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Heart failure - chronic - Management
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How should I manage someone with angina as a comorbidity in heart failure?
- Ischaemic heart disease is a common cause of heart failure, and people with heart failure often have angina.
- Consider referral for a specialist opinion on treatment, including revascularization.
- Ensure that angina symptoms are well controlled, with optimum use of medical management.
- Beta-blockers are recommended for the treatment of both heart failure and angina.
- Nitrates have a good safety profile for use in heart failure.
- Calcium-channel blockers are effective at controlling angina symptoms, but some may aggravate heart failure.
- Amlodipine is recommended, as randomized controlled trial evidence indicates that it has a good safety profile in people with heart failure.
- Verapamil, diltiazem, and short-acting dihydropyridines should be avoided.
- Nicorandil is contraindicated in people with heart failure with low filling pressure. Seek specialist advice if considering prescription of nicorandil.
- Ivabradine is contraindicated in people with New York Heart Association class III or IV heart failure; however it may be considered for treatment by some specialists in secondary care.
- Ensure that fluid retention is well controlled with diuretics.
- Low-dose aspirin is recommended for people with angina and heart failure.
- For information on the management of angina, see the CKS topic on Angina.
Basis for recommendation
These recommendations are based on guidelines from the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2007] and information published by the manufacturers [ABPI Medicines Compendium, 2010g; ABPI Medicines Compendium, 2010l].
- It is important to control fluid retention, because anti-anginal medication may produce little benefit unless fluid retention is controlled with diuretics [ACC and AHA, 2005]. The decrease in ventricular volume and pressures produced by diuretics may also exert independent anti-anginal effects.
- Ivabradine
- Although the manufacturers of ivabradine state that it is contraindicated in stage III or stage IV heart failure, a recently published large randomized controlled trial (SHIFT [Systolic Heart failure treatment with the If inhibitor ivabradine Trial]) found that ivabradine reduces the risk of cardiovascular death and hospitalization for worsening heart failure in people with moderate to severe heart failure [Swedberg et al, 2010].
- Ivabradine may be initiated in secondary care by a specialist to treat heart failure.
Specialist
- NICE defines the term 'specialist' as a physician with sub-speciality interest in heart failure (often a consultant cardiologist) who leads a specialist multidisciplinary heart failure team of professionals with appropriate competencies from primary and secondary care. The team will involve, where necessary, other services (such as rehabilitation, tertiary care, and palliative care) in the care of individual persons.
How should I manage someone with asthma or COPD as a comorbidity in heart failure?
- Beta-blockers are contraindicated in people with a history of asthma or bronchospasm.
- Beta-blockers can be used in people with stable chronic obstructive pulmonary disease (without reversibility).
- Treatment should be started at a low dose and slowly titrated up.
- If symptoms worsen, a reduction in dose, or withdrawal, may be necessary.
- Bisoprolol or nebivolol may be preferred to carvedilol, as these are more cardioselective.
Basis for recommendation
Asthma
- Current guidelines from the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre for Acute and Chronic Conditions, 2010] and the European Society of Cardiology [European Society of Cardiology, 2008] both state that a history of asthma is a contraindication to the use of any beta-blocker, because these drugs can precipitate an asthma attack. The Commission on Human Medicines and the Medicines and Healthcare products Regulatory Agency also advises that beta-blockers (including those considered to be cardioselective) should not be given to people with a history of asthma or bronchospasm [CSM, 1996].
Chronic obstructive pulmonary disease (COPD)
- NICE recommends that people who have COPD without reversibility should be able to tolerate beta-blockers and are likely to benefit significantly from their use. NICE states that:
- These people are often undertreated when they develop heart failure and their outcomes are worse than the average person with heart failure.
- There is no evidence that cardioselective beta-blockers will worsen pulmonary function in these people.
How should I manage someone with atrial fibrillation as a comorbidity in heart failure?
- Atrial fibrillation is the most common arrhythmia in people with heart failure. Its onset may lead to worsening of symptoms and poor prognosis.
- Consider referral for assessment for possible cardioversion or rhythm control.
- If rate control is chosen, then a beta-blocker is first-line choice. Digoxin is an alternative if a beta-blocker cannot be taken.
- Antithrombotic treatment is recommended for all people with atrial fibrillation and heart failure, unless it is contraindicated.
- For detailed information on the management of atrial fibrillation, see the CKS topic on Atrial fibrillation.
Basis for recommendation
How should I manage someone with diabetes as a comorbidity in heart failure?
- Diabetes mellitus is a frequent comorbidity in people with heart failure and may increase the progression of heart failure.
- Good glycaemic control should be maintained (not only as standard management of diabetes, but also because it reduces thirst that can lead to excessive fluid intake).
- If using metformin, renal function should be monitored and the use of metformin reviewed if the serum creatinine level is greater than 130 micromol/L or the estimated glomerular filtration rate is less than 45 mL/min/1.73 m2.
- Thiazolidinediones (glitazones) are contraindicated in people with heart failure.
- Non-selective beta-blockers can mask warning signs of hypoglycaemia (for example tremor and tachycardia). A cardioselective beta-blocker (such as bisoprolol or nebivolol) is therefore preferred in people with diabetes.
- See the CKS topic on Diabetes type 2 for details of managing glucose control in people with type 2 diabetes.
Basis for recommendation
- A direct beneficial effect of glucose lowering in reducing the risk of heart failure has not been demonstrated. However, most experts consider this to be good practice [European Society of Cardiology, 2008].
- Lactic acidosis is a rare but potentially fatal event which has been associated with metformin use. To minimize the risk of lactic acidosis, the National Institute for Health and Clinical Excellence (NICE) recommends that metformin treatment should be reviewed if the serum creatinine level is greater than 130 micromol/L or the estimated glomerular filtration rate (eGFR) is less than 45 mL/min/1.73 m2, and treatment should be withdrawn if the serum creatinine level is greater than 150 micromol/L or eGFR is less than 30 mL/min/1.73 m2 or when tissue hypoxia is suspected [NICE, 2008a].
- There is an increased risk of fluid retention with the thiazolidinediones, which can exacerbate or precipitate heart failure. They are therefore contraindicated in all New York Heart Association stages of heart failure [MeReC, 2007; MHRA, 2007a].
How should I manage someone with gout as a comorbidity in heart failure?
- Loop diuretics can cause an increase in uric acid levels and may precipitate or aggravate gout.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in people with heart failure; in those with acute gout, colchicine is an alternative treatment to suppress inflammation and pain.
- If NSAIDs and colchicine are contraindicated, consider systemic corticosteroids.
- If allopurinol is used to prevent recurrence of gout, renal function should be monitored.
- For information on the management of gout, see the CKS topic on Gout.
Basis for recommendation
How should I manage someone with renal impairment as a comorbidity in heart failure?
- Renal impairment is common in people with heart failure and is strongly associated with increased morbidity and mortality.
- Assess the underlying cause and manage potentially reversible causes. Possible causes include:
- Dehydration — consider a reduction in the dose of diuretic, or temporary cessation of the diuretic.
- Deterioration due to an angiotensin-converting enzyme inhibitor or angiotensin-II receptor antagonist — consider reducing the dose or stopping the drug.
- Coincident renal disease (such as diabetic nephropathy or renovascular disease) — undertake investigations as appropriate.
- Use aldosterone antagonists with caution in people with renal impairment because these drugs may cause clinically significant hyperkalaemia. Monitor serum potassium closely.
- Renal impairment is associated with impaired clearance of digoxin — to avoid toxicity, consider reducing the dose of digoxin and monitoring for signs and symptoms of toxicity.
Basis for recommendation
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