Heart Failure protocol (Read Code G580) - Pennine GP Training



Chronic Heart Failure

Means reduced LV ejection fraction 400: refer within 2w via Rapid access HF clinic

3. Normal 150, K > 5.5, angioedema, renal artery stenosis, significant aortic stenosis /valvular disease = refer in these situations

CAUTION in women of childbearing age and contraindicated if trying to conceive or pregnant.

Starting regime for Primary Care derived from the HOPE study regime and BNF guidelines.

If U&Es pre treatment reveal a creatinine < 150, K 130 mmol/l then 2.5 mg Ramipril daily (1.25mg if on concomitant diuretics) for one week with check U&Es and an increase to 5.0 mg Ramipril for a further three weeks.

Re-check U&Es 1 week after each dose increment and attempt to up titrate all patients to the 10mg dose. Thereafter repeat U&Es on an annual basis.

Do not modify ACE/ARB if after introduction/dose increase eGFR rise is less than 25% or change on creatinine 25% or change in creatinine >30% then

i) investigate other causes e.g concurrent meds such as nsaid or volume

depletion

ii) if not other cause found stop/reduce to previously tolerated dose

Stop ACE/ARB if K rises above 6.0 and other hyperkalaemia promoting drugs been stopped

If patient is unable to tolerate ACE inhibitors try an ARB e.g. Candesartan. If intolerant of both e.g renal dysfunction then refer to consider hydralazine/nitrate as alternative 1st line therapy.

B - Beta blockers

This should include patients with COPD (without reversibility), PVD, diabetes and ED. The 3 B blockers shown to convey most advantage are carvedilol, bisoprolol and metoprolol.

Bisoprolol starting regime ‘Start low & go slow’ (consider referral to Heart Failure Specialist Nurse if needed)

Week 1 2 3 5 8 12

Bisoprolol (mg) 1.25 2.5 3.75 5.0 7.5 10

Patients esp prone to feeling more breathless when these started which may mean addition of/uptitration of diuretic for a short time

Consider back dose titration if the patient develops symptomatic hypotension, asymptomatic systolic BP < 90mmHg, bradycardia < 50bpm or respiratory symptoms

If develop HF while on non cardioselective B blocker then switch to one of 3 above.

C- Co-prescribing

Try to avoid NSAIDs, COX II inhibitors, Diltiazem/Verapamil, Tricyclics, Corticosteroids and effervescent preparations e.g. eff. Solpadol, Movicol as these have a high sodium content.

D- Diuretics

- Loop diuretics

Diuretics are used to reduce fluid overload (oedema and pulmonary congestion) and may be reduced/stopped once on established HF treatment.

Weight is a useful marker for fluid loss and daily self weighing can be used to advise patients on when they need to up their diuretics e.g notify GP if gain more than 1.5-2kg (3-4lbs) over 2 days

Tips for increasing furosemide doses

40mg in the morning to 80mg in the morning

80mg in the morning to 80mg in the morning & 40mg at lunch

80mg morning & 40mg at lunch to 80mg in the morning and 80mg at lunch

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- Spironolactone – NICE says we shouldn’t be initiating this alone (2nd line therapy) but recent SIGN guidance suggests starting if remain symptomatic on maximal ACE/B blocker unless renal impairment/diabetic nephropathy.

If already on – monitor U&es at least 6 monthly

Halve dose if K rises to 5.5 -5.9

Stop if K rises above 6.0 or creatinine above 220

For those interested in cardiology details…read on otherwise skip page 5

Ivabradine ( an SA node inhibitor without effects on myocardial contractility)is indicated if:

- NYHA class II-IV stable chronic HF

- Pulse 75 or more, sinus rhythm.

- Taking standard therapy inc. BB, ACEI and aldosterone antagonists *OR when BB is CI or not tolerated.

- LV ejection fraction 35% or less.

*Only after 4 weeks stabilisation period on standard therapy.

Digoxin indicated if worsening or severe HF despite first and second line treatment.

Routine digoxin levels not needed, only if concerned toxicity and should be taken 8-12 hrs post dose.Beware can still have toxicity even if levels in normal range.

Eplerenone. Patients post acute MI & LVD benefit from Eplerenone (an aldosterone antagonist) post MI, so you may see some patients discharged on this.Also given if develop gynaecomastia with spironolactone

Sacubitril-Valsartan (Enestro) – new class of drug called ARNI (angiotensin receptor-neprilysin inhibitor).Neprilysin inhibition affects natriuretic peptides improving vasodilatation,inhibits renin angiotensin system and has antihypertrophy effects. Therefore not with ACE/ARB.

- (NYHA) class II to IV symptoms and

-left ventricular ejection fraction of 35% or less

-who are already taking a stable dose of (ACE) inhibitors or angiotensin II receptor-blockers (ARBs).

Cardiac resynchronisation - Essentially involves pacing both ventricles (and R atrium ) to get more efficient contraction (c/w pacemakers – single chamber just RV, dual chamber R atrium/RV)

Cardiac resynchronisation or ICD is indicated if LVEF ................
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