adherence to this general advice is made difficult by practitioners concerns about side effects of therapy. In particular, many clinicians are concerned about renal impairment and reduced blood pressure in patients with heart failure. The 2003 guideline included tables of practical recommendations that were based on the publication by McMurray 1. These covered aspects of clinical management that were not included in the evidence reviewed but which the GDG considered important. In updating the guideline the GDG reviewed these recommendations and agreed that they were helpful to all practitioners caring for patients with heart failure and would enable patients and practitioners avoid the frequent scenario where essential medications for heart failure are inappropriately discontinued. General advice For optimal prognostic and symptomatic benefit doses of ACE inhibitors and beta blockers should be up-titrated to the maximum tolerated. This may require repeated or prolonged supervision in some patients. The dose of diuretic should be the minimum necessary to control oedema. Communication with patients Identify a clinician from whom patients may seek advice regarding heart failure. 1 McMurray JJ, Cohen-Solal A, Dietz R et al. (2001) Practical recommendations for the use of ACE inhibitors, beta-blockers and spironolactone in heart failure: putting guidelines into practice. European Journal of Heart Failure 3: 495 502. Chronic heart failure: NICE guideline DRAFT (January 2010) Page 2 of 5
Explain the purpose of the medication prescribed and the importance of uptitration to optimal dose. Explain the need for regular monitoring and at times alteration of medication. Explain that improvement with ACE inhibitors or beta blockers may take time to accrue. Explain that minor worsening of symptoms may occur when beta blockers are being initiated. Encourage individuals to monitor their weight and to report any change Renal function Monitor in all patients routinely. Monitor more frequently in patients taking combined loop and thiazide diuretic therapy, and in those taking aldosterone antagonists. Monitor more frequently when commencing and up-titrating ACE inhibitors, angiotensin II receptor antagonists or aldosterone antagonist. Where serum urea and/or creatinine increases (up to 50% above the baseline, or 200 micromol/l), or potassium (to K+ less than 5.9 mmol/l) no immediate action is required. Monitor renal function closely and consider reducing the dose of aldosterone antagonist then ACE inhibitors. Where renal function is deteriorating discontinue nephrotoxic drugs (such as NSAIDs) and non-essential hypotensive drugs. Discontinue ACE inhibitors if: the potassium rises to more than 6 mmol/l, or creatinine rises by more than 100% from the baseline, or to above 350 micromol/l. Discontinue aldosterone antagonists if the potassium rises to more than 6 mmol/l, or creatinine rises above 220 micromol/l. Chronic heart failure: NICE guideline DRAFT (January 2010) Page 3 of 5
Blood pressure Monitor in all patients routinely. If blood pressure is low, first consider discontinuing nitrates, calcium channel blockers and other vasodilators. If blood pressure is low, reduce diuretics in patients who do not have signs of congestion. In asymptomatic hypotension do not alter dose of ACE inhibitors or beta blockers. Where at all possible maintain treatment with both ACE inhibitors and beta blockers, at reduced dose if necessary. Increasing congestion/fatigue If temporary deterioration occurs during the initiation or up-titration of beta blockers diuretic dose may need to be briefly increased. If congestion occurs increase diuretics and consider reducing dose of beta blocker (but not discontinuing). If there is extreme fatigue (or bradycardia less than 50 beats per minute) consider reducing the dose of beta blocker. Seek specialist advice if serious deterioration (fatigue, oedema, weight gain and dyspnoea) does not improve. Consider specialist review (see above) Where fluid retention is resistant. When commencing ACE inhibitors in patients taking large doses of diuretics. Where renal function continues to deteriorate or deteriorated rapidly. Where there are concerns about low blood pressure. Where fatigue, oedema, weight gain and dyspnoea do not rapidly improve. Chronic heart failure: NICE guideline DRAFT (January 2010) Page 4 of 5
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