Congestive Cardiac Failure (CCF)

I50.0

DESCRIPTION

CCF is a clinical syndrome and has several causes. The cause and immediate precipitating factor(s) of the CCF must be identified and treated to prevent further harm.
Potentially reversible causes include:

  • hypertension
  • thiamine deficiency
  • thyroid disease
  • ischaemic heart disease
  • valvular heart disease
  • haemochromatosis
  • constrictive pericarditis
  • tachycardia

GENERAL MEASURES

Patient and family education.
Monitor body weight to assess changes in fluid balance.
Limit fluid intake to 1–1.5 L/day if fluid overloaded despite diuretic therapy.
Limit alcohol intake to a maximum 2 drinks per day if at all.
Salt restriction (dietician guided when possible).
Regular exercise within limits of symptoms.
Avoid NSAIDs as these may exacerbate fluid retention.
Counsel that pregnancy may exacerbate heart failure and some medicines used in treatment of heart failure are contraindicated in pregnancy e.g. ACE-inhibitors, angiotensin-receptor blockers, spironolactone. Advise on contraception or refer for such advice.

LoEIII [47]

MEDICINE TREATMENT

Where heart failure is due to left ventricular systolic dysfunction, mortality is significantly reduced by the use of ACE-inhibitors, ß-blockers and spironolactone and every effort should be made to ensure eligible patients receive all these agents in appropriate doses.

Note: All the guideline evidence presented here relates to treatment of patients in whom the heart failure syndrome is due to left ventricular systolic dysfunction and cannot necessarily be extrapolated to patients in whom heart failure is due to other causes of the syndrome.

Digoxin has only been shown to improve symptoms and reduce hospitalisation.

LoEI [48]

Diuretic

Mild volume overload (mild CCF) and normal renal function, thiazide diuretic:

  • Hydrochlorothiazide, oral, 25–50 mg daily.
    • Caution in patients with gout.
    • Less effective in impaired renal function.
    • Caution in patients with a history or family history of skin cancer; and counsel all patients on sun avoidance and sun protection.

LoEIII [49]

Significant volume overload or abnormal renal or hepatic function, loop diuretic:

  • Furosemide, oral, daily.
    • Initial dose: 40 mg/day.
    • Higher dosages may be needed, especially if comorbid renal failure.
    • Advise patients to weigh themselves daily and adjust the dose if necessary.

LoEIII

NOTE:

  • Unless patient is clinically fluid overloaded, reduce the dose of diuretics before adding an ACE-inhibitor. After introduction of an ACE-inhibitor, try to reduce diuretic dose and consider a change to hydrochlorothiazide.
  • Routine use of potassium supplements with diuretics is not recommended. They should be used short term only, to correct documented low serum potassium level.

LoEI [50]

Renin-angiotensin-aldosterone system (RAAS) blockers

  • ACE-inhibitor, e.g.:
    • Enalapril, oral, 2.5 mg 12 hourly, titrated to 10 mg 12 hourly.
      • In the absence of significant side-effects always try to increase the dose to the level shown to improve prognosis (i.e.10 mg 12 hourly).

LoEI [51]

If ACE-inhibitor intolerant, i.e. intractable cough:

  • Angiotensin receptor blocker (ARB), e.g.:
    • Losartan, oral, 50–100 mg daily. Specialist initiated.

Spironolactone

Use with an ACE-inhibitor and furosemide in patients presenting with Class III or IV heart failure.

Do not use if eGFR < 30 mL/minute.

Monitoring of potassium levels is essential if spironolactone is used with an ACE-inhibitor or other potassium sparing agent or in the elderly.

  • Spironolactone, oral, 25–50 mg once daily

LoEIII [52]

ß-blockers

For all stable patients with heart failure who tolerate it:

Note: Patients should not be fluid overloaded or have a low BP before initiation of therapy.

  • Carvedilol, oral.
    • Initial dose: 3.125 mg 12 hourly.
    • Increase at 2-weekly intervals by doubling the daily dose until a maximum of 25 mg 12 hourly, if tolerated.
    • If not tolerated, i.e. worsening of cardiac failure symptoms, reduce the dose to the previously tolerated dose.
    • Up-titration should take several weeks or months.

LoEI [53]

Digoxin

Patients in sinus rhythm remaining symptomatic despite the above-mentioned agents (Specialist consultation):

  • Digoxin, oral, 0.125 mg daily, adjust according to response and trough plasma level.
    • Digoxin trough plasma levels (before the morning dose) should be maintained between 0.6-1 nmol/L.
    • Patients at high risk of digoxin toxicity: the elderly, patients with renal dysfunction, hypokalaemia and patients with lean body mass.

LoEII [54]

Anticoagulants

Heparin: for DVT prophylaxis for patients admitted to hospital, unless contraindicated: See: Venous thrombo-embolism.
Warfarin: See: Narrow QRS complex (supraventricular) tachydysrhythmias.

Anti-dysrhythmic medicines

Only for potentially life-threatening ventricular dysrhythmias. See: Cardiac dysrhythmias.
Always exclude electrolyte abnormalities and medicine toxicity first.

Thiamine

Consider as a trial of therapy in all unexplained heart failure:

  • Thiamine, oral/IM, 100 mg daily for 4 weeks.

Prophylaxis (Z29.2)

REFERRAL

  • Where specialised treatment and diagnostic work-up is needed and to identify treatable and reversible causes.
  • All patients with audible cardiac murmurs should undergo specialist evaluation, as should all patients with potentially reversible causes of the heart failure syndrome and those with persistent and severe symptoms and signs of fluid overload despite adequate doses of diuretic.
  • Patients who have LBBB on the ECG are potential candidates for cardiac resynchronization therapy. An ECG should be recorded at baseline and repeated at 6-monthly intervals.
  • Patients with LBBB should be referred for consideration for resynchronsation therapy, discussed with a specialist.