Comprehensive Guidelines for the Diagnosis and Treatment of Chronic Heart Failure Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology

The aim of this report is to provide practical guidelines for the diagnosis, assessment and treatment of heart failure for use in clinical practice and in addition for epidemiological surveys and for clinical trials. The recommendations in these guidelines should always be considered in the light of local regulatory requirements for the administration of any chosen drug or device. This report is a comprehensive summary of the full report 1. The full report should be used when in doubt or when further information is required. Recommendations regarding treatments have been based on the degree of available evidence. Heart failure is usually associated with evidence of left ventricular (LV) systolic dysfunction, although diastolic impairment at rest is a common if not universal accompaniment. Diastolic heart failure is often presumed to be present when symptoms and signs of heart failure occur in the presence of a preserved LV systolic function. The aetiology of heart failure and the presence of exacerbating factors or other diseases that may have an important influence on management should be considered carefully in all cases. Symptoms of chronic heart failure, pulmonary oedema and shock may be caused by tachy- and bradyarrhythmias or myocardial ischaemia even in patients without major, permanent cardiac dysfunction. It is important to identify any reversible factors in order to treat heart failure optimally. Once a diagnosis of heart failure has been established symptoms may be used to classify the severity of heart failure, e.g. by NYHA class or into mild, moderate or severe and should be used to monitor the effects of therapy. Electrocardiographic changes in patients with heart failure are frequent. The negative predictive value of normal ECG to exclude LV systolic dysfunction exceeds 90% The most important parameter of ventricular function is the LV ejection fraction for distinguishing patients with cardiac systolic dysfunction and those with preserved systolic function. Echocardiography also provides rapid and semi-quantitative assessment of valvular function, cardiac filling characteristics through Doppler measurements, and is helpful in determining the etiology of heart failure. Coronary angiography and hemodynamic monitoring should be considered in patients with acute or acutely decompensated chronic heart failure and in the presence of severe heart failure (shock or acute pulmonary oedema) not responding to initial treatment. Routine hemodynamic monitoring should not be used to tailor therapy in chronic heart failure These peptides may be most useful clinically as a ‘rule out’ test due to consistent and very high negative predictive values. To satisfy the definition of heart failure, symptoms and/or signs of heart failure and objective evidence of cardiac dysfunction, preferably obtained by echocardiography, must both be present. Conditions which mimic or exacerbate the symptoms and signs of heart failure need to be excluded (Table 1). Fig. 2 presents a diagnostic scheme to be performed routinely in patients with suspected heart failure. Additional tests (Table 2) should be performed or re-evaluated in cases where diagnostic doubt persists or clinical features suggest a reversible cause for heart failure. Table 3 provides a management outline which connects the diagnosis part of the guidelines with the treatment section. The therapeutic approach in chronic heart failure due to cardiac systolic dysfunction consists of general advice and other non-pharmacological measures, pharmacological therapy, mechanical devices and surgery. General advice and measures (Table 4) Level C for all advice and measures unless stated otherwise Rest, exercise and exercise training (Table 4) Level C for all recommendations unless stated otherwise Important adverse effects associated with ACE inhibitors are hypotension, syncope, renal insufficiency, hyperkalaemia and angioedema. Changes in systolic and diastolic blood pressure and increases in serum creatinine are usually small in normotensive patients. Initiating ACE inhibitor therapy (Table 5) Detailed recommendations and major side effects are outlined in Table 6. Initiation of therapy — see Table 7 Whether concomitant beta-blockade negatively affects the effect of ARB needs further evaluation Side effects, notably cough are significantly less than with ACE-inhibitors. Contraindications: bradycardia, second- and third-degree AV-block, sick sinus syndrome, carotid sinus syndrome, hypokalaemia and hypercalcaemia. The usual daily dose of oral digoxin is 0.25–0.375 mg if serum creatinine is in the normal range (in the elderly 0.625–0.125 mg, occasionally 0.25 mg). No loading dose is needed when treating chronic conditions. The treatment can be initiated with 0.25 mg bid. for 2 days. Class I anti-arrhythmics should be avoided (level C). Beta-blockers reduce sudden death in heart failure (level A). They may be indicated in the management of sustained or non-sustained ventricular tachy-arrhythmias, either alone or in combination with amiodarone or non-pharmacological therapy (level C). Amiodarone is effective against most supraventricular and ventricular arrhythmias (level B). But routine administration of amiodarone in patients with heart failure is not justified (level B). There are no controlled data to support the use of revascularisation procedures for the relief of heart failure symptoms, but in individual patients with heart failure of ischaemic origin revascularisation may lead to symptomatic improvement (level C). Mitral valve surgery in patients with severe left ventricular dysfunction and severe mitral valve insufficiency may lead to symptomatic improvement in selected heart failure patients (level C). Cardiomyoplasty and partial left ventriculotomy (Batista procedure) cannot be recommended for the treatment of heart failure (level C). Current indications for ventricular assist devices and artificial heart include bridging to transplantation, transient myocarditis and in some permanent hemodynamic support (level C). Treatment with an ACE inhibitor is recommended in patients with reduced systolic function as indicated by a substantial reduction in left ventricular ejection fraction. In patients with asymptomatic left ventricular dysfunction following an acute myocardial infarction add a beta-blocker. With signs of fluid retention — diuretics in combination with an ACE inhibitor and a beta-blocker: first, the ACE inhibitor and diuretic should be co-administered. When symptomatic improvement occurs, i.e. fluid retention disappears, try to reduce the dose of diuretic, but the optimal dose of the ACE inhibitor should be maintained. To avoid hyperkalaemia, any potassium-sparing diuretic should be omitted from the diuretic regimen before introducing an ACE inhibitor. Potassium-sparing diuretics may be added if hypokalaemia persists. Add a beta-blocker and titrate to target dosages. Patients in sinus rhythm receiving cardiac glycosides, who have improved from severe to mild heart failure, should continue cardiac glycoside therapy. In case of intolerance to ACE inhibition or beta-blockade, consider addition of an ARB to the remaining drug. Avoid adding an ARB to the combination ACE inhibitor and a beta-blocker. For most frequent causes of worsening heart failure see full text. Patients in NYHA class III who have improved from NYHA class IV during the preceding 6 months or are currently NYHA class IV should receive low-dose spironolactone (12.5–50 mg daily, Table 8). Cardiac glycosides are often added. Loop diuretics can be increased in dose. Combinations of diuretics (a loop diuretic with a thiazide) are often helpful (Fig. 3). Consider cardiac transplantation Patients should be (re)considered for heart transplantation. Consider palliative treatment in terminal patients, e.g. opiates for the relief of symptoms (Fig. 3). There is little evidence from clinical trials or observational studies as to how to treat diastolic dysfunction, and there is uncertainty about the prevalence of diastolic dysfunction in patients with heart failure symptoms and a normal systolic function in the community. The therapeutic approach to systolic dysfunction in the elderly should be principally identical to that in younger heart failure patients with respect to the choice of drug treatment. There is no evidence in patients with persistent atrial fibrillation and heart failure suggesting that restoring and maintaining sinus rhythm is superior to control of heart rate. In permanent (cardioversion not attempted or failed) atrial fibrillation, rate control is mandatory. In asymptomatic patients, beta-blockade, digitalis glycosides or the combination may be considered, in symptomatic patients digitalis glycosides are the first choice (level C). If digoxin or warfarin is used in combination with amiodarone, their dosages may need to be adapted. Specific recommendations in addition to general treatment for heart failure due to systolic left ventricular dysfunction. Comprehensive non-pharmacological intervention programmes are helpful in improving quality of life, reducing readmission and decreasing cost (level of evidence B). However, it is unclear what the best content of organisation of these programs is. Different models (e.g. heart failure outpatient clinic, heart failure nurse specialist, community nurse specialist, patient tele-monitoring) may be appropriate depending on the stage of the disease, patient population and national resources (level of evidence C). Although basic agreement can be achieved on the content of care needed by patients with heart failure, the organisation of the care should be closely adapted to the needs of the patient group and the resources of the organisation.