Cardiac failure, congestive (CCF), adults

I50.0-1/I50.9

DESCRIPTION

CCF is a clinical syndrome and has several causes. The cause and immediate precipitating factor(s) must be identified and treated to prevent further damage to the heart.

Signs and symptoms include:

  • dyspnoea (breathlessness)
  • ankle swelling with pitting oedema
  • tachypnoea
    • men: breathing rate > 18 breaths/minute
    • women: breathing rate > 20 breaths/minute
  • fatigue
  • tachycardia
  • inspiratory basal crackles or wheezing on auscultation of the lungs
  • orthopnoea
  • enlarged liver, often tender
  • raised jugular venous pressure

GENERAL MEASURES

  • Monitor body weight to assess changes in fluid balance.
  • Salt (sodium chloride) restriction to less than 2–3 g/day.
  • Regular exercise within limits of symptoms.

MEDICINE TREATMENT

All patients should be assessed by a doctor for initiation or change of treatment.

  • Many of the medicines used can affect renal function and electrolytes.
  • Monitor sodium, potassium and serum creatinine.

STEP 1: Diuretic plus ACE-inhibitor

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 [35]

Significant volume overload or abnormal renal function – loop diuretic

  • Furosemide, oral, daily (Doctor initiated).
    • Initial dose: 40 mg.
    • If dose > 80 mg/day is required, change dose interval to 12 hourly.
    • Higher doses may be needed if co-morbid kidney impairment is present.
    • Once CCF has improved, consider switching to hydrochlorothiazide.
    • Monitor electrolytes and creatinine.

Acute pulmonary oedema

Note:

  • Use a lower diuretic dose when given in combination with an ACE-inhibitor.
  • Routine use of potassium supplements with diuretics is not recommended. They should only be used short-term to correct documented low serum potassium level.

All patients with CCF, unless contraindicated or poorly tolerated

  • ACE-inhibitor, e.g.:
  • Enalapril, oral, 2.5 mg 12 hourly, up to maximum of 10 mg twice daily.
    • Titrate dosages gradually upwards until an optimal dose is achieved
    • Absolute contraindications include: (refer to package insert)
      • cardiogenic shock
      • bilateral renal artery stenosis, or stenosis of an artery to a dominant/single kidney
      • aortic valve stenosis and hypertrophic obstructive cardiomyopathy
      • pregnancy
      • history of angioedema associated with previous ACE-inhibitor or angiotensin II receptor blocker (ARB) therapy

STEP 2: After titration of ACE-inhibitor, add carvedilol (alpha 1 and non-selective beta blocker) unless contra-indicated.

(Refer to package insert for full prescribing information).

Note: Do not use atenolol for cardiac failure.

  • Carvedilol, oral (Doctor initiated).
    • Starting dose: 3.125 mg twice daily.
    • Increase dose at two-weekly intervals by doubling the daily dose until a maximum of 25 mg twice daily, if tolerated.
    • If not tolerated, i.e. worsening of cardiac failure manifestations, reduce the dose to the previously tolerated dose.
    • Up-titration can take several months.
    • Should treatment be discontinued for > 14 days, reinstate therapy as above.
    • Absolute contraindications include: (Refer to package insert)
      • cardiogenic shock, bradycardia, various forms of heart block
      • severe fluid overload
      • hypotension
      • asthma

OR

  • Spironolactone, oral, 25mg daily (Doctor initiated).

CAUTION
Spironolactone can cause severe hyperkalemia and should only be used when serum potassium and renal function can be monitored. Check potassium levels within one month of starting therapy and thereafter, as per clinical need . Routine monitoring of potassium levels is essential if spironolactone is used with an ACE-inhibitor, other potassium sparing agent or in the elderly.
Do not use together with potassium supplements.
Do not use in kidney failure (Do not use if eGFR < 30 mL/min).

LOEIII [36]

STEP 3: If carvedilol added in step 2, add spironolactone in step 3; if spironolactone added step 2, add carvedilol in step 3).Spironolactone, oral, 25mg daily (Doctor initiated).

CAUTION

Spironolactone can cause severe hyperkalemia and should only be used when serum potassium and renal function can be monitored.Check potassium levels within one month of starting therapy and thereafter, as per clinical need . Routine monitoring of potassium levels is essential if spironolactone is used with an ACE-inhibitor, other potassium sparing agent or in the elderly.
Do not use together with potassium supplements.
Do not use in kidney failure (Do not use if eGFR < 30 mL/min).

LOEIII [37]

OR

  • Carvedilol, oral (Doctor initiated).
    • Starting dose: 3.125 mg twice daily.
    • Increase dose at two-weekly intervals by doubling the daily dose until a maximum of 25 mg twice daily, if tolerated.
    • If not tolerated, i.e. worsening of cardiac failure manifestations, reduce the dose to the previously tolerated dose.
    • Up-titration can take several months.
    • Should treatment be discontinued for > 14 days, reinstate therapy as above.
    • Absolute contraindications include: (Refer to package insert)
      • cardiogenic shock, bradycardia, various forms of heart block
      • severe fluid overload
      • hypotension
      • asthma

STEP 4:

Symptomatic CCF despite above-mentioned therapy:

Refer to hospital for step up therapy with digoxin.

CAUTION

Patients with CCF on diuretics may become hypokalaemic.

Digoxin therapy should not be initiated if the patient is hypokalaemic.

REFERRAL

Urgent

  • Patients with prosthetic heart valve.
  • Suspected infective endocarditis.
  • Fainting spells.

Non urgent

  • Initial assessment and initiation of treatment.
  • Poor response to treatment.