10-MINUTE CONSULTATION

Diagnosis and management of chronic heart failure

Rupert P Williams specialist registrar in cardiology, British Heart Foundation clinical research training
fellow
1 2
, Pippa Oakeshott reader in general practice
3
1
Kings College London British Heart Foundation Centre of Excellence, Rayne Institute, St Thomas Hospital, London SE1 7EH, UK;
2
National
Institute for Health Research Biomedical Research Centre at Guys and St Thomas NHS Foundation Trust, London, UK;
3
Population Health Sciences,
St Georges, University of London, UK
This is part of a series of occasional articles on common problems in
primary care. The BMJ welcomes contributions from GPs.
An 80 year old woman who rarely attends your surgery presents
with a two month history of difficulty getting her shoes on due
to swollen feet and breathlessness going upstairs.
What you should cover
Ask about
How far can she walk before feeling breathless? Does she
wake at night feeling breathless? How many pillows does
she use? Has she ever had chest pain or been told shes had
a heart attack? Any palpitations or feeling faint?
Risk factors or causes of heart failure:
- Any history of myocardial infarction or angina,
hypertension, valvular heart disease, atrial fibrillation,
diabetes, smoking, excessive alcohol intake, or family
history of ischaemic heart disease or cardiomyopathy?
- Coronary heart disease is the most common cause of heart
failure and requires a specialist referral within two weeks
(see box 1).
Precipitating factors for heart failure:
- Any recent symptoms of tachyarrhythmias,
hyperthyroidism, or anaemia?
- Is she taking any drugs that might exacerbate heart failure
(such as non-steroidal anti-inflammatory drugs, steroids,
diltiazem, or verapamil)?
Differential diagnoses:
- Consider other causes of breathlessness such as
pulmonary emboli, lung malignancy, chronic obstructive
pulmonary disease, and chest infection. Any cough,
haemoptysis, pleuritic chest pain, smoking, or weight loss?
- Consider other causes of ankle swelling such as dependent
oedema due to sleeping in a chair all night.
Clinical examination
Check pulse rate and rhythm (for tachycardia or atrial
fibrillation), blood pressure, and listen for murmurs
suggesting valvular heart disease.
Check respiratory rate and listen for bilateral basal
crepitations.
Assess volume overload including extent of peripheral
oedema and weight. Assess overall severity (see box 1).
What you should do
Talk to the patient
Explain her heart may not be pumping very efficiently.
She may have heart failure, which is a common, treatable
condition affecting about one in 20 people her age.
Arrange for her to have blood tests and an
electrocardiogram this week and to see you in 7-10 days
with the results. Depending on these, you plan to refer her
for an echocardiogram and to see a specialist at the heart
failure clinic.
Establish the diagnosis
Blood tests
B-type natriuretic peptide (BNP) or N-terminal pro-B-type
natriuretic peptide (NT pro-BNP), as per NICE guidance
to assess likelihood of heart failure:
- BNP >400 pg/mLor NTpro-BNP >2000 pg/mLsuggests
strong probability of heart failure. Specialist referral within
two weeks is recommended (box 1).
- BNP 100400 pg/mL or NT pro-BNP 4002000 pg/mL
suggests moderate probability of heart failure and requires
specialist referral within six weeks.
Correspondence to: R P Williams [email protected]
For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1429 doi: 10.1136/bmj.g1429 (Published 12 February 2014) Page 1 of 2
Practice
PRACTICE
Box 1: Indications for urgent specialist assessment within two weeks
Any one of:
Previous myocardial infarction on electrocardiogram or medical history
Inability to perform simple daily activities because of severe breathlessness or breathlessness at rest (NYHA class 4*)
Valvular heart disease
B-type natriuretic peptide >400 pg/mL or N-terminal pro-B-type natriuretic peptide >2000 pg/mL
Baseline blood creatinine concentration >250 mol/L
*New York Heart Association classification of severity of heart failure symptoms: class 1=no symptoms, 2=mild limitation
of physical activity, 3=marked limitation of physical activity, 4=symptoms at rest.
- BNP <100 pg/mL or NT pro-BNP <400 pg/mL suggests
an alternative cause (see differential diagnoses above).
Full blood count and thyroid status to exclude anaemia or
thyroid disease which may precipitate heart failure.
Renal and liver function tests alongside a urinary dipstick
to exclude renal or liver failure as a cause of oedema.
Lipid profile and fasting glucose or HbA
1C
to assess
cardiovascular risk.
Other tests
Arrange an electrocardiogramEvidence of previous
myocardial infarction requires a specialist referral within
two weeks (box 1). A normal electrocardiogram and BNP
make a diagnosis of heart failure unlikely.
Refer for echocardiography and specialist heart failure
clinic within six weeks unless BNP <100 pg/mL or NT
pro-BNP <400 pg/mL suggests an alternative diagnosis.
Consider chest radiography and lung function tests,
especially if there is a history of smoking.
Make a management plan
Drug treatment
Diuretics (such as furosemide 20 mg once daily) can be
started immediately. They can be titrated up or down
according to the degree of oedema. Diuretics improve
symptoms but not mortality.
Angiotensin converting enzyme (ACE) inhibitors
- ACE inhibitors and blockers improve prognosis and
symptoms in heart failure due to left ventricular systolic
dysfunction (diagnosed by echocardiography), but evidence
for their use in heart failure with preserved ejection fraction
is currently inadequate.
- ACE inhibitors may be started at follow-up once the
diagnosis is established and you have results of baseline
renal function tests. Prioritise ACE inhibitors (initially low
dose, such as ramipril 1.25 mg daily) over blockers.
Repeat renal function tests within 1-2 weeks.
blockers (such as bisoprolol 1.25 mg daily) can be started
(usually by the specialist) in addition to ACE inhibitors as
long as no severe asthma or chronic obstructive pulmonary
disease, pulmonary oedema, or bradycardia. Start low, go
slow.
- If patients are already taking a blocker for hypertension,
this should be switched to one licensed for heart failure
(such as bisoprolol).
Reviewor stop medications that could worsen heart failure
(such as non-steroidal anti-inflammatory drugs).
Further monitoring (may be by the heart failure
team depending on local arrangements)
At each review (for example, every 2-4 weeks) assess
clinical status (such as exercise tolerance and oedema),
heart rate and blood pressure (ensure patient is not
hypotensive or feeling faint). Only increase one drug at a
time.
Uptitrate ACE inhibitor (for example, double the dose
every 2-4 weeks) until target dose is achieved (such as
ramipril 5 mg twice daily or highest tolerated dose).
Arrange renal function tests within 1-2 weeks of each dose
increment to check that blood creatinine levels and
estimated glomerular filtration rate are stable and there is
no hyperkalaemia.
Uptitrate blocker (for example, double the dose every
four weeks) until target dose is achieved (such as bisoprolol
5 mg twice daily or highest tolerated dose). Check no
significant bradycardia or lethargy.
Patients should be encouraged to monitor their weight and
to inform you if they gain 2 kg over three days.
Treatment of comorbidities
Optimise treatment for hypertension, coronary heart
disease, diabetes, and atrial fibrillation.
Long term health promotion and rehabilitation
Where appropriate advise on smoking cessation, exercise
and weight loss, and avoidance of excessive salt or alcohol
intake.
Recommend referral to local community heart failure clinic
and exercise based rehabilitation programme. Heart failure
nurses can optimise treatment and provide psychosocial
support.
Contributors: RPW wrote the first draft of the manuscript. Both authors
were involved in critical review and revision of the manuscript
Competing interests: We have read and understood the BMJ Group
policy on declaration of interests and have no relevant interests.
Accepted: 13 November 2013
Cite this as: BMJ 2014;348:g1429
BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1429 doi: 10.1136/bmj.g1429 (Published 12 February 2014) Page 2 of 2
PRACTICE
Useful reading
For patients
British Heart Foundation. Heart failure. www.bhf.org.uk/heart-health/conditions/heart-failure.aspx
For health professionals
Kotecha T, Fox K. Investigating suspected heart failure. BMJ 2013;346:f2442
Arroll B, Doughty R, Andersen V. Investigation and management of congestive heart failure. BMJ 2010;341:c3657
Al-Mohammad A, Mant J, Laramee P, Swain S; the Chronic Heart Failure Guideline Development Group. Diagnosis and management
of adults with chronic heart failure: summary of updated NICE guidance. BMJ 2010;341:c4130.
National Institute for Health and Care Excellence. NICE Pathways: Chronic heart failure overview. http://pathways.nice.org.uk/pathways/
chronic-heart-failure
For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1429 doi: 10.1136/bmj.g1429 (Published 12 February 2014) Page 3 of 2
PRACTICE