Recent updates in the management protocol for Heart Failure

M3 India Newsdesk May 16, 2018

This article aims to inform the doctors about the latest evidences that can guide to recognize and diagnose chronic heart failure early and optimize management.


The management protocol for heart failure includes measures which aim to reduce the workload on the heart. This may be seemingly simple, but it involves an overwhelming number of measures. Patients who may fail to adhere to the treatment for many number of reasons- some show little interest in following these measures, some may not be properly informed about all the measures, some may forget following few measures on a daily basis. Thus, it is important for clinicians to follow a proper treatment regime backed by latest evidences to make life better for patients with HF.


The Current Status in India

Incidence Stats:

  • The estimation about incidence of HF in India vary widely from 1.3 to 23 million.
  • HF with preserved ejection fraction (HFpEF) accounts for about 25% of the total HF burden.
  • In India, patients have HF at a younger age when compared to USA.

Rural Vs Urban Issues:

  • Almost 75 percent of the Indian population are in rural areas, where physicians in the primary health centres practice myriad form of systems including indigenous system.
  • In the urban areas, a large proportion of health care is provided by private practitioners which is usually heavy on pockets.

These situations pose a hurdle for managing the stable conditions for HF patients.


Diagnosis of Heart Failure

Usually, HF can be diagnosed in patients by basic blood estimations, 12-lead electrocardiography (ECG), chest X-ray, 2D echocardiography and biomarkers. In certain conditions, other diagnostic tests should be performed, i.e.:

Test Usage
Cardiac Magnetic Resonance (CMR) In Non-diagnostic echocardiographic studies, complex congenital heart diseases, infiltrative myocardial disease
Cardiac Angiography To rule out coronary artery disease
Single-photon Emission Computed Tomography (SPECT) To assess ischemia and myocardial viability
Positron Emission Tomography (PET) To detect ischemia, viability, non-specific aorto-arteritis, IgG gammopathy and other inflammatory disorders such as sarcoidosis
Late Gadolinium Enhancement (LGE) To indicate myocardial fibrosis and detection of scars
Right Heart Catheterization To identify pulmonary vascular assistance
Endomyocardial Biopsy Should be considered in rapid progression HF or worsening ventricular dysfunction


Get HF under control!

HF treatment goals include alleviating symptoms, improving prognosis, and reducing mortality and morbidity by reversing or slowing the cardiac and peripheral dysfunction. Some of the methods to ensure successful management of HF are enlisted below.

  • Informing patients and making them familiar with HF, clearing misconceptions, motivating self-care, and providing tips for disease management. The patient must be persuaded to discuss with the physician and have regular follow ups to overcome poor adherence.
  • Non-pharmacological management involves following a heathy diet and taking adequate fluids, avoiding alcohol consumption, limiting salt use, monitoring weight, regular exercise, preventing smoking and handling stress.
  • Immunization by pneumococcal vaccine (first dose after confirmation of HF diagnosis and a second dose after 5 years) and influenza vaccines (every year before the onset of winter) are also important aspects of HF management.
  • Pharmacological treatment plays a key role in managing HF. HF with reduced ejection fraction (HFrEF) patients can be administered with neurohormonal modulators as follows:
Drugs Special care should be taken for
Angiotensin converting enzyme (ACE) inhibitors Hyperkalaemia, Hypotension, Renal Dysfunction and Angioneurotic Oedema
Angiotensin receptor blockers (ARBs) Patients who receive the combination of ACE inhibitor and ARB must be strictly monitored
Mineralocorticoid receptor antagonists (MRAs) Diabetes mellitus patients must be supervised for hyperkalaemia
Beta-blockers Patients must be observed for bradycardia, hypotension, and wheezing
Angiotensin receptor neprilysin inhibitors (ARNIs) Should not be combined with an ACE inhibitor/ARB and patients must be watched out for hypotension, hyperkalaemia, and angioneurotic oedema


 

  • For HFrEF patients, treatment strategies should focus on appropriate management of co-morbidities such as hypertension, DM, etc.
  • Advance treatment involves device therapy, Implantable cardioverter defibrillators (ICD), cardiac resynchronization therapy (CRT) and revascularization.

Management of co-morbidities

HF is a multimorbid condition. Its treatment may impact the co-morbidities or vice versa. The table below shows the co-morbidities and the precautions to be taken while treating HF.

Co-morbidities Precautions
 Diabetes Sulfonylurea derivatives, Thiazolidinediones, Insulin avoided
Hypertension Diltiazem, Verapamil, Moxonidine should be avoided in HFrEF
Coronary Artery Disease Diltiazem and Verapamil unsafe in HFrEF
Atrial Fibrillation Non-dihydropyridine Calcium Channel Blockers should be avoided
Electrolyte Dysfunction
  • Loop diuretics and thiazide diuretics: to reduce serum potassium
  • ACE inhibitors, ARBs and MRAs increase serum potassium

There is a myriad of research done in the field of management of HF. The management guidelines are large and often overwhelming for clinicians. A simple algorithm or a protocol of HF management is the need of the hour, one which can be easily prescribed and fits the needs of the clinicians. This document gives a simple summary of the management protocol for HF based on the latest evidences.

Access the full article here.

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