Heart Failure Treatment Guidelines - The Easy Version!

Some General Information 

• Heart failure is now generally called HF rather than CHF.
• HF is not the same as cardiomyopathy, CAD, or LV dysfunction. These are possible causes of HF. Heart failure is a set of specific symptoms including shortness of breath, fatigue, edema, and rales.
• Many elderly people with HF may have normal EF.
• Patients with a very low EF may have no symptoms, while patients with normal EF may have severe disability. Why is not understood. Possible factors include heart wall motion changes, valve dysfunction, heart rhythm, problems with the heart's electrical signals, right heart dysfunction, blood vessel dysfunction, skeletal muscle changes, lung dynamics, neurohormonal and nervous system activity, and kidney function changes.
• Heart function may improve without quick or noticeable improvement in symptoms.
• Beta-blocker and ACE inhibitor therapy should never stop, even if heart function returns to normal and all symptoms disappear.
• Other conditions like diabetes, CAD, high blood pressure, and a-fib can worsen heart failure and require management.
• HF is "rated" in functional classes - class 4 patients may have symptoms at rest, class 3 patients have symptoms with less-than-ordinary exertion, class 2 patients have symptoms with every day type exertion, and class one patients have no HF symptoms.
• HF is also described in "stages." Stage one patients are at risk for HF but don't have it, stage B patients have heart problems but no HF symptoms yet, stage C patients have - or have had in the past - heart failure symptoms, and stage D patients have severe HF that doesn't respond well to treatment.

To Prevent Heart Failure 

• lower high blood pressure;
• control irregular or too-fast heart rhythms;
• correct too-low or too-high thryoid function;
• lower bad cholesterol and raise good cholesterol;
• if diabetic, control blood sugar;
• if diabetic, also consider taking an ACE inhibitor or ARB to prevent heart failure;
• if you've had a heart attack, restore lost blood flow with bypass surgery or angioplasty if possible;
• if you've had a heart attack (even if long ago), take an ACE inhibitor or ARB, and also take a beta-blocker to reduce risk of heart failure down the road, even if you have no symptoms and even if your EF is normal;
• if you have reduced EF, take a beta-blocker and an ACE inhibitor even if you have no symptoms;
• if you have significant heart valve dysfunction, get it fixed;
• do regular echos in people who have had chemotherapy;
• lose extra weight;
• quit smoking;
• quit using alcohol;
• stop illegal drug use.

To Test Heart Failure When First Diagnosed 

• Definitely do a BNP blood test if it is uncertain whether a patient has heart failure.
• Definitely take a thorough history. This may identify possible causes of heart failure and also identify anything that may aggravate heart failure. History should include description of all supplements use; drug use legal, illegal, or over-the-counter; chemo use for cancer past and present; smoking; and alcohol use.
• Definitely perform physical exam that includes body weight; sitting and standing blood pressure; checking for edema in ankles, stomach and liver; and checking amount of neck vein swelling.
• Definitely ask how well you can do all the usual activities of daily living.
• Definitely do blood and urine testing. This includes complete blood count (CBC) electrolytes (BMP), kidney function (BUN and creatinine), liver function, fasting blood sugar, cholesterol (lipids), and thyroid - see this page for explanations.
• Definitely do EKG
• Definitely do chest x-ray
• Definitely do echocardiogram to measure EF, heart size, heart wall thickness, and heart valve function.
• Possibly do a cath if a patient has angina and may need artery blockages opened.
• Possibly do a Vo2max test to see how much ability to exercise is reduced; and to see if you are high-risk enough to need heart transplant or other advanced treatments; and to set standards for a personalized exercise program.
• Possibly test for: hemochromatosis, HIV, sleep disturbances, or rheumatologic diseases like amyloidosis or pheochromocytoma if a patient is suspected of having one of these problems.
• Possibly do a heart biopsy if a patient is suspected of having heart inflammation or infiltrative heart disorder.
• Possibly do Holter monitoring if a patient is suspected of having serious arrhythmia and may need an EPS.

Testing To Monitor Heart Failure After Diagnosis 

1. For all heart failure patients, a doctor should at every visit:
    
   
   • Definitely update medical history to identify anything that may be aggravating heart failure. History should include all current supplements use; drug use legal, illegal, or over-the-counter; chemo use for cancer; smoking; current alcohol use; and whether you are following your diet as in low sodium and diabetic requirements.
   • Definitely perform physical exam that includes body weight; sitting and standing blood pressure; checking for edema in ankles, stomach and liver; and checking amount of neck vein swelling.
   • Definitely ask how well you can do all the usual activities of daily living.
   • Definitely do routine blood testing (and urine testing if needed): electrolytes (BMP) - especially potassium which should stay in the 4 to 5 mmol/liter range, kidney function (BUN and creatinine), and liver function. See this page for explanations.
     
     • Patients on spironolactone or Inspra should have potassium levels checked more often and every time a drug dose is changed.
     • Patients on digoxin need dig level testing.
     • Patients on Coumadin (warfarin) need INR testing.
     • Patients on amiodarone need thyroid and lung function testing.
   • Definitely use echo to re-measure EF, heart size and shape, and valve function if a patient has changed heart class or seems to have improved or worsened during treatment.

Treating Heart Failure After Diagnosis 

• Prevent edema with low-sodium diet.
• Weigh yourself every morning. If you gain more than 2 to 3 pounds in 24 hours, take extra diuretic (this plan should be checked with your doctor) and lower sodium intake even more for a couple of days.
• Patients who can walk unassisted should do an exercise routine tailored to their needs, and avoid too much bed rest.
• In CHFers with a-fib, reduce stroke risk by using blood thinners.
• In CHFers with a-fib, heart rhythm should be restored to normal when possible to control HF symptoms. However, it is more important to control ventricular rate since this reduces hospitalizations.
• In CHFers with blocked arteries, restore blood flow using bypass surgery or angioplasty.
• CHFers with CAD should consider taking a blood thinner to prevent heart attack.
• Avoid NSAIDs.
• Avoid alcohol.
• Don't smoke.
• Have your heart failure managed by a heart failure specialist.

1. Take diuretics to relieve symptoms like edema and shortness of breath.
2. In CHFers with high blood pressure and only mild edema, thiazide diuretics may be preferred because they are better for blood pressure.

1. All CHFers should take an ACE inhibitor, unless they truly cannot.
2. ACE inhibitors are preferred over ARBs.
3. Patients who cannot take an ACE inhibitor should try taking an ARB. However, if you have angioedema on ACE inhibitors, be cautious trying an ARB since angioedema is also possible with ARBs.
4. Class 2, 3 and 4 CHFers already taking a beta-blocker and ACE inhibitor but who still have HF symptoms may try adding an ARB.
5. Do not take an ACE inhibitor, an ARB, and an aldosterone blocker.
6. Target dose is preferred but lower doses will still give benefit.
7. One to 2 weeks after starting a drug, blood testing should be done, and again shortly after any dose change.

1. All stable CHFers (even if they have no HF symptoms) should take a beta-blocker unless they truly cannot. The beta-blocker used should be Coreg, Toprol-XL, or bisoprolol.
2. Beta-blockers should be started at very low dose, and the dose increased by small amounts no more often than every 2 weeks.
3. Patients with asthma or other lung disease should be very cautious starting a beta-blocker.
4. Target dose is best, but lower doses will help.
5. Beta-blocker use should never be stopped - even if all your symptoms go away or you are told your heart failure is "cured."

1. In class 2, 3 and 4 CHFers, digoxin may make you feel better and may reduce risk of hospitalization.
2. In CHFers with a-fib, digoxin may be used to control the ventricles' response rate.
3. Digoxin will not lower your risk of death.
4. Digoxin should not be taken by people who have never had HF symptoms even if they have reduced EF.

1. Black CHFers (African-Americans) should consider taking BiDil in addition to their other HF meds.
2. Class 2, 3 and 4 CHFers already taking a beta-blocker and ACE inhibitor but who still have symptoms may try adding hydralazine plus isosorbide dinitrate to relieve symptoms.
3. Class 2, 3 and 4 CHFers who cannot take an ACE inhibitor or ARB should try hydralazine plus isosorbide dinitrate.

1. Aldosterone blockers like spironolactone or Inspra should be considered for patients with moderately severe to severe HF symptoms. Spironolactone causes permanent breast enlargement in one of 10 men.
2. If HF decompensates, an aldosterone blocker should be considered.
3. If HF occurs soon after a heart attack, an aldosterone blocker should be considered.
4. Patients with weakened kidney function should not take aldosterone blockers.
5. Within 3 days after starting such a drug and again at one week, blood testing should be done to check blood potassium level. This should be checked at least once a month for the next 3 months and then at least once every 3 months. Blood potassium can be increased by aldosterone blockers and potassium supplements are usually stopped as soon as you start taking one.
6. During episodes of diarrhea, aldosterone blockers should not be taken.

1. Calcium channel blockers should not be used in heart failure patients, even for angina or high blood pressure control. If you absolutely need to use one, amlodipine (Norvasc) should be used.

1. Class one anti-arrhythmic drugs should not be used, except for life-threatening arrhythmias.
2. If necessary, amiodarone or dofetilide are preferred as they do not increase risk of death in CHFers.

1. Inotropic infusions may improve quality of life in CHFers but probably increase risk of death. So IV inotropes are mainly for end-of-life palliative care.

Notes: CHFers with low EF who have fainting spells of unknown cause may be at risk for sudden cardiac death and should consider ICD implant. However, when ventricular arrhythmias occur in a CHFer whose HF is getting progressively worse, death from other causes is likely, so ICD implant is not recommended. An exception may be for patients considered good candidates for heart transplant.
     HF meds generally reduce risk of sudden death. While ICDs prevent death from ventricular arrhythmias, frequent ICD shocks can also reduce quality of life. To help with this, adding amiodarone or dofetilide may be tried. If this does not help, catheter ablation may be tried.
     ICDs can aggravate HF and have been linked to increased HF hospitalizations. Careful attention to the details of ICD implant, programming, and pacing function is important for all low EF patients receiving an ICD.
     The decision to get an ICD is highly individual. Reducing risk for sudden cardiac death may not reduce overall risk of death. Reduced risk of sudden death may also mean reduced quality of life. This should be considered, especially in patients with poor prognosis because of advanced HF or other serious health problems. Most reductions in risk of death came after the first year in major trials.

Heart attack patients who have never had HF symptoms (class one, stage B)

ICD implant may be considered if you had a heart attack 40 or more days ago, have ischemic cardiomyopathy, have EF of 30% or less, take all the standard HF meds, and are expected to survive for at least a year with good functional status.

Reduced EF patients with no heart attacks and no HF symptoms (class one, stage B)

ICD implant may be considered if you have non-ischemic cardiomyopathy, have EF of 30% or less, take all the standard HF meds, and are expected to survive for at least a year with good functional status.

Reduced EF patients with HF symptoms (class 2 or 3, stage C)

ICD implant is recommended if you have a history of cardiac arrest, ventricular fibrillation, or dangerous ventricular tachycardia.

Heart attack patients with reduced EF and HF symptoms (class 2 or 3, stage C)

ICD implant is recommended if you have ischemic heart disease, had a heart attack 40 or more days ago, have EF of 30% or less, are class 2 or 3 despite taking all the standard HF meds, and are expected to survive for at least a year with good functional status.

Non-heart attack patients with reduced EF and HF symptoms (class 2 or 3, stage C)

ICD implant is recommended if you have non-ischemic cardiomyopathy, have EF of 30% or less, are class 2 or 3 despite taking all the standard HF meds, and are expected to survive for at least a year with good functional status.

Reduced EF patients with HF symptoms from any cause (class 2 or 3, stage C)

ICD implant may be considered if you have HF from any cause, have EF 30 to 35%, are class 2 or 3 despite taking all the standard HF meds, and are expected to survive for at least a year with good functional status.

Cardiac Resynchronization Therapy or CRT (use of a biventricular pacemaker) may help patients who have symptoms despite taking all the standard HF meds. BiV pacing may improve quality of life, heart class, exercise ability, EF, and survival. An ICD/BiV pacer should be used in patients who need an ICD as described above.

Who should get a CRT pacemaker?

Patients with EF 35% or less, normal heart rhythm, in heart class 3 or 4 despite taking all standard HF meds, and who have a QRS duration more than 120 ms (milliseconds), should receive a CRT pacer unless contraindicated.

Possibly, an LVAD may be considered as a permanent device in very carefully selected end-stage HF patients whose risk of death in the next year despite drug therapy is over 50%.

1. Refractory HF is when serious HF symptoms remain despite using all recommended therapies. If prognosis is poor as well, which is usual, this is end-stage heart failure.
2. Definitely, recognizing and controlling edema is critical in end-stage heart failure
3. Definitely, patients who are candidates for heart transplant should be referred to transplant team.
4. Definitely, patients whose HF does not respond well to treatment should be treated by a heart failure specialist.
5. Definitely, end of life care options should be discussed with patient and family. How to use an advance directive, palliative care, and hospice services should be discussed. These should be discussed whenever an end-stage CHFer's situation changes.
6. Hospice methods to relieve suffering - including narcotic drugs - are recommended for end of life HF care. Hospice care should also include options such as inotrope use and IV diuretics to relieve symptoms seen in end-stage HF.
7. Definitely, end-stage CHFers who have an ICD should be told that they can have their ICD turned off if they so desire, to prevent being brought back to life after a sudden death episode.
8. Definitely, using both inpatient and outpatient settings for end of life care must be carefully coordinated so care is proper and continuous.
9. Possibly, an LVAD may be considered as a permanent device in very carefully selected end-stage HF patients whose risk of death in the next year despite drug therapy is over 50%.
10. Possibly, implanting a pulmonary artery catheter to guide therapy in end-stage CHFers with severe symptoms may be considered.
11. Possibly, continuous IV infusion of an inotropic drug may be considered for symptom relief in end-stage CHFers. This should not be used until all other therapies have failed to stabilize HF because this approach can be a major burden to the family and health services; and may increase risk of death. However, inotrope infusion can relieve end-stage symptoms as part of a plan to let a patient die with comfort at home.

Not recommended for end-stage HF

Routine intermittent infusion of inotropic drugs.

Not recommended for end-stage HF

Mitral valve repair or replacement for severe secondary mitral valve regurgitation.

Not recommended for end-stage HF

Aggressive procedures during final days of life - including intubation and ICD implant - in class 4 patients not expected to improve.

Not recommended for non-ischemic end-stage HF

Partial left ventriculectomy (as in Batista procedure)

All information on this site is opinion only. All concepts, explanations, trials, and studies have been re-written in plain English and may contain errors. I am not a doctor. Use the reference information at the end of each article to search MedLine for more complete and accurate information. All original copyrights apply. No information on this page should be used by any person to affect their medical, legal, educational, social, or psychological treatment in any way. I am not a doctor. This web site and all its pages, graphics, and content copyright © 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005 Jon C.