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## Complete Summary

#### GUIDELINE TITLE

Guidelines for the prevention, detection and management of chronic heart
failure in Australia, 2006.

#### BIBLIOGRAPHIC SOURCE(S)

National Heart Foundation of Australia, Cardiac Society of Australia and
New Zealand, Chronic Heart Failure Guidelines Expert Writing Panel.
Guidelines for the prevention, detection and management of chronic heart
failure in Australia, 2006. Sydney (Australia): National Heart
Foundation of Australia; 2006 Nov. 79 p. \[335 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: National Heart Foundation of
Australia, Cardiac Society of Australia and New Zealand. Guidelines on
contemporary management of the patient with chronic heart failure in
Australia. Sydney (Australia): National Heart Foundation of Australia;
2002.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [October 18, 2007, PDE5 inhibitors, Viagra (sildenafil citrate),
    Levitra (vardenafil HCL), Cialis
    (tadalafil)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#PDE5):
    The PRECAUTION and updated Adverse Reactions Sections of the
    approved product labeling for Viagra, Levitra, and Cialis were
    revised in response to reports of sudden decreases or loss of
    hearing.

-   [August 16, 2007, Coumadin
    (Warfarin)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Warfarin):
    Updates to the labeling for Coumadin to include pharmacogenomics
    information to explain that people\'s genetic makeup may influence
    how they respond to the drug.

-   [October 6, 2006, Coumadin (warfarin
    sodium)](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Coumadin):
    Revisions to the labeling for Coumadin to include a new patient
    Medication Guide as well as a reorganization and highlighting of the
    current safety information to better inform providers and patients.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Chronic heart failure

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Nursing

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To obtain better health outcomes by improving the management of
    chronic heart failure (CHF)

-   To reduce unwarranted variation from best practice treatment of CHF
    throughout Australia

#### TARGET POPULATION

Patients with, or at risk of developing, chronic heart failure (CHF)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Evaluation of signs and symptoms

2.  Electrocardiography, chest x-ray, echocardiography

3.  Full blood count, plasma urea, creatine, and electrolytes

4.  Measurement of plasma levels of B-type natriuretic peptide

**Management**

1.  Non-pharmacological

    -   Patient support, including discussion of lifestyle, personal
        issues, medical issues, and support

    -   Physical activity and dietary restrictions

    -   Referral for sleep apnoea

    -   Risk factor modification

2.  Pharmacological

    -   Angiotensin-converting enzyme inhibitors (ACEIs)

    -   Beta-blockers

    -   Statins

    -   Diuretics

    -   Aldosterone receptor antagonists

    -   Angiotensin II receptor antagonists

    -   Eplerenone

    -   Hydralazine isosorbide dinitrate combination

    -   Digoxin

3.  Devices, including biventricular pacing and implantable cardioverter
    defibrillators

4.  Surgical approaches that may include myocardial revascularisation,
    insertion of devices, and cardiac transplantation

5.  Post-discharge multidisciplinary management programs and palliative
    care strategies

6.  Treatment of associated disorders

#### MAJOR OUTCOMES CONSIDERED

-   Morbidity and mortality

-   Quality of life

-   Hospitalization durations and rates

-   Functional status

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**I**: Evidence obtained from a systematic review of all relevant
randomized controlled trials (RCTs)

**II**: Evidence obtained from at least one properly designed randomised
controlled trial

**III-1**: Evidence obtained from well-designed pseudo-randomised
controlled trials (alternate allocation or some other method)

**III-2**: Evidence obtained from comparative studies with concurrent
controls and allocation not randomised (cohort studies), case-control
studies, or interrupted time series with a control group

**III-3**: Evidence obtained from comparative studies with historical
control, two or more single-arm studies, or interrupted time series
without a parallel control group

**IV**: Evidence obtained from case series, either post-test or pre-test
and post-test

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendations**

1.  Rich body of high-quality randomized controlled trial (RCT) data

2.  Limited body of RCT data or high-quality non-RCT data

3.  Limited evidence

4.  No evidence available -- panel consensus judgment

#### COST ANALYSIS

**Economic Burden**

Chronic cardiovascular disease contributes to more than \$5 billion per
annum in healthcare costs in Australia. Although chronic heart failure
(CHF) is a major component of such expenditure, there are limited data
relating to its exact share of this burden. In 1993--94, the Australian
Institute of Health and Welfare estimated CHF accounted for the
following costs:

-   \$411 million of healthcare costs (representing 0.4% of total
    healthcare costs)

-   \$140 million per annum in hospitalisation costs

-   \$135 million per annum for nursing home costs

Based on data from at least six other developed countries, this was a
likely under-estimate. For example, CHF is reported to directly consume
approximately 1.5--2% of total healthcare costs, hospital admissions
being the greatest single component (around 70%). A more recent analysis
suggests that CHF contributes to more than \$1 billion in healthcare
expenditure per annum in Australia.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Throughout the original guideline document, boxed \"practice points\"
highlight key issues, while summaries of graded recommendations are
provided for most sections.

The grades of recommendations (A-D) are defined at the end of the
\"Major Recommendations\" field.

**Diagnosis**

**Symptoms of Chronic Heart Failure (CHF)**

*Practice Point*

Clinical diagnosis of CHF is often unreliable, especially in obese
patients, those with pulmonary disease and the elderly. Therefore, it is
important to perform investigations to confirm the diagnosis.

**Diagnostic Investigations**

*Practice Point*

The classic symptom of CHF is exertional dyspnoea or fatigue.
Orthopnoea, paroxysmal nocturnal dyspnoea (PND) and ankle oedema may
appear at a later stage.

Physical signs are often normal in the early stages. Examination should
include assessment of vital signs, cardiac auscultation (murmurs, S3
gallop) and checking for signs of fluid retention (e.g., raised jugular
venous pressure, peripheral oedema, basal inspiratory crepitations).

All patients with suspected CHF should undergo an electrocardiogram
(ECG), chest x-ray, and echocardiogram, even if the physical signs are
normal.

Full blood count, plasma urea, creatinine, and electrolytes should be
measured during the initial workup, and if there are any changes in the
patient\'s clinical status. Urea, creatinine, and electrolytes should
also be checked regularly in stable patients, and when changes are made
to medical therapy.

The role of plasma B-type natriuretic peptide (BNP) measurements is
evolving, but it has been shown to improve diagnostic accuracy in
patients presenting with unexplained dyspnoea. In patients with new
symptoms, where the diagnosis is not clear following the initial
clinical assessment and an echocardiogram cannot be organised in a
timely fashion, then measurement of BNP or N-terminal proBNP may be
helpful. In this setting, a normal level makes the diagnosis of heart
failure unlikely (especially if the patient is not taking cardioactive
medication). If the level is raised, further investigation---including
echocardiography --- is warranted.

Underlying aggravating or precipitating factors (e.g., arrhythmias,
ischaemia, non-adherence to diet or medications, infections, anaemia,
thyroid disease, addition of exacerbating medications) should be
considered and managed appropriately.

**Recommendations for Diagnostic Investigation of CHF**

-   All patients with suspected CHF should undergo an echocardiogram to
    improve diagnostic accuracy and determine the mechanism of heart
    failure. (Grade of recommendation = D)

-   Coronary angiography should be considered in patients with a history
    of exertional angina or suspected ischaemic left ventricular (LV)
    dysfunction. (Grade of recommendation = D)

-   Plasma BNP measurement may be helpful in patients presenting with
    recent-onset dyspnoea; it has been shown to improve diagnostic
    accuracy with a high negative predictive value. (Berger et
    al., 2002) (Grade of recommendation = B)

-   Haemodynamic measurements may be particularly helpful in patients
    with refractory CHF, recurrent heart failure with preserved systolic
    function (HFPSF) (diastolic CHF), or in whom the diagnosis of CHF is
    in doubt (Stevenson et al., 1990) (Grade of recommendation = D)

-   Endomyocardial biopsy may be indicated in patients with
    cardiomyopathy with recent onset of symptoms, where coronary heart
    disease (CHD) has been excluded by angiography, or where an
    inflammatory or infiltrative process is suspected (McCarthy et
    al., 2000) (Grade of recommendation = D)

-   Nuclear cardiology, stress echocardiography and positron emission
    tomography (PET) can be used to assess reversibility of ischaemia
    and viability of myocardium in patients with CHF who have myocardial
    dysfunction and CHD. Protocols have been developed using magnetic
    resonance imaging (MRI) to assess ischaemia and myocardial
    viability, and to diagnose infiltrative disorders. However, MRI is
    not widely available. (Grade of recommendation = D)

-   Thyroid function tests should be considered, especially in older
    patients without pre-existing CHD who develop atrial fibrillation,
    or in whom no other cause of CHF is evident. (Grade of
    recommendation = D)

**Supporting Patients**

**Recommendations for Discussion with Patients with CHF**

-   **Lifestyle**: Adopt a healthier lifestyle to address risk
    factors/conditions contributing to the development and progression
    of CHF (see Section 6, Non-pharmacological management, in the
    original guideline document).

-   **Personal issues**: Understand the effect of CHF on personal energy
    levels, mood, depression, sleep disturbance and sexual function, and
    develop strategies to cope with changes and emotions related to
    family, work and social roles.

-   **Medical issues**: Consider practical issues related to pregnancy,
    contraception, genetic predisposition and practical items, such as
    an alert bracelet and a diary for daily weights/medications.

-   **Support**: Access to support services, such as Heart Support
    Australia, Cardiomyopathy Association of Australia, home help and
    financial assistance.

*Practice Point*

Information for people with CHF can be obtained through the Heart
Foundation\'s telephone information service, Heartline 1300 36 27 87
(local call cost) and the Heart Foundation website:
[www.heartfoundation.com.au](http://www.heartfoundation.com.au/).

Patients should also consult their local phone directories for contact
details for Heart Support Australia and the Cardiomyopathy Association
of Australia in each state.

**Non-pharmacological Management**

**Physical Activity and Rehabilitation**

*Practice Point*

Non-pharmacological management may be as important as prescribing
appropriate medications. Patients with CHF may develop physical
deconditioning. Therefore, regular physical activity is recommended
using a rehabilitation program tailored to suit the individual. Other
measures are listed in the recommendations below.

**Sleep Apnoea**

*Practice Point*

If sleep apnoea is suspected, referral to a sleep physician is
indicated.

**Recommendations for Non-pharmacological Management of CHF\***

-   Regular physical activity is recommended (Mancini et al., 1992). All
    patients should be referred to a specially designed physical
    activity program, if available (Chati et al., 1996; Meyer et al.,
    1997; Sinoway, 1998) (Grade of recommendation = B)

-   Patient support by a doctor and pre-discharge review and/or home
    visit by a nurse is recommended to prevent clinical deterioration
    (Rich et al., 1995; Stewart et al., 1999) (Grade of recommendation =
    A)

-   Patients frequently have coexisting sleep apnoea and, if suspected,
    patients should be referred to a sleep clinician as they may benefit
    from nasal continuous positive airway pressure (CPAP)
    (Naughton, 1998) (Grade of recommendation = D)

-   Patients who have an acute exacerbation, or are clinically unstable,
    should undergo a period of bed rest until their condition improves
    (McDonald, Burch, & Walsh, 1972) (Grade of recommendation = D)

-   Dietary sodium should be limited to below 2 g/day (Stewart et
    al., 1999) (Grade of recommendation = C)

-   Fluid intake should generally be limited to 1.5 L/day with mild to
    moderate symptoms, and 1 L/day in severe cases, especially if there
    is coexistent hyponatraemia (Fonarow et al., 1997) (Grade of
    recommendation = C)

-   Alcohol intake should preferably be nil, but should not exceed 10 to
    20 g a day (one to two standard drinks) (Fonarow et al., 1997)
    (Grade of recommendation = D)

-   Smoking should be strongly discouraged. (Grade of recommendation =
    D)

-   Patients should be advised to weigh themselves daily and to consult
    their doctor if weight increases by more than 2 kg in a two-day
    period, or if they experience dyspnoea, oedema, or abdominal
    bloating. (Grade of recommendation = D)

-   Patients should be vaccinated against influenza and pneumococcal
    disease. (Grade of recommendation = B)

-   High-altitude destinations should be avoided. Travel to very humid
    or hot climates should be undertaken with caution, and fluid status
    should be carefully monitored. (Grade of recommendation = C)

-   Sildenafil and other phosphodiesterase V inhibitors are generally
    safe in patients with heart failure. However, these medications are
    contraindicated in patients receiving nitrate therapy, or those who
    have hypotension, arrhythmias, or angina pectoris (Zusman et
    al., 1999) (Grade of recommendation = C)

-   Obese patients should be advised to lose weight. (Grade of
    recommendation = D)

-   A diet with reduced saturated fat intake and a high fibre intake is
    encouraged in patients with CHF. (Grade of recommendation = D)

-   No more than two cups of caffeinated beverages per day recommended.
    (Grade of recommendation = D)

-   Pregnancy should be avoided in patients with CHF. (Grade of
    recommendation = D)

\* These grades of recommendation apply only to patients with CHF

**Pharmacological Therapy**

**Recommendations for Preventing CHF and Treating Asymptomatic LV
Dysfunction**

-   All patients with asymptomatic systolic LV dysfunction should be
    treated with an angiotensin-converting enzyme inhibitor (ACEI)
    indefinitely, unless intolerant (Pfeffer et al., 1992; \"Effect of
    enalapril,\" 1992) (Grade of recommendation = A)

-   Anti-hypertensive therapy should be used to prevent subsequent CHF
    in patients with elevated blood pressure (Kostis et al., 1997;
    Dahlof et al., 1991; \"Medical Research Council trial of
    treatment,\" 1992; Hansson et al., 1999; Hansson et al., 2000; Brown
    et al., 2000) (Grade of recommendation = A)

-   Preventive treatment with an ACEI may be considered in individual
    patients at high risk of ventricular dysfunction (Yusuf et
    al., 2000) (Grade of recommendation = B)

-   Beta-blockers should be commenced early after a myocardial
    infarction (MI), whether or not the patient has systolic ventricular
    dysfunction (Dahlof et al., 1991; \"Medical Research Council trial
    of treatment,\" 1992) (Grade of recommendation = B)

-   Statin therapy should be used as part of a risk management strategy
    to prevent ischaemic events and subsequent CHF in patients who
    fulfill criteria for lipid-lowering (Kjekshus et al., 1997) (Grade
    of recommendation = B)

**Treatment of Symptomatic Systolic Heart Failure**

*Practice Point*

All patients with systolic LV dysfunction, whether symptomatic or
asymptomatic, should be commenced on ACE inhibitors with every effort
made to up-titrate to the dose shown to be of benefit in major trials.
Other recommended medications are listed in the recommendations below.

*Practice Point*

Drugs to avoid in CHF:

-   Anti-arrhythmic agents (apart from beta-blockers and amiodarone)

-   Non-dihydropyridine calcium-channel blockers (verapamil, diltiazem)

-   Tricyclic antidepressants

-   Non-steroidal anti-inflammatory drugs and COX-2 inhibitors

-   Clozapine

-   Metformin and thiazolidinediones (pioglitazone, rosiglitazone)

-   Corticosteroids (glucocorticoids and mineralocorticoids)

-   Tumour necrosis factor antagonist biologicals

**Recommendations for Pharmacological Treatment of Symptomatic CHF**

*First-line Agents*

-   ACEIs, unless not tolerated or contraindicated, are recommended for
    all patients with systolic heart failure (left ventricular ejection
    fraction \[LVEF\] \<40%), whether symptoms are mild, moderate, or
    severe (The SOLVD Investigators, 1991; The CONSENSUS Trial Study
    Group, 1987) (Grade of recommendation = A)

-   Every effort should be made to increase doses of ACEIs to those
    shown to be of benefit in major trials (\"Clinical outcome,\" 1998;
    Packer et al., 1999). If this is not possible, a lower dose of ACEI
    is preferable to none at all. (Grade of recommendation = B)

-   **Diuretics** should be used, if necessary, to achieve euvolaemia in
    fluid-overloaded patients. In patients with systolic LV dysfunction,
    diuretics should never be used as monotherapy, but should always be
    combined with an ACEI to maintain euvolaemia. (Grade of
    recommendation = D)

-   **Beta-blockers** are recommended, unless not tolerated or
    contraindicated, for all patients with systolic CHF who remain
    mildly to moderately symptomatic despite appropriate doses of an
    ACEI (Packer et al., \"The effect of carvedilol,\" 1996; \"Effect of
    metoprolol CR/XL,\" 1999; \"The Cardiac Insufficiency Bisoprolol
    Study II (CIBIS-II),\" 1999; Packer et al., 2001) (Grade of
    recommendation = A)

-   Beta-blockers are also indicated for patients with symptoms of
    advanced CHF (Packer et al.,  2001) (Grade of recommendation = B)

-   **Aldosterone receptor blockade with spironolactone** is recommended
    for patients who remain severely symptomatic, despite appropriate
    doses of ACEIs and diuretics (Pitt et al., 1999) (Grade of
    recommendation = B)

-   **Eplerenone** is recommended in the early post-MI period for
    patients with LV systolic dysfunction and symptoms of heart failure.
    (Grade of recommendation = B)

-   **Angiotensin II receptor antagonists** may be used as an
    alternative in patients who do not tolerate ACEIs due to
    kinin-mediated adverse effects (e.g., cough) (Pitt et al., 1997).
    They should also be considered for reducing morbidity and mortality
    in patients with systolic CHF who remain symptomatic despite
    receiving ACEIs. (Grade of recommendation = A)

*Second-line Agents*

-   **Digoxin** may be considered for symptom relief and to reduce
    hospitalisation in patients with advanced CHF (Digitalis
    Investigation Group, 1997). It remains a valuable therapy in CHF
    patients with atrial fibrillation. (Grade of recommendation = B)

-   **Hydralazine-isosorbide dinitrate combination** should be reserved
    for patients who are truly intolerant of ACEIs and angiotensin II
    receptor antagonists, or for whom these agents are contraindicated
    and no other therapeutic option exists (Cohn et al., 1986) (Grade of
    recommendation = B)

*Other Agents*

-   **Amlodipine** and **felodipine** can be used to treat comorbidities
    such as hypertension and CHD in patients with systolic CHF. They
    have been shown to neither increase nor decrease mortality (Packer
    et al., \"Effect of amlodipine,\" 1996; Cohn et al., 1997;
    Packer, 2000) (Grade of recommendation = B)

**Devices**

**Pacing**

*Practice Point*

Bradycardia is common in elderly patients with advanced heart disease
treated with beta-blocker therapy.

**Implantable Cardioverter Defibrillators**

*Practice Point*

Prophylactic implantable cardioverter defibrillator (ICD) implantation
may be considered in patients with an LVEF [\<]{.underline}35%; however,
this is currently constrained by funding and other logistical issues.
Until these issues are resolved, this therapy may not be universally
available.

Decisions about pacing, cardiac resynchronisation therapy,
defibrillators, and choice of device are complex and generally require
specialist review.

**Recommendations for Device-Based Treatment of Symptomatic CHF**

-   Biventricular pacing (cardiac resynchronisation therapy, with or
    without ICD) should be considered in patients with CHF who fulfill
    each of the following criteria (Cazeau et al., 2001) (Grade of
    recommendation = A):

    -   New York Heart Association \[NYHA\] symptoms Class III--IV on
        treatment

    -   Dilated heart failure with left ventricular ejection fraction
        [\<]{.underline}35%

    -   QRS duration [\>]{.underline}120 ms

    -   Sinus rhythm

-   ICD implantation should be considered in patients with CHF who
    fulfill any of the following criteria (Bristow et al., 2004) (Grade
    of recommendation = A):

    -   Survived cardiac arrest resulting from ventricular fibrillation
        or ventricular tachycardia not due to a transient or reversible
        cause

    -   Spontaneous sustained ventricular tachycardia in association
        with structural CHD

    -   LVEF [\<]{.underline}30% measured at least 1 month after acute
        MI, or 3 months after coronary artery revascularisation surgery

    -   Symptomatic CHF (i.e., NYHA functional class II--III) and left
        ventricular ejection fraction [\<]{.underline}35%

**Surgery**

**Indications for Cardiac Transplantation**

+-----------+----------------------------------------------------------+
| **D       | -   Persistent NYHA Class IV symptoms                    |
| efinite** |                                                          |
|           | -   VO~2~ max \<10 mL/kg/min                             |
|           |                                                          |
|           | -   Severe ischaemia not amenable to revascularisation   |
|           |                                                          |
|           | -   Recurrent uncontrollable ventricular arrhythmias     |
+-----------+----------------------------------------------------------+
| **P       | -   NYHA Class III                                       |
| robable** |                                                          |
|           | -   VO~2~ max \<14 mL/kg/min + major limitation          |
|           |                                                          |
|           | -   Recurrent unstable angina with poor LV function      |
+-----------+----------------------------------------------------------+
| **Ina     | -   LVEF \<20% without significant symptoms              |
| dequate** |                                                          |
|           | -   Past history of NYHA Class III or IV symptoms        |
|           |                                                          |
|           | -   VO~2~ max \>14 mL/kg/min without other indication    |
+-----------+----------------------------------------------------------+

**Acute Exacerbations of CHF**

*Practice Point*

Acute pulmonary oedema (APO) is a life-threatening disorder. However,
appropriate therapy will often result in a marked improvement in the
patient\'s clinical status within a few hours.

**Emergency Management of Suspected Cardiogenic APO**

+--------------+-------------------------------------------------------+
| **A**        | -   Exclude obstruction                               |
| (airway)     |                                                       |
+--------------+-------------------------------------------------------+
| **B**        | -   Hypoxaemia (→ oxygenation)                        |
| (breathing)  |                                                       |
|              | -   Respiratory fatigue (→ mechanical ventilation)    |
+--------------+-------------------------------------------------------+
| **C**        | -   Heart rate/rhythm (→                              |
| (            |     anti-arrthymics/cardioversion)                    |
| circulation) |                                                       |
|              | -   Hypotension (→ inotropes/intra-aortic balloon     |
|              |     pump)                                             |
+--------------+-------------------------------------------------------+
| **D**        | -   Cardiogenic APO                                   |
| (            |                                                       |
| differential | -   Non-cardiogenic pulmonary oedema                  |
| diagnosis)   |                                                       |
|              | -   Acute exacerbation of airways disease             |
|              |                                                       |
|              | -   Acute massive pulmonary embolism                  |
|              |                                                       |
|              | -   Pneumothorax                                      |
|              |                                                       |
|              | -   Foreign body aspiration                           |
|              |                                                       |
|              | -   Hyperventilation syndrome                         |
+--------------+-------------------------------------------------------+
| **E**        | -   Precipitants                                      |
| (aetiology)\ |                                                       |
| (cardiogenic | -   Ischaemia, tachyarrhythmia, fluid overload,       |
| APO)         |     medication                                        |
|              |                                                       |
|              | -   Underlying pathology                              |
|              |                                                       |
|              | -   Systolic LV dysfunction---coronary heart disease, |
|              |     dilated cardiomyopathy, mitral regurgitation      |
|              |                                                       |
|              | -   Diastolic LV dysfunction---hypertensive heart     |
|              |     disease, hypertrophic cardiomyopathy, aortic      |
|              |     stenosis                                          |
|              |                                                       |
|              | -   Normal LV function---mitral stenosis              |
+--------------+-------------------------------------------------------+

See Figure 10.1 in the original guideline document for emergency therapy
of acute heart failure.

**Heart Failure with Preserved Systolic Function (HFPSF)**

**Epidemiology/Clinical Characteristics**

*Practice Point*

Although the epidemiology of HFPSF or diastolic heart failure has been
incompletely described, the main risk factors are advanced age,
hypertension, diabetes, LV hypertrophy, and CHD. Diagnosis,
investigation, and treatment are summarised in the Table below.

**Diagnosis, Investigation, and Treatment of HFPSF**

+-----------------------------------------------------------------------+
| **Diagnosis**                                                         |
|                                                                       |
| -   Clinical history of CHF                                           |
|                                                                       |
| -   Exclude myocardial ischaemia, valvular disease                    |
|                                                                       |
| -   Objective evidence of CHF (x-ray consistent with CHF)             |
|                                                                       |
| -   Ejection fraction [\>]{.underline}45% (echocardiography, gated    |
|     blood pool scanning, left ventriculography)                       |
|                                                                       |
| -   Echocardiographic or cardiac catheterization evidence of          |
|     diastolic dysfunction, where possible                             |
|                                                                       |
| -   Use of plasma BNP measurement for diagnosis of diastolic heart    |
|     failure is not proven.                                            |
+-----------------------------------------------------------------------+
| **Investigations**                                                    |
|                                                                       |
| Echocardiography                                                      |
|                                                                       |
| -   Pseudonormal or restrictive filling pattern demonstrated by       |
|     mitral inflow (age appropriate)                                   |
|                                                                       |
| -   Left atrial enlargement                                           |
|                                                                       |
| -   Reduced septal annular velocity (Ea) on tissue Doppler imaging    |
|                                                                       |
| -   Ratio of E wave to Ea \>15                                        |
|                                                                       |
| Cardiac catheterisation                                               |
|                                                                       |
| -   Elevated LV end diastolic pressure                                |
|                                                                       |
| -   Prolonged Tau                                                     |
+-----------------------------------------------------------------------+
| **Treatment (empirical at this stage)**                               |
|                                                                       |
| -   Aggressive risk factor reduction                                  |
|                                                                       |
| -   Hypertension---blood pressure (BP) reduction; consider ACEIs or   |
|     angiotensin II receptor antagonists to reduce LV hypertrophy      |
|                                                                       |
| -   Diabetes mellitus---strict glycaemic and BP control; consider     |
|     ACEIs or angiotensin II receptor antagonists early, using lower   |
|     BP recommendations for treating hypertension in diabetic patients |
+-----------------------------------------------------------------------+

**Treatment of Associated Disorders**

See Chapter 12 in the original guideline document for a discussion of
treatment of associated disorders, including cardiac arrhythmia,
valvular heart disease, CHD, arthritis, chronic renal failure, anaemia,
cancer, diabetes, thromboembolism, and gout.

**Post-discharge Management Programs**

*Practice Point*

Multidisciplinary programs of care targeting high-risk CHF patients
following acute hospitalisation prolong survival, improve quality of
life, and are cost effective in reducing recurrent hospital stays.

**Palliative Support**

*Practice Point*

An individualised program of palliative care should be considered for
patients facing the strong possibility of death within 12 months and who
have advanced symptoms (i.e., NYHA Class IV) and poor quality of life,
resistant to optimal pharmacological and non-pharmacological therapies.

*Practice Point*

Palliative care should only be considered when progressive symptoms
prove to be refractory to optimal treatment.

Treating doctors should discuss with their patients the level of
intervention appropriate and/or desirable during this phase of their
illness, so that unwanted, traumatic interventions are prevented in the
last few days of life. Both the patient and their family and carers may
need significant emotional support during this process.

**Definitions**:

**Grades of Recommendations**

A.  Rich body of high-quality randomized controlled trial (RCT) data

B.  Limited body of RCT data or high-quality non-RCT data

C.  Limited Evidence

D.  No evidence available -- panel consensus judgment

#### CLINICAL ALGORITHM(S)

Clinical algorithms are provided in the original guideline document for
the following:

-   Diagnostic algorithm for chronic heart failure (CHF)

-   Advanced diagnostic/treatment algorithm for CHF

-   Pharmacological treatment of asymptomatic left ventricular (LV)
    dysfunction (left ventricular ejection fraction \[LVEF\] \<40%) (New
    York Heart Association \[NYHA\] Class I)

-   Pharmacologic treatment of systolic heart failure (LVEF \<40%) (NYHA
    Class II-III)

-   Pharmacologic treatment of refractory systolic heart failure (LVEF
    \<40%) (NYHA Class IV)

-   Pharmacologic treatment of heart failure after recent or remote
    myocardial infarction (MI)

-   Management of clinical deterioration in CHF

-   Management of heart failure with preserved systolic function (HFPSF)
    (diastolic heart failure)

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=10372)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations (see \"Major Recommendations\" field).

Recommendations based on consensus expert opinion are also included
where evidence-based recommendations are not available.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Accurate diagnosis and appropriate management of chronic heart failure

#### POTENTIAL HARMS

-   Beta-blockers should not be initiated during a phase of acute
    decompensation, but only after the patient\'s condition has
    stabilised. Adverse effects of beta-blockade in this setting include
    symptomatic hypotension, worsening of symptoms due to withdrawal of
    sympathetic drive, and bradycardia.

-   The risk of hyperkalaemia --- which is potentially lethal,
    particularly in the presence of angiotensin-converting enzyme
    inhibitors (ACEI) and/or renal impairment --- requires vigilance
    when using spironolactone. The latter is also an androgen receptor
    antagonist and may cause feminisation side effects, such as
    gynaecomastia.

-   Sustained inotropic stimulation can potentially increase myocardial
    oxygen demand in patients with myocardial ischaemia and possibly
    promote arrhythmia. For this reason, inotropic therapy should be
    reserved for patients not responding to other treatments for
    short-term support, until they can recover from acute haemodynamic
    compromise.

-   Milrinone is less frequently used in chronic heart failure (CHF)
    because of concerns about arrhythmogenesis.

-   Implantable cardioverter device (ICD) implantation may worsen
    quality of life, and the mortality benefit from ICD implantation
    needs to be balanced against the effects of living with a device
    that delivers painful shocks which are not controllable by the
    patient.

-   In one study of left ventricular assist devices (LVADs) there was a
    greater than two-fold increased risk of serious adverse events,
    including infection, bleeding, thromboembolism and device
    malfunction.

-   In using diuretics to relieve fluid overload in decompensation,
    great care must be taken to avoid overzealous diuresis leading to
    hypovolaemia and its consequences (acute renal failure, postural
    dizziness), as well as hypokalaemia.

-   There is some evidence that morphine may be detrimental in acute
    myocardial infarction (MI) and acute cardiogenic pulmonary oedema
    (APO), and its place in management of APO is now controversial.

-   Beta-blockers should not be commenced or increased during the acute
    decompensation episode, as the acute negative inotropic effect of
    these agents at a time of fluid overload may worsen clinical status.

-   Sotalol is associated with a 1& to 3% incidence of ventricular
    proarrhythmia, and efficacy at one year is only 40 to 50%.

-   While efforts should be made to achieve good glycaemic control,
    metformin should be avoided --- particularly in patients with severe
    or decompensated chronic heart failure --- because of an increased
    risk of lactic acidosis. Thiazolidinediones (\'glitazones\') may
    lead to fluid retention and should not be used in patients with New
    York Heart Association (NYHA) Class III or IV symptoms. In patients
    with Class I and II symptoms, \'glitazone\' therapy should be
    initiated with caution and promptly withdrawn if heart failure
    worsens.

-   Patients with diabetes, in whom hyporeninaemic hypoaldosteronism is
    common, may be at risk of developing hyperkalaemia when an
    angiotensin II receptor antagonist is added to
    angiotensin-converting enzyme inhibitor therapy, and vigilant
    monitoring of serum potassium is recommended.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Sildenafil is contraindicated in patients receiving nitrate therapy,
    or those who have hypotension, arrhythmias or angina pectoris.

-   Many of the medications used in treatment are contraindicated in
    pregnancy.

-   Non-dihydropyridine calcium-channel blockers that are direct
    negative inotropes, such as verapamil and diltiazem, are
    contraindicated in patients with systolic heart failure.

-   Therapy with class I anti-arrhythmic agents (e.g., flecainide) is
    generally contraindicated in the presence of systolic heart failure.

-   Arterial vasodilators, including angiotensin-converting enzyme
    inhibitors (ACEIs), are usually contraindicated in patients with
    severe aortic stenosis because of the risk of coronary
    hypoperfusion.

-   Pre-existent impairment of left ventricular (LV) systolic function
    represents a relative contraindication to aggressive chemotherapy
    with such agents.

-   Treatment of gout in the patient with chronic heart failure (CHF) is
    made somewhat more complex by the contraindication to the use of
    non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 enzyme
    (COX-2) inhibitors. Similarly, corticosteroids are also best avoided
    in the management of this complication in the CHF patient.

**Relative Contraindications to Cardiac Transplantation:**

-   Age \>65

-   Active infection

-   Untreated malignancy, or treated malignancy in remission and \<5
    years follow-up

-   Fixed high pulmonary pressures (pulmonary vascular resistance \>4
    Wood units, or mean transpulmonary gradient \>12 mmHg or pulmonary
    artery systolic pressure \>60 mmHg)

-   Current substance abuse (including tobacco and alcohol)

-   Coexisting systemic illness likely to limit survival

-   Severe and irreversible major organ dysfunction

-   Adverse psychosocial factors limiting compliance with medical
    therapy

-   Recent pulmonary embolism (\<6 weeks)

-   Diabetes mellitus with severe or progressive end-organ damage

-   Morbid obesity

-   Unhealed peptic ulceration

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The guidelines are not prescriptive, as patient circumstances and
clinical judgement will determine the most appropriate course of
treatment for each individual with chronic heart failure (CHF). Clinical
trials provide group data and clinical practice requires individual
judgement.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

National Heart Foundation of Australia, Cardiac Society of Australia and
New Zealand, Chronic Heart Failure Guidelines Expert Writing Panel.
Guidelines for the prevention, detection and management of chronic heart
failure in Australia, 2006. Sydney (Australia): National Heart
Foundation of Australia; 2006 Nov. 79 p. \[335 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2002 (revised 2006 Nov)

#### GUIDELINE DEVELOPER(S)

Cardiac Society of Australia and New Zealand - Disease Specific Society\
National Heart Foundation of Australia - Disease Specific Society

#### SOURCE(S) OF FUNDING

National Heart Foundation of Australia\
Cardiac Society of Australia and New Zealand

#### GUIDELINE COMMITTEE

Writing Panel

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Prof Henry Krum (*Co-chair*); A/Prof Michael Jelinek
(*Co-chair*); Prof Simon Stewart; Prof Andrew Sindone; A/Prof John
Atherton; Dr Anna Hawkes (*Executive Officer*)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Many members of the Writing Panel have received paid honoraria for work
performed on behalf of manufacturers of therapies described in these
guidelines. However, no members of the Writing Panel stand to gain
financially from their involvement in these guidelines and no conflicts
of interest exist for Writing Panel members, the National Heart
Foundation of Australia or the Cardiac Society of Australia and New
Zealand.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: National Heart Foundation of
Australia, Cardiac Society of Australia and New Zealand. Guidelines on
contemporary management of the patient with chronic heart failure in
Australia. Sydney (Australia): National Heart Foundation of Australia;
2002.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[National Heart Foundation of
Australia](http://www.heartfoundation.com.au/document/NHF/CHF_2006_Guidelines_NHFA-CSANZ_WEB_PDF-1.2MB.pdf).

Print copies: Available from the National Heart Foundation of
Australia\'s national telephone information service at 1300 36 27 87 or
E-mail: <heartline@heartfoundation.com.au>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Guidelines for the prevention, detection and management of people
    with chronic heart failure in Australia 2006. Position statement.
    MJA 2006; 185(10)549-56. Electronic copies: Available from the [MJA
    Web
    site](http://www.mja.com.au/public/issues/185_10_201106/kru10726_fm.html).

-   Diagnosis and management of chronic heart failure 2006. Quick
    reference guide for health professionals. 2006. 9 p. Available in
    Portable Document Format (PDF) from the [National Heart Foundation
    of
    Australia](http://www.heartfoundation.org.au/document/NHF/CHF_QRG_PP-603_2006_FINAL.pdf).

Print copies: Available from the National Heart Foundation of
Australia\'s national telephone information service at 1300 36 27 87 or
E-mail: <heartline@heartfoundation.com.au>.

#### PATIENT RESOURCES

The following are available:

-   Information Sheet including Action Plan - Summary version of booklet
    \"Living well with chronic heart failure.\" 2008. Available in
    Portable Document Format (PDF) from the [National Heart Foundation
    of
    Australia](http://www.heartfoundation.org.au/document/NHF/CHF_IS-346_InfoSheet_LivingWell_CHF_FINAL.pdf).

-   Symptoms of chronic heart failure. 2008. Available in Portable
    Document Format (PDF) from the [National Heart Foundation of
    Australia](http://www.heartfoundation.org.au/document/NHF/CHF_IS-346_InfoSheet_LivingWell_CHF_FINAL.pdf).

-   Lifestyle issues. 2008. Available in Portable Document Format (PDF)
    from the [National Heart Foundation of
    Australia](http://www.heartfoundation.org.au/document/NHF/CHF_LifestyleIssues_sectionfromLivingWell.pdf).

-   Monitoring and controlling fluid balance. 2008. Available in
    Portable Document Format (PDF) from the [National Heart Foundation
    of
    Australia](http://www.heartfoundation.org.au/document/NHF/CHF_FluidBalance_sectionfromLivingWell.pdf).

-   Medicines. 2008. Available in Portable Document Format (PDF) from
    the [National Heart Foundation of
    Australia](http://www.heartfoundation.org.au/document/NHF/CHF_Medicines_sectionfromLivingWell.pdf).

-   Commonly asked questions. 2008. Available in Portable Document
    Format (PDF) from the [National Heart Foundation of
    Australia](http://www.heartfoundation.org.au/document/NHF/CHF_CommonlyAskedQuestions_sectionfromLivingWell.pdf).

Print copies of the entire booklet available via e-mail at:
<heartline@heartfoundation.org.au>.

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on April 12, 2007. The
information was verified by the guideline developer on June 27, 2007.
This summary was updated by ECRI Institute on September 7, 2007
following the revised U.S. Food and Drug Administration (FDA) advisory
on Coumadin (warfarin). This summary was updated by ECRI Institute on
November 6, 2007, following the updated U.S. Food and Drug
Administration advisory on Viagra, Cialis, Levitra, and Revatio.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline.

Copyright for the original guideline/evidence review remains with the
National Heart Foundation of Australia. The content contained within the
original guideline/evidence review may not be reproduced in any form or
language without permission from the National Heart Foundation of
Australia. Before applying for permissions, request for the copyright
terms and conditions document from <copyright@heartfoundation.com.au>.
In addition, content contained within the original guideline and/or the
NGC summary of this guideline may not be used for commercial and/or
product endorsement.

© November 2006 National Heart Foundation of Australia

### DISCLAIMER

#### NGC DISCLAIMER

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<http://www.guideline.gov/about/inclusion.aspx> .

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Date Modified: 11/3/2008