Algorithm for the diagnosis and pharmacological management of heart failure

Patient Presentation

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Patient assessment Clinical history, dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, cardiac arrhythmias/palpitations, life-style factors i.e. smoking, alcohol, diet, activity, weight. Examination Previous cardiac history Paroxysmal nocturnal dyspnoea Tachycardia/new onset AF Increased jugular venous pressure Gallop-rhythm New heart murmur with symptoms Lung crepitations Sleep apnoea

New onset breathlessness Ankle Oedema Dyspnoea on exertion/rest Orthopnoea Fatigue/tiredness

If Heart Failure suspected because of history, symptoms and signs -

Seek to exclude heart failure through:

Se 12-lead ECG and natriuretic peptides (BNP or NTproBNP - where available

Other recommended tests:

(mostly to exclude other conditions) Chest X-ray; Blood tests U&Es, creatinine, FBC, TFTs, LFTs, glucose and lipids; Urinalysis; Peak flow or Spirometry

Both normal Heat Failure unlikely consider alternative diagnosis

If one or more abnormal

Imaging by echocardiography

If no abnormality detected Heart failure unlikely, but if diagnostic doubt persists consider diastolic dysfunction and consider referral for specialist assessment

Abnormal echo result Assess heart failure severity, aetiology, precipitating and exacerbating factors and type of cardiac dysfunction. Correctable causes must be identified. Consider referral

Generalist Add diuretic Diuretic therapy is likely to be required to control congestive symptoms and fluid retention Add digoxin If a patient in sinus rhythm remains symptomatic despite therapy with a diuretic, ACE inhibitor (or angiotensin II receptor antagonist) and beta-blocker or if patient is in atrial fibrillation then use as first-line therapy Specialist

New diagnosis of LVD

Start ACE inhibitor and titrate upwards Or if ACE inhibitor not tolerated (e.g. due to severe cough) Consider angiotension II receptor antogonist

Add beta-blocker and tritrate upwards

Add spironolactone If patients remains moderately to severely symptomatic despite optimal drug therapy listed above

Seek specialist advice

JW Cov & Warks CHD Network 2007