Chronic heart failure

Clinical features

– Left-sided HF (left ventricle failure; most frequent form)
Fatigue  and/or progressive onset of dyspnoea, occurs on exertion and then at rest, accentuated by the decubitus position, preventing the patient from lying down; peripheral oedema.
– Right-sided HF (right ventricle failure)
Oedema of the lower limbs, hepatomegaly, jugular vein distention, hepatojugular reflux; ascites in advanced stages.
– Global HF (failure of both ventricles)
Left and right-sided signs; right-sided signs are often the most prominent.

Evaluate severity of HF1:

Class I

No limitation of physical activity. No symptoms during ordinary physical activity.

Class II

Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnoea.

Class III

Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnoea.

Class IV

Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest.


Identify causative or aggravating factors:
− Coronary or valvular heart disease, hypertension, viral or toxic cardiopathy, pericarditis.
− Anaemia, American trypanosomiasis, rheumatic fever, diabetes, thyroid disorder, drug/alcohol addiction.

Paraclinical investigations

− Echocardiogram: if available, method of choice to confirm cardiopathy.
− Electrocardiogram (ECG): can diagnose left ventricular cardiomyopathy (left ventricular hypertrophy and/or left bundle branch block) or arrhythmia and particularly atrial fibrillation (AF or Afib) or signs of myocardial ischemia or infarction.
− Chest X-ray: can exclude lung disease in patients with dyspnoea or can show cardiomegaly or pleural effusion (often bilateral) and alveolar-interstitial syndrome.
− Blood test: blood count, ionogram, serum creatinine.
− Other necessary laboratory tests according to comorbidities (e.g. diabetes, thyroid disorder).

Treatment

Lifestyle and dietary advice

− Reduce salt intake to limit fluid retention.
− Normal fluid intake except in cases of very severe oedema.
− Stop smoking.
− Physical activity adapted to the patient’s capacity.
− Weight loss if BMI ≥ 25.

Treatment of fluid retention

furosemide PO: start with 20 mg once daily; increase if necessary, according to clinical response (certain patients need doses of 80 mg 1 to 2 times daily) then reduce once oedema decrease (20 to 40 mg once daily).
The reabsorption of oedema can sometimes be slow, taking up to 2 to 3 weeks.
The gradual worsening of HF may require an increase in dosage. Lifelong-term treatment with diuretics is not always necessary. 
In the event of resistant oedema, add hydrochlorothiazide PO (25 mg 1 to 2 times daily for a few days) but only in hospital settings and monitoring renal function.

Long-term (lifelong) treatment

− ACE inhibitors are the first line treatment. Start with low doses, especially in patients with hypotension, renal impairment, hyponatraemia. 
While increasing the dose monitor: drug tolerance (dry cough), blood pressure (the systolic BP should remain above > 90 mmHg), serum potassium and creatinine levels.
In patients taking diuretics, reduce the dose of the diuretic if possible while introducing ACE inhibitors (risk of hypotension if the patient is on high doses of diuretics).
enalapril PO:
Week 1: 2.5 mg once daily for 3 days then 5 mg once daily 
Week 2: 10 mg once daily for 3 days then 20 mg once daily
The effective dose is usually 20 mg once daily (or 10 mg 2 times daily). Doses of 10 mg daily are sometimes enough; conversely, doses of 40 mg daily (maximum) are sometimes necessary.

− Once the patient has been stable for at least 2 weeks taking ACE inhibitors and in the absence of any contra-indications (asthma, hypotension, bradycardia, conduction disorders, particularly atrio-ventricular heart blocks), add a beta blocker.
bisoprolol PO: start with a low dose and gradually increase as long as the drug is well tolerated (monitor for signs of worsening HF, blood pressure, heart rate).
Week 1: 1.25 mg once daily 
Week 2: 2.5 mg once daily
Week 3: 3.75 mg once daily
Weeks 4 to 8: 5 mg once daily
If insufficient:
Weeks 9 to 12: 7.5 mg once daily
As from week 13: 10 mg once daily (max. 10 mg daily)
In the event of temporarily worsening HF, hypotension or bradycardia, readjust doses of associated treatments and reduce the dose of bisoprolol or gradually stop treatment (stopping abruptly can lead to acute deterioration of the patient’s condition). Once the patient is stabilized, re-increase/recommence bisoprolol.

Other treatments

− Antagonist of aldosterone: only if serum potassium levels and ECG can be monitored (risk of severe hyperkalaemia), add spironolactone PO (25 mg once daily) to long-term treatment, particularly in cases of severe HF (Classes III and IV).
− Nitrates: can be used in left-sided or global HF in patients with intolerance to ACE inhibitors (cough is not tolerated, renal impairment, severe hypotension).
isosorbide dinitrate PO: start with 5 to 40 mg 2 to 3 times daily and increase up to the effective dose, usually 15 to 120 mg daily.
− Digitalis glycosides: administer with caution, in intensive care unit (the therapeutic dose is close to the toxic dose), only in patients with AF with rapid ventricular response confirmed by ECG: no visible P waves, irregularly irregular QRS complex (120-160).

Treatment of causative or aggravating factors

According to the cause.

Surveillance and monitoring

Laboratory surveillance 
According to treatment (ACE, diuretic, etc.).

Clinical monitoring
− Once stabilised, consultations once a month for the first 6 months, then individualised frequency of consultations depending on the patient's characteristics.
− Routine consultations: weight curve, BP, progress of signs (dyspnoea, oedema, etc.).
− Monitoring of comorbidities and causative or aggravating.

Patient education
− Lifestyle and dietary measures (diet, weight control, physical activity adapted to the patient’s capacity, etc.).
− Warning signs (shortness of breath or oedema of the lower limbs, serious adverse effects of treatment) and management (timely/urgent medical consultation).



References

  1. Chop WM, Jr. Extending the New York Heart Association classification system. JAMA. 1985;254:505.