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



Chronic Heart Failure

CHF with reduced LV ejection fraction 400: refer within Rapid access HF clinic - seen within 2 weeks

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

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 specialist.

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 are especially 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

How to use a loop diuretic in patients - BMJ 2019

Loop diuretics with regards to the diuresis they produce are either ‘fully off’ or ‘fully on’.

The threshold for the switch to fully on varies between patients.

Increase loops diuretic dose every few days until a diuresis is achieved – passing 2 to 4l in the four hours after taking a dose, wt loss of 2 to 4kg in the four hours after taking the dose or PUing a good volume at least every 15 mins for 2 to four hours indicates diuresis is taking place.

Once the threshold dose for adequate diuresis has been defined

a) Do not increase it, even if the patient is still hypervolaemic as the drug is ‘fully on’ and dose increase does not increase the diuresis. In that situation add a dose 4 hours later to prolong the diuresis.

b) Do not reduce it, as the diuresis and therapeutic benefit will switch off but SE will remain.

Cr will rise as the haemodilution is corrected by diuresis – expert opinion is not to worry if Cr rise is < 30%.

Also, if a patient is complaining of peeing all day and all night it suggests that they have not had an adequate diuresis and that the Rx needs increasing (dose rise if evidence of inadequate diuresis or split dose to prolong diuresis to achieve normovolaemia which in turn should switch of whole day frequency).

Bumetenide is more potent and shorter acting than furosemide and less likely to cause hypokalaemia

MRAs e.g. Spironolactone .

• Extreme caution re initiation if K>5.0 or eGFR < 30

• If already on them – 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

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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