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## Complete Summary

#### GUIDELINE TITLE

Guidelines for the diagnosis and treatment of chronic heart failure
(update 2005).

#### BIBLIOGRAPHIC SOURCE(S)

Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M,
Tavazzi L, Smiseth OA, Gavazzi A, Haverich A, Hoes A, Jaarsma T,
Korewicki J, Levy S, Linde C, Lopez-Sendon JL, Nieminen MS, Pierard L,
Remme WJ. Guidelines for the diagnosis and treatment of chronic heart
failure: full text (update 2005): The Task Force for the Diagnosis and
Treatment of Chronic Heart Failure of the European Society of
Cardiology. Sophia Antipolis (FR): European Society of Cardiology (ESC);
2005. 45 p. \[358 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Remme WJ, Swedberg K, Task
Force for the Diagnosis and Treatment of Chronic Heart Failure, European
Society of Cardiology. Guidelines for the diagnosis and treatment of
chronic heart failure. Eur Heart J 2001 Sep;22(17):1527-60.

### \*\* 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.

-   [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 (CHF)

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Thoracic Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide updated practical guidelines for the diagnosis, assessment,
and treatment of heart failure for use in clinical practice, as well as
for epidemiological surveys and clinical trials

#### TARGET POPULATION

Patients with chronic heart failure (CHF)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation/Diagnosis**

1.  Assessment of signs and symptoms of heart failure

2.  Establish severity with New York Heart Association (NYHA)
    classification and quality of life with Minnesota Living with Heart
    Failure questionnaire

3.  Electrocardiogram (ECG)

4.  Chest x-ray

5.  Laboratory investigations including haematology and biochemistry

6.  Echocardiography (transthoracic Doppler, transoesophageal)

7.  Stress echocardiogram

8.  Nuclear cardiology (radionuclide angiography \[RNA\], planar
    scintigraphy, single photon emission computer tomography \[SPECT\])

9.  Cardiac magnetic resonance imaging (MRI)

10. Measurement of pulmonary function, including forced vital capacity
    (FVC) measurement, forced expiratory volume (FEV), and peak
    expiratory flow rate (PEFR)

11. Exercise testing

12. Invasive investigations (coronary angiography, haemodynamic
    monitoring, endomyocardial biopsy)

13. Measurement of plasma natriuretic peptides including B-type
    natriuretic peptide (BNP) and N-terminal prohormone B-type
    natriuretic peptide (NT-proBNP)

14. Holter electrocardiography

**Treatment/Management**

**Non-pharmacological Management**

1.  General advice and measures including weight control and monitoring;
    dietary measures such as salt restriction; fluid and alcohol intake
    reduction; weight control; smoking cessation; advice on traveling,
    sexual activity, and immunizations; and drug counseling

2.  Exercise and exercise training

3.  Rest

**Pharmacological Therapy**

1.  Angiotensin-converting enzyme (ACE) inhibitors

2.  Diuretics, including loop diuretics, thiazides, and
    potassium-sparing diuretics

3.  Beta-adrenoceptor antagonists

4.  Aldosterone receptor antagonists

5.  Angiotensin receptor blockers

6.  Cardiac glycosides (e.g., digoxin)

7.  Vasodilator agents

8.  Positive inotropic therapy

9.  Antithrombotic agents

10. Antiarrhythmic agents

11. Oxygen therapy (considered, but not recommended)

**Devices and Surgery**

1.  Revascularization procedures (considered, but not recommended)

2.  Mitral valve surgery

3.  Left ventricular (LV) aneurysmectomy

4.  Cardiomyoplasty (considered, but not recommended)

5.  Partial left ventriculectomy (Batista operation) (considered, but
    not recommended)

6.  External ventricular restoration (considered, but not recommended)

7.  Pacemakers

8.  Implantable cardioverter defibrillators

9.  Heart transplantation, ventricular assist devices, artificial heart

10. Ultrafiltration

**Follow-up Care**

Follow-up care including multi-disciplinary approach, discharge
planning, intense education and counseling, etc.

**Note**: Interventions and practices related to treatment of diastolic
heart failure, heart failure in the elderly, and heart failure in
patients with concomitant arrhythmia, hypertension, or angina are also
presented.

#### MAJOR OUTCOMES CONSIDERED

-   Accuracy, sensitivity, and specificity of diagnostic assessments

-   Rates of heart failure

-   Symptoms of heart failure

-   Progression of heart failure, including hospitalization for
    worsening heart failure

-   Mortality, including total mortality, cardiovascular mortality,
    sudden death, and death due to progression of heart failure

-   Quality of life

-   Adverse effects

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

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

Searches were performed of the following resources: PubMed, medicals
journals by specialty, the Cochrane Library.

#### 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**:

A.  Data derived from multiple randomized clinical trials or
    meta-analyses

B.  Data derived from a single randomized clinical trial or large
    non-randomized studies

C.  Consensus of opinion of the experts and/or small studies,
    retrospective studies, registries

#### 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

This clinical scientific statement represents the consensus of a panel
of experts appointed by the European Society of Cardiology (ESC). The
writing group comprises cardiovascular specialists and pharmacologists
and if necessary surgeons, each having extensive experience with chronic
heart failure. The panel focused largely on the management of this
complex disease and derived prudent, practical, and contemporary
treatment strategies for the many subgroups of patients comprising the
broad chronic heart failure disease spectrum.

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

**Classes of Recommendations:**

**Class I**: Evidence and/or general agreement that a given diagnostic
procedure/treatment is beneficial, useful, and effective

**Class II**: Conflicting evidence and/or a divergence of opinion about
the usefulness/efficacy of the treatment

**Class IIa**: Weight of evidence/opinion is in favour of
usefulness/efficacy.

**Class IIb**: Usefulness/efficacy is less well established by
evidence/opinion.

**Class III**\*: Evidence or general agreement that the treatment is not
useful/effective and in some cases may be harmful

\*Use of Class III evidence is discouraged by the European Society of
Cardiology (ESC)

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This report was drafted by a Writing Group of the Task Force appointed
by the Committee for Practice Guidelines (CPG) of the European Society
of Cardiology (ESC). The draft was sent to the Committee and the
document reviewers and after their input the document was updated,
reviewed, and then approved for presentation.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence (A-C) and classes of recommendations (I, II, IIa,
IIb, III) are defined at the end of the \"Major Recommendations\" field.

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

**Definition of Chronic Heart Failure**

-   Heart failure should never be the only diagnosis.

Heart failure is a syndrome in which the patients should have the
following features: symptoms of heart failure, typically breathlessness
or fatigue, either at rest or during exertion, or ankle swelling and
objective evidence of cardiac dysfunction at rest (See Table below
titled \"Definition of Heart Failure\"). The distinctions between
cardiac dysfunction, persistent heart failure, heart failure that has
been rendered asymptomatic by therapy, and transient heart failure are
outlined in Figure 1 in the original guideline document. A clinical
response to treatment directed at heart failure alone is not sufficient
for diagnosis, although the patient should generally demonstrate some
improvement in symptoms and/or signs in response to those treatments in
which a relatively fast symptomatic improvement could be anticipated
(e.g., diuretic or nitrate administration).

Asymptomatic left ventricular systolic dysfunction is considered as
precursor of symptomatic CHF and is associated with high mortality (Wang
et al., 2003). It is important when diagnosed and treatment is
available, and the condition is therefore included in these Guidelines.

**Table. Definition of Heart Failure**

+-----------------------------------------------------------------------+
| I.  Symptoms of heart failure (at rest or during exercise)\           |
|     *and*                                                             |
|                                                                       |
| II. Objective evidence (preferably by echocardiography) of cardiac    |
|     dysfunction (systolic and/or diastolic) (at rest) and (in cases   |
|     where the diagnosis is in doubt)\                                 |
|     *and*                                                             |
|                                                                       |
| III. Response to treatment directed towards heart failure             |
+-----------------------------------------------------------------------+

Criteria I and II should be fulfilled in all cases.

**Possible Methods for the Diagnosis of Heart Failure in Clinical
Practice**

*Symptoms and Signs in the Diagnosis of Heart Failure*

-   Symptoms and signs are important as they alert the observer to the
    possibility that heart failure exists. The clinical suspicion of
    heart failure must be confirmed by more objective tests particularly
    aimed at assessing cardiac function (See Figure 2 in the original
    guideline document).

Breathlessness, ankle swelling, and fatigue are the characteristic
symptoms and signs of heart failure but may be difficult to interpret,
particularly in elderly patients, in obese, and in women. It should be
interpreted carefully and different modes (e.g., effort and nocturnal)
should be assessed.

Fatigue is also an essential symptom in heart failure. The origins of
fatigue are complex including low cardiac output, peripheral
hypoperfusion, skeletal muscle deconditioning, and confounded by
difficulties in quantifying this symptom.

Peripheral oedema, raised venous pressure, and hepatomegaly are the
characteristic signs of congestion of systemic veins (Butman et al.,
1993; Stevenson & Perloff, 1989). Clinical signs of heart failure should
be assessed in a careful clinical examination, including observing,
palpating, and auscultating the patient.

*Symptoms and the Severity of Heart Failure*

-   There is a poor relationship between symptoms and the severity of
    cardiac dysfunction. (Cleland et al., 2001; Marantz et al., 1988)
    However, symptoms may be related to prognosis particularly if
    persisting after therapy. (Adams & Zannad, 1989)

Once a diagnosis of heart failure has been established, symptoms may be
used to classify the severity of heart failure and should be used to
monitor the effects of therapy. However, as noted subsequently, symptoms
cannot guide the optimal titration of neurohormonal blockers. The New
York Heart Association (NYHA) classification is in widespread use (See
Table 2 in the original guideline document). In other situations, the
classification of symptoms into mild, moderate, or severe is used.
Patients in NYHA class I would have to have objective evidence of
cardiac dysfunction, have a past history of heart failure symptoms, and
be receiving treatment for heart failure in order to fulfill the basic
definition of heart failure.

*Electrocardiogram*

-   A normal electrocardiogram (ECG) suggests that the diagnosis of CHF
    should be carefully reviewed.

Electrocardiographic changes are common in patients suspected of having
heart failure whether or not the diagnosis proves to be correct. An
abnormal ECG, therefore, has little predictive value for the presence of
heart failure. On the other hand, if the ECG is completely normal, heart
failure, especially due to left ventricular (LV) systolic dysfunction,
is unlikely. The presence of pathological Q-waves may suggest myocardial
infarction as the cause of cardiac dysfunction. A QRS width \>120 ms
suggests that cardiac dyssynchrony may be present and a target for
treatment.

*The Chest X-ray*

Chest x-ray should be part of the initial diagnostic work-up in heart
failure. It is useful to detect cardiomegaly and pulmonary congestion;
however, it has only predictive value in the context of typical signs
and symptoms and in abnormal ECG.

*Haematology and Biochemistry*

Routine diagnostic evaluation of patients with CHF includes complete
blood count (Hb, leukocytes, and platelets), S-electrolytes,
S-creatinine, S-glucose, S-hepatic enzymes, and urinalysis. Additional
tests to evaluate thyroid function should be considered according to
clinical findings. In acute exacerbations, acute myocardial infarction
is excluded by myocardial specific enzyme analysis.

*Natriuretic Peptides*

-   Plasma concentrations of certain natriuretic peptides or their
    precursors, especially BNP and NT-proBNP, are helpful in the
    diagnosis of heart failure.

-   A low-normal concentration in an untreated patient makes heart
    failure unlikely as the cause of symptoms.

-   BNP and NT-proBNP have considerable prognostic potential, although
    evaluation of their role in treatment monitoring remains to be
    determined.

In considering the use of BNP and NT-proBNP as diagnostic aids, it
should be emphasized that a \"normal\" value cannot completely exclude
cardiac disease, but a normal or low concentration in an untreated
patient makes heart failure unlikely as the cause of symptoms.

In clinical practice today, the place of BNP and NT-proBNP is as \"rule
out\" tests to exclude significant cardiac disease, particularly in
primary care but also in certain aspects of secondary care (e.g., the
emergency room and clinics). The cost-effectiveness of the test suggests
that a normal result should obviate the need for further cardiological
tests such as in the first instance echocardiography as well as more
expensive investigations (Maisel et al., 2002).

*Echocardiography*

-   Echocardiography is the preferred method for the documentation of
    cardiac dysfunction at rest.

-   The most important measurement of ventricular function is the left
    ventricular ejection fraction (LVEF) for distinguishing patients
    with cardiac systolic dysfunction from patients with preserved
    systolic function.

The access to and use of echocardiography is encouraged for the
diagnosis of heart failure. Transthoracic Doppler echocardiography (TDE)
is rapid, safe, and widely available.

Please refer to the original guideline document for discussion on the
assessment of LV diastolic function and diagnostic criteria of diastolic
dysfunction.

*Additional Non-invasive Tests to be Considered*

In patients in whom echocardiography at rest has not provided enough
information and in patients with coronary artery disease (e.g., severe
or refractory CHF and coronary artery disease), further non-invasive
imaging may include stress echocardiography, radionuclide imaging, and
cardiac magnetic resonance imaging (CMR).

[Cardiac Magnetic Resonance Imaging (CMR)]{.underline}

-   CMR is a versatile, highly accurate, and reproducible imaging
    technique for the assessment of left and right ventricular volumes,
    global function, regional wall motion, myocardial thickness,
    thickening, myocardial mass, and cardiac valves (Bellenger et al.,
    2000; Grothues et al., 2004). The method is well suited for
    detection of congenital defects, masses and tumours, valvular, and
    pericardial disease.

*Pulmonary Function*

-   Measurements of lung function are of little value in diagnosing CHF.
    However, they are useful in excluding respiratory causes of
    breathlessness. Spirometry can be useful to evaluate the extent of
    obstructive airways disease which is a common comorbidity in
    patients with heart failure.

*Exercise Testing*

-   In clinical practice, exercise testing is of limited value for the
    diagnosis of heart failure. However, a normal maximal exercise test
    in a patient not receiving treatment for heart failure excludes
    heart failure as a diagnosis. The main applications of exercise
    testing in CHF are focused more on functional and treatment
    assessment and on prognostic stratification.

*Invasive Investigation*

-   Invasive investigation is generally not required to establish the
    presence of CHF but may be important in elucidating the cause or to
    obtain prognostic information.

[Cardiac Catheterization]{.underline}

Please refer to the original guideline document for a discussion on
cardiac catheterization.

*Tests of Neuroendocrine Evaluations Other Than Natriuretic Peptides*

-   Tests of neuroendocrine activation are not recommended for
    diagnostic or prognostic purposes in individual patients.

*Holter Electrocardiography: Ambulatory ECG and Long-time ECG Recording
(LTER)*

Conventional Holter monitoring is of no value in the diagnosis of CHF,
though it may detect and quantify the nature, frequency, and duration of
atrial and ventricular arrhythmias which could be causing or
exacerbating symptoms of heart failure. Recording LTER should be
restricted to patients with CHF and symptoms suggestive of an
arrhythmia.

**Requirements for the Diagnosis of Heart Failure in Clinical Practice**

To satisfy the definition of heart failure, symptoms of heart failure
and objective evidence of cardiac dysfunction must be present. (See
table above titled \"Definition of Heart Failure.\") The assessment of
cardiac function by clinical criteria alone is unsatisfactory. Cardiac
dysfunction should be assessed objectively.

The echocardiogram is the single most effective tool in widespread
clinical use. Other conditions may mimic or exacerbate the symptoms and
signs of heart failure and therefore need to be excluded. (See table
below titled \"Assessments to Be Performed Routinely to Establish the
Presence and Likely Cause of Heart Failure.\") An approach (see Figure 2
in the original guideline document) to the diagnosis of heart failure in
symptomatic patients should be performed routinely in patients with
suspected heart failure in order to establish the diagnosis. Additional
tests (see table below titled \"Additional Tests to be Considered to
Support the Diagnosis or to Suggest Alternative Diagnoses\") should be
performed or re-evaluated in cases in which diagnostic doubt persists or
clinical features suggest a reversible cause for heart failure.

Figure 2 in the original guideline document represents a simplified plan
for the evaluation of a patient presenting with symptoms suggestive of
heart failure or signs giving suspicion of left ventricular systolic
dysfunction. The table below titled \"Management Outline\" provides a
management outline connecting the diagnosis component of the guidelines
with the treatment section.

**Table. Assessments to Be Performed Routinely to Establish the Presence
and Likely Cause of Heart Failure**

  -----------------------------------------------------------------------------------
  **Assessments**      **Diagnosis                                **Suggests
                       of heart                                   alternative or
                       failure**                                  additional
                                                                  diagnosis**
  -------------------- ------------- -------------- ------------- -------------------
  ** **                **Necessary   **Supports**   **Opposes**   ** **
                       for**                                      

  Appropriate symptoms +++                          +++ (If        
                                                    absent)       

  Appropriate signs                  +++            \+ (If         
                                                    absent)       

  Cardiac dysfunction  +++                          +++ (If        
  on imaging (usually                               absent)       
  echocardiography)                                               

  Response of symptoms               +++            +++ (If        
  or signs to therapy                               absent)       

  ECG                                               +++ (If        
                                                    Normal)       

  Chest x-ray                        If pulmonary   \+ (If        Pulmonary disease
                                     congestion or  normal)       
                                     cardiomegaly                 

  Full blood count                                                Anaemia/secondary
                                                                  polycythaemia

  Biochemistry and                                                Renal or hepatic
  urinalysis                                                      disease/diabetes

  Plasma concentration               \+ (If         +++ (If       Can be normal in
  of natriuretic                     elevated)      normal)       treated patients
  peptides in                                                     
  untreated patients                                              
  (where available)                                               
  -----------------------------------------------------------------------------------

\+ = of some importance; +++ = of great importance

**Table. Additional Tests to Be Considered to Support the Diagnosis or
to Suggest Alternative Diagnoses**

  -------------------------------------------------------------------------
  **Tests**             **Diagnosis of ** **            **Suggests
                        heart                           alternative or
                        failure**                       additional
                                                        diagnosis**
  --------------------- -------------- ---------------- -------------------
  ** **                 **Supports**   **Opposes**      ** **

  Exercise test         \+ (If         +++ (If normal)   
                        impaired)                       

  Pulmonary function                                    Pulmonary disease
  tests                                                 

  Thyroid function                                      Thyroid disease
  tests                                                 

  Invasive                                              Coronary artery
  investigation and                                     disease, ischaemia
  angiography                                           

  Cardiac output        +++ (If        +++ (If normal;   
                        depressed at   especially       
                        rest)          during exercise) 

  Left atrial pressure  \+ (If         +++ (If normal;   
  (pulmonary capillary  elevated at    in absence of    
  wedge pressure)       rest)          therapy)         
  -------------------------------------------------------------------------

\+ = of some importance; +++ = of great importance

**Table. Management Outline**

+-----------------------------------------------------------------------+
| -   Establish that the patient has heart failure (in accordance with  |
|     the definition presented on page 4, \"Definition of CHF\" in the  |
|     original guideline document).                                     |
|                                                                       |
| -   Ascertain presenting features: pulmonary oedema, exertional       |
|     breathlessness, fatigue, peripheral oedema.                       |
|                                                                       |
| -   Assess severity of symptoms.                                      |
|                                                                       |
| -   Determine aetiology of heart failure.                             |
|                                                                       |
| -   Identify precipitating and exacerbating factors.                  |
|                                                                       |
| -   Identify concomitant diseases relevant to heart failure and its   |
|     management.                                                       |
|                                                                       |
| -   Estimate prognosis based on Table 7 in the original guideline     |
|     document.                                                         |
|                                                                       |
| -   Assess complicating factors (e.g., renal dysfunction, arthritis). |
|                                                                       |
| -   Counsel patient and relatives.                                    |
|                                                                       |
| -   Choose appropriate management.                                    |
|                                                                       |
| -   Monitor progress and manage accordingly.                          |
+-----------------------------------------------------------------------+

**Prognostication**

-   The problem of defining prognosis in heart failure is complex for
    many reasons: several aetiologies, frequent comorbidities, limited
    ability to explore the paracrine pathophysiological systems, varying
    individual progression and outcome (sudden vs. progressive heart
    failure death), and efficacy of treatments. Moreover, several
    methodological limitations weaken many prognostic studies. The
    variables more consistently indicated as independent outcome
    predictors are reported in Table 7 in the original guideline
    document.

**Treatment of Heart Failure**

**Aims of Treatment in Heart Failure**

i.  Prevention\--a primary objective

    a.  Prevention and/or controlling of diseases leading to cardiac
        dysfunction and heart failure

    b.  Prevention of progression to heart failure once cardiac
        dysfunction is established

ii. Maintenance or improvement in quality of life

iii. Improved survival

**Prevention of Heart Failure**

-   The development of ventricular dysfunction and heart failure may be
    delayed or prevented by treatment of conditions Leading to heart
    failure, in particular in patients with hypertension and/or coronary
    artery disease (Class of recommendation I, Level of evidence A)
    (Turnbull, 2003).

-   The prevention of heart failure should always be a primary
    objective.

When myocardial dysfunction is already present, the first objective is
to remove the underlying cause of ventricular dysfunction if possible
(e.g., ischaemia, toxic substances, alcohol, drugs, and thyroid
disease), providing the benefits of intervention outweigh the risks.
When the underlying cause cannot be corrected treatment should be
directed at delaying or preventing left ventricular dysfunction that
wilt increase the risk of sudden death and the development of heart
failure.

**Management of Chronic Heart Failure**

The therapeutic approach in patients with CHF that is caused by left
ventricular systolic dysfunction includes general advice and other
non-pharmacological measures, pharmacological therapy, mechanical
devices, and surgery.

*Non-pharmacological Management*

[General Advice and Measures]{.underline}

(Class of recommendation I, level of evidence C for non-pharmacological
management unless stated otherwise)

Educating Patients and Family\
Patients with CHF and their close relatives should receive general
advice.

Weight Monitoring\
Patients are advised to weigh on a regular basis to monitor weight gain
(preferably as part of a regular daily routine, for instance after
morning toilet) and, in case of a sudden unexpected weight gain of \>2
kg in 3 days, to alert a health care provider or adjust their diuretic
dose accordingly (e.g., to increase the dose if a sustained increase in
weight is noted).

Dietary Measures

*Sodium*. Controlling the amount of salt in the diet is a problem, that
is, more relevant in advanced than in mild heart failure.

*Fluids*. Instructions on fluid control should be given to patients with
advanced heart failure, with or without hyponatraemia. The exact amount
of fluid restriction remains unclear, however. In practice, a fluid
restriction of 1.5 to 2 L/day is advised in advanced heart failure.

*Alcohol*. Moderate alcohol intake (one beer, 1 to 2 glasses of
wine/day) is permitted other than in case of alcoholic cardiomyopathy
when it is prohibited.

Obesity\
Treatment of CHF should include weight reduction in obese patients.

Abnormal Weight Loss\
Clinical or subclinical malnutrition is present in approximately 50% of
patients with severe CHF. The wasting of total body fat and lean body
mass that accompanies weight loss is called cardiac cachexia. Cardiac
cachexia is an important predictor of reduced survival (Anker et al.,
1997).

Smoking\
Smoking should always be discouraged. The use of smoking cessation aids
should be actively encouraged and may include nicotine replacement
therapies.

Travelling\
High altitudes or very hot or humid places should be discouraged. In
general, short air flights are preferable to long journeys by other
means of transport.

Sexual Activity\
It is not possible to dictate guidelines about sexual activity
counselling. Recommendations are given to reassure the not severely
compromised, but frightened patient, to reassure the partner who is
often even more frightened, and perhaps refer the couple for specialist
counselling. Little is known about the effects of treatments for heart
failure on sexual function.

Advice on Immunizations\
There is no documented evidence of the effects of immunization in
patients with heart failure. Immunization for influenza is widely used.

Drug Counselling\
Self-management (when practical) of the dose of the diuretic, based on
changes in symptoms and weight (fluid balance), should be encouraged.
Within pre-specified and individualized limits, patients are able to
adjust their diuretics.

Drugs to Avoid or Beware

The following drugs should be used with caution when co-prescribed with
any form of heart failure treatment or avoided:

1.  Non-steroidal anti-inflammatory drugs (NSAIDS) and coxibs

2.  Class I anti-arrhythmic agents

3.  Calcium antagonists (verapamil, diltiazem, and short-acting
    dihydropyridine derivatives

4.  Tricyclic anti-depressants

5.  Corticosteroids

6.  Lithium

[Rest, Exercise, and Exercise Training]{.underline}

Rest\
In acute heart failure or destabilization of CHF, physical rest or bed
rest is recommended.

Exercise\
Exercise improves skeletal muscle function and therefore overall
functional capacity. Patients should be encouraged and advised on how to
carry out daily physical and leisure time activities that do not induce
symptoms. Exercise training programs are encouraged in stable patients
in NYHA class Il-Ill. Standardized recommendations for exercise training
in heart failure patients by the European Society of Cardiology have
been published (Working Group on Cardiac Rehabilitation, 2001).

*Pharmacological Therapy*

[Angiotensin-Converting Enzyme Inhibitors]{.underline}

Angiotensin-converting enzyme (ACE) inhibitors are recommended as
first-line therapy in patients with a reduced left ventricular systolic
function expressed as a subnormal ejection fraction, i.e., \<40-45% with
or without symptoms (see non-invasive imaging on page 11 in the original
guideline document) (Class of recommendation I, level of evidence A).

ACE-inhibitors should be uptitrated to the dosages shown to be effective
in the large, controlled trials in heart failure (Class of
recommendation I, level of evidence A), and not titrated based on
symptomatic improvement alone (Class of recommendation I, level of
evidence C).

[ACE Inhibitors in Asymptomatic Left Ventricular
Dysfunction]{.underline}

Asymptomatic patients with a documented left ventricular systolic
dysfunction should be treated with an ACE-inhibitor to delay or prevent
the development of heart failure. ACE-inhibitors also reduce the risk of
myocardial infarction and sudden death in this setting (Class of
recommendation I, level of evidence A) (\"Effect of enalapril on
mortality,\" 1992; Pfeffer et al., 1992; Kober et al., 1995; Jong et
al., 2003).

[ACE Inhibitors in Symptomatic Heart Failure]{.underline}

-   All patients with symptomatic heart failure that is caused by
    systolic left ventricular dysfunction should receive an ACE
    inhibitor (Class of recommendation I, level of evidence A). (Flather
    et al., 2000).

-   ACE inhibition improves survival, symptoms, functional capacity, and
    reduces hospitalization in patients with moderate and severe heart
    failure and left ventricular systolic dysfunction.

-   ACE inhibitors should be given as the initial therapy in the absence
    of fluid retention. In patients with fluid retention, ACE inhibitors
    should be given together with diuretics (Class of recommendation I,
    level of evidence B) (Flather et al., 2000; The CONSENSUS Trial
    Study Group, 1987).

-   ACE inhibition should be initiated in patients with signs or
    symptoms of heart failure, even if transient, after the acute phase
    of myocardial infarction, even if the symptoms are transient to
    improve survival and to reduce reinfarctions and hospitalizations
    for heart failure (Class of recommendation I, level of evidence A)
    (Pfeffer et al., 1992; Kober et al., 1995, \"Effect of ramipril,\"
    1993).

-   Asymptomatic patients with a documented left ventricular systolic
    dysfunction benefit from long-term ACE inhibitor therapy (Class of
    recommendation I, level of evidence A) (\"Effect of enalapril on
    mortality,\" 1992; Pfeffer et al., 1992; Kober et al., 1995; Jong et
    al., 2003).

-   Important adverse effects associated with ACE-inhibitors are cough,
    hypotension, renal insufficiency, hyperkalaemia, syncope, and
    angioedema. Angiotensin receptor blockers may be used as an
    effective alternative in patients who develop cough or angioedema on
    an ACE-inhibitor (Class of recommendation I, level of evidence A).
    Changes in systolic and diastolic blood pressure and increases in
    serum creatinine are usually small in normotensive patients.

-   ACE inhibitor treatment is contraindicated in the presence of
    bilateral renal artery stenosis and angioedema during previous
    ACE-inhibitor therapy (Class of recommendation III, level of
    evidence A).

Target maintenance dose ranges of ACE inhibitors shown to be effective
in various trials are given in Table 12 in the original guideline
document. Recommended initiating and maintenance dosages of
ACE-inhibitors which have been approved for the treatment of heart
failure in Europe are presented in Table 13 in the original guideline
document.

The dose of ACE inhibitors should always be initiated at the lower dose
level and titrated to the target dose. The recommended procedures for
starting an ACE inhibitor are given in the table below titled \"The
Recommended Procedure for Starting an ACE Inhibitor or an Angiotensin
Receptor Blocker.\"

Regular monitoring of renal function is recommended: (1) before, 1-2
weeks after each dose increment, and at 3-6 months interval; (2) when
the dose of an ACE inhibitor is increased or other treatments, which may
affect renal function, are added (e.g., aldosterone antagonist or
angiotensin receptor blocker), (3) in patients with past or present
renal dysfunction or electrolyte disturbances more frequent measurements
should be made, or (4) during any hospitalization.

**Table. The Recommended Procedure for Starting an ACE Inhibitor or an
Angiotensin Receptor Blocker**

+-----------------------------------------------------------------------+
| -   Review the need for and dose of diuretics and vasodilators.       |
|                                                                       |
| -   Avoid excessive diuresis before treatment. Consider reducing or   |
|     withholding diuretics, if being used, for 24 h.                   |
|                                                                       |
| -   It may be advisable to start treatment in the evening, when       |
|     supine, to minimize the potential negative effect on blood        |
|     pressure, although there are no data in heart failure to support  |
|     this (Level of Evidence C). When initiated in the morning,        |
|     supervision for several hours with blood pressure control is      |
|     advisable in risk patients with renal dysfunction or low blood    |
|     pressure.                                                         |
|                                                                       |
| -   Start with a low dose (see Table 13 in the original guideline     |
|     document) and build-up to maintenance dosages shown to be         |
|     effective in large trials (see Table 12 in the original guideline |
|     document).                                                        |
|                                                                       |
| -   If renal function deteriorates substantially, stop treatment.     |
|                                                                       |
| -   Avoid potassium-sparing diuretics during initiation of therapy.   |
|                                                                       |
| -   Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) and Cox-2     |
|     inhibitors (coxibs).                                              |
|                                                                       |
| -   Check blood pressure, renal function, and electrolytes            |
|                                                                       |
|     -   1-2 weeks after each dose increment, at 3 months, and         |
|         subsequently at 6 regular monthly intervals                   |
|                                                                       |
| -   The following patients should be referred for specialist care:    |
|                                                                       |
|     -   Cause of heart failure unknown                                |
|                                                                       |
|     -   Systolic blood pressure \<100 mmHg                            |
|                                                                       |
|     -   Serum creatinine \>150 micromoles/L                           |
|                                                                       |
|     -   Serum sodium \<135 mmol/L                                     |
|                                                                       |
|     -   Severe heart failure                                          |
|                                                                       |
|     -   Valve disease as primary cause                                |
+-----------------------------------------------------------------------+

[Diuretics]{.underline}

Loop Diuretics, Thiazides, and Metolazone

-   Diuretics are essential for symptomatic treatment when fluid
    overload is present and manifest as pulmonary congestion or
    peripheral oedema. The use of diuretics results in rapid improvement
    of dyspnoea and increased exercise tolerance (Class of
    recommendation I, level of evidence A) (Kaddoura et al., 1996,
    Bayliss et al., 1987).

-   There are no controlled randomized trials that have assessed the
    effect on symptoms or survival of these agents. Diuretics should
    always be administered in combination with ACE inhibitors and
    beta-blockers if tolerated (Class of recommendation I, level of
    evidence C).

Detailed recommendations and major side effects are outlined in Tables
15 and 16 in the original guideline document.

Potassium-sparing Diuretics

-   Potassium-sparing diuretics should only be prescribed if
    hypokalaemia persists despite ACE inhibition, or in severe heart
    failure despite the combination ACE inhibition and low-dose
    spironolactone (Class of recommendation I, level of evidence C). In
    patients who are unable to tolerate even low doses of aldosterone
    antagonists due to hyperkalaemia and renal dysfunction, amiloride or
    triamterene may be used (Class of recommendation IIb, level of
    evidence C).

-   Potassium supplements are generally ineffective in this situation
    (Class of recommendation III, level of evidence C).

The use of all potassium-sparing diuretics should be monitored by
repeated measurements of serum creatinine and potassium. A practical
approach is to measure serum creatinine and potassium every 5-7 days
after initiation of treatment until the values are stable. Thereafter,
measurements can be made every 3-6 months.

[Beta-adrenoceptor Antagonists]{.underline}

-   Beta-blockers should be considered for the treatment of all patients
    (in NYHA class II-IV) with stable, mild, moderate, and severe heart
    failure from ischaemic or non-ischaemic cardiomyopathies and reduced
    LVEF on standard treatment, including diuretics, and ACE-
    inhibitors, unless there is a contraindication (Class of
    recommendation I, level of evidence A)  (Packer, et al., 1996;
    \"Randomised, placebo-controlled trial of carvedilol,\" 1997; Packer
    et al., 2001; \"The cardiac insufficiency bisoprolol study II
    (CIBIS-II),\" 1999; \"Effect of metoprolol CR/XL,\" 1999; \"Effects
    of metoprolol CR,\" 2000; Flather et al., 2005).

-   Beta-blocking therapy reduces hospitalizations (all, cardiovascular,
    and heart failure), improves the functional class, and leads to less
    worsening of heart failure. This beneficial effect has been
    consistently observed in subgroups of different age, gender,
    functional class, LVEF, and ischaemic or non-ischaemic aetiology
    (Class of recommendation I, Level of evidence A).

-   In patients with left ventricular systolic dysfunction, with or
    without symptomatic heart failure, following an acute myocardial
    infarction long-term beta-blockade is recommended in addition to ACE
    inhibition to reduce mortality (Class of recommendation I, level of
    evidence B). (Dargie, 2001)

-   Differences in clinical effects may be present between different
    beta-blockers in patients with heart failure (The Beta-Blocker
    Evaluation of Survival Trial Investigators, 2001; Poole-Wilson et
    al., 2003). Accordingly, only bisoprolol, carvedilol, metoprolol
    succinate, and nebivolol can be recommended (Class of recommendation
    I, level of evidence A).

Please refer to the original guideline document for a discussion on
initiation of beta-blocker therapy and dose titration.

[Aldosterone Receptor Antagonists]{.underline}

-   Aldosterone antagonists are recommended in addition to
    ACE-inhibitors, beta-blockers, and diuretics in advanced heart
    failure (NYHA III-IV) with systolic dysfunction to improve survival
    and morbidity (Class of recommendation I, level of evidence B) (Pitt
    et al., 1999).

-   Aldosterone antagonists are recommended in addition to ACE
    inhibitors and beta-blockers in heart failure after myocardial
    infarction with left ventricular systolic dysfunction and signs of
    heart failure or diabetes to reduce mortality and morbidity (Class
    of recommendation I, level of evidence B) (Pitt et al., 2003).

Administration and dosing considerations for aldosterone antagonists are
provided in Table 19 in the original guideline document.

[Angiotensin II Receptor Blockers]{.underline}

For patients with left ventricular systolic dysfunction:

-   Angiotensin II receptor blockers (ARBs) can be used as an
    alternative to ACE inhibition in symptomatic patients intolerant to
    ACE-inhibitors to improve morbidity and mortality (Class of
    recommendation I, level of evidence B) (Granger et al., 2003;
    Pfeffer et al., \"Effects of candesartan,\" 2003; Maggioni et al.,
    2002; Cohn & Tognoni, 2001).

-   ARBs and ACE inhibitors seem to have similar efficacy in CHF on
    mortality and morbidity (Class of recommendation IIa, level of
    evidence B).

-   In acute myocardial infarction with signs of heart failure or left
    ventricular dysfunction, ARBs and ACE inhibitors have similar or
    equivalent effects on mortality (Class of recommendation I, level of
    evidence B) (Pfeffer et al., \"Valsartan, captopril, or both,\"
    2003).

-   ARBs can be considered in combination with ACE inhibitors in
    patients who remain symptomatic, to reduce mortality (Class of
    recommendation IIa, Level of evidence B) and hospital admissions for
    heart failure (Class of recommendation I, level of evidence A)
    (Pfeffer et al., \"Effects of candesartan,\" 2003; McMurray et al.,
    2003; Jong et al., 2002; Coletta & Cleland, 2003).

In NYHA class III patients remaining symptomatic despite therapy with
diuretics, ACE inhibitors, and beta-blockers, there is no definite
evidence for the recommendation of next addition; an ARB or an
aldosterone antagonist to reduce further heart failure hospitalizations
or mortality. Concerns raised by initial studies about a potential
negative interaction between ARBs and beta-blockers have not been
confirmed by recent studies in post-myocardial infarction or CHF (Class
of recommendation I, Level of evidence A) (Pfeffer et al., \"Effects of
candesartan,\" 2003; \"Valsartan, captopril, or both,\" 2003).

Dosing\
Initiation and monitoring of ARBs, which are outlined in above, are
similar to procedures for ACE-inhibitors. Available ARBs and the
recommended dose levels are shown in Table 20 in the original guideline
document.

[Cardiac Glycosides]{.underline}

-   Cardiac glycosides are indicated in atrial fibrillation and any
    degree of symptomatic heart failure, whether or not left ventricular
    dysfunction is the cause. Cardiac glycosides slow the ventricular
    rate, which improves ventricular function and symptoms (Class of
    recommendation I, Level of evidence B) (Khand et al., \"Systematic
    review,\" 2000).

    -   A combination of digoxin and beta-blockade appears superior to
        either agent alone in patients with atrial fibrillation (Class
        of recommendation IIa, level of evidence B) (Khand et al.,
        \"Digoxin or carvedilol,\" 2000).

    -   Digoxin has no effect on mortality but may reduce
        hospitalizations and, particularly, worsening heart failure
        hospitalizations, in the patients with heart failure caused by
        left ventricular systolic dysfunction and sinus rhythm treated
        with ACE inhibitors, beta-blockers, diuretics, and, in severe
        heart failure, spironolactone (Class of recommendation IIa,
        level of evidence A).

Digoxin\
The usual daily dose of oral digoxin is 0.125 to 0.25 mg if serum
creatinine is in the normal range (in the elderly 0.0625 to 0.125 mg,
occasionally 0.25 mg).

[Vasodilator Agents in Chronic Heart Failure]{.underline}

-   There is no specific role for direct-acting vasodilator agents in
    the treatment of CHF (Class of recommendation III, level of
    evidence A) though they may be used as adjunctive therapy for angina
    or concomitant hypertension (Class of recommendation I, level of
    evidence A).

Hydralazine-isosorbide Dinitrate

-   In case of intolerance for ACE inhibitors and ARBs, the combination
    hydralazine/nitrates can be tried to reduce mortality and morbidity
    and improve quality of life (Class of recommendation IIa, level of
    evidence B) (Taylor et al., 2004).

Nitrates

-   Nitrates may be used for the treatment of concomitant angina or
    relief of dyspnoea. (Class of recommendation IIa, level of evidence
    C). Evidence that oral nitrates improve symptoms of heart failure
    chronically or during an acute exacerbation is lacking.

Alpha-adrenergic Blocking Drugs

-   There is no evidence to support the use of alpha-adrenergic blocking
    drugs in heart failure (Class of recommendation III, level of
    evidence B) (Cohn et al., 1986).

Calcium Antagonists

-   Calcium antagonists are not recommended for the treatment of heart
    failure caused by systolic dysfunction. Diltiazem- and
    verapamil-type calcium antagonists, in particular, are not
    recommended in heart failure because of systolic dysfunction; they
    are contraindicated in addition to beta-blockade (Class of
    recommendation III, level of evidence C) (Cohn et al., 1997;
    Thackray et al., 2000).

-   Addition of newer calcium antagonists (felodipine and amlodipine) to
    standard treatment for heart failure does not improve symptoms and
    does not impact on survival (Class of recommendation III, level of
    evidence A) (Cohn et al., 1997; Thackray et al., 2000).

As long-term safety data with felodipine and amlodipine indicate a
neutral effect on survival, they may offer a safe alternative for the
treatment of concomitant arterial hypertension or angina not controlled
by nitrates and beta-blockers.

[Positive Inotropic Therapy]{.underline}

-   Repeated or prolonged treatment with oral inotropic agents increases
    mortality and is not recommended in CHF (Class of recommendation
    III, level of evidence A).

-   Intravenous administration of inotropic agents is commonly used in
    patients with severe heart failure with signs of both pulmonary
    congestion and peripheral hypoperfusion. However, treatment-related
    complications may occur and their effect on prognosis is uncertain.
    Depending on agent, level of evidence and strength of recommendation
    varies (Nieminen et al., 2005).

Preliminary data suggests that some calcium sensitizers (e.g.,
levosimendan) may have beneficial effects on symptoms and end-organ
function and are safe. (Follath et al., 2002)

[Anti-thrombotic Agents]{.underline}

-   In CHF associated with atrial fibrillation, a previous
    thromboembolic event or a mobile left ventricular thrombus,
    anti-coagulation is firmly indicated (Class of recommendation I,
    level of evidence A) (Cleland, Cowburn, & Falk, 1996).

-   There is little evidence to show that anti-thrombotic therapy
    modifies the risk of death or vascular events in patients with heart
    failure.

-   After a prior myocardial infarction, either aspirin or oral
    anti-coagulants are recommended as secondary prophylaxis (Class of
    recommendation IIa, level of evidence C) (Antithrombotic Trialists\'
    Collaboration, 2002)

-   Aspirin should be avoided in patients with recurrent hospitalization
    with worsening heart failure (Class of recommendation IIb, level of
    evidence B).

Because of the potential for increased bleeding complications,
anti-coagulant therapy should be administered under the most controlled
conditions, planning monitoring in properly managed anti-coagulation
clinics.

[Anti-arrhythmics]{.underline}

Anti-arrhythmic drugs other than beta-blockers are generally not
indicated in patients with CHF. In patients with atrial fibrillation
(rarely flutter), non-sustained, or sustained ventricular tachycardia
treatment with anti-arrhythmic agents may be indicated.

Class I Anti-arrhythmics

-   Class I anti-arrhythmics should be avoided as they may provoke fatal
    ventricular arrhythmias, have an adverse haemodynamic effect, and
    reduce survival in heart failure (Class of recommendation III, level
    of evidence B) (\"Preliminary report,\" 1989).

Class II Anti-arrhythmics

-   Beta-blockers reduce sudden death in heart failure (Class of
    recommendation I, level of evidence A) (see also page 23 in the
    original guideline document) (Lόpez-Sendόn et al., 2004).
    Beta-blockers may also be indicated alone or in combination with
    amiodarone or non- pharmacological therapy in the management of
    sustained or non-sustained ventricular tachyarrhythmias (Class of
    recommendation IIa, Level of evidence C) (Steinbeck et al., 1992).

Class III Anti-arrhythmics

-   Amiodarone is effective against most supraventricular and
    ventricular arrhythmias (Class of recommendation I, Level of
    evidence A). It may restore and maintain sinus rhythm in patients
    with heart failure and atrial fibrillation even in the presence of
    enlarged left atria, or improve the success of electrical
    cardioversion, and amiodarone is the preferred treatment in this
    condition (\"Effect of prophylactic amiodarone,\" 1997; Levy et al.,
    1998). Amiodarone is the only anti-arrhythmic drug without
    clinically relevant negative inotropic effects.

Routine administration of amiodarone in patients with heart failure is
not justified (Class of recommendation III, level of evidence A) (Singh
et al., 1995; Bardy et al., 2005).

*Oxygen Therapy*

-   Oxygen is used for the treatment of acute heart failure (AHF), but
    in general has no application in CHF (Class of recommendation III,
    level of evidence C).

**Surgery and Devices**

*Revascularization Procedures, Mitral Valve Surgery, and Ventricular
Restoration*

-   If clinical symptoms of heart failure are present, surgically
    correctable pathologies must always be considered (Class of
    recommendation I, level of evidence C).

*Revascularization*

-   There are no data from multicenter trials to support the use of
    revascularization procedures for the relief of heart failure
    symptoms. Single centre, observational studies on heart failure of
    ischaemic origin suggest that revascularization might lead to
    symptomatic improvement (Class of recommendation IIb, level of
    evidence C).

-   Until the results of randomized trials are reported,
    revascularization (surgical or percutaneous) is not recommended as
    routine management of patients with heart failure and coronary
    disease (Class of recommendation III, level of evidence C).

*Mitral Valve Surgery*

-   Mitral valve surgery in patients with severe left ventricular
    systolic dysfunction and severe mitral valve insufficiency due to
    ventricular insufficiency may lead to symptomatic improvement in
    selected heart failure patients (Class of recommendation IIb, level
    of evidence C). This is also true for secondary mitral insufficiency
    due to left ventricular dilatation.

*Left Ventricular Restoration*

LV Aneurysmectomy

-   LV aneurysmectomy is indicated in patients with large, discrete left
    ventricular aneurysms who develop heart failure (Class of
    recommendation I, level of evidence C).

Cardiomyoplasty

-   Currently, cardiomyoplasty cannot be recommended for the treatment
    of heart failure (Class of recommendation III, level of evidence C).

-   Cardiomyoplasty cannot be considered a viable alternative to heart
    transplantation (Class of recommendation III, level of evidence C).

Partial Left Ventriculectomy (Batista Operation)

-   Partial left ventriculectomy cannot be recommended for the treatment
    of heart failure (Class of recommendation I, level of evidence C).
    Furthermore, the Batista operation should not be considered an
    alternative to heart transplantation (Class of recommendation III,
    level of evidence C).

External Ventricular Restoration

-   Currently, external ventricular restoration cannot be recommended
    for the treatment of heart failure. Preliminary data suggest an
    improvement in LV dimensions and NYHA class with some devices (Class
    of recommendation IIb, level of evidence C).

*Pacemakers*

Pacemakers have been used in patients with heart failure to treat
bradycardia when conventional indications exist. Pacing only of the
right ventricle in patients with systolic dysfunction will induce
ventricular dyssynchrony and may increase symptoms (Class of
recommendation III, level of evidence A).

-   Resynchronization therapy using bi-ventricular pacing can be
    considered in patients with reduced ejection fraction and
    ventricular dyssynchrony (QRS width [\>]{.underline}120 ms) and who
    remain symptomatic (NYHA III-IV) despite optimal medical therapy to
    improve symptoms (Class of recommendation I, level of evidence A),
    hospitalizations (Class of recommendation I, level of evidence A),
    and mortality (Class of recommendation I, level of evidence B).

*Implantable Cardioverter Defibrillators*

-   Implantation of an implantable cardioverter defibrillators (ICD) in
    combination with bi-ventricular pacing can be considered in patients
    who remain symptomatic with severe heart failure NYHA class lll-IV
    with LVEF [\<]{.underline} 35% and QRS duration [\>]{.underline}120
    ms to improve mortality or morbidity (Class of recommendation IIa,
    level of evidence B) (Bristow et al., 2004).

-   ICD therapy is recommended to improve survival in patients who have
    survived cardiac arrest or who have sustained ventricular
    tachycardia, which is either poorly tolerated or associated with
    reduced systolic left ventricular function (Class of recommendation
    I, level of evidence A) (Moss et al., 1996).

-   ICD implantation is reasonable in selected patients with LVEF \<30
    to 35%, not within 40 days of a myocardial infarction, on optimal
    background therapy including ACE inhibitor, ARB, beta-blocker, and
    an aldosterone antagonist, where appropriate, to reduce sudden death
    (Class of recommendation I, level of evidence A) (Bardy et al.,
    2005; Moss et al., 2002; Kadish et al., 2004)

*Heart Replacement Therapies: Heart Transplantation, Ventricular Assist
Devices, and Artificial Heart*

Heart Transplantation

-   Heart transplantation is an accepted mode of treatment for end stage
    heart failure. Although controlled trials have never been conducted,
    it is considered to significantly increase survival, exercise
    capacity, return to work and quality of life compared with
    conventional treatment, provided proper selection criteria are
    applied (Class of recommendation I, level of evidence C).

Patients who should be considered for heart transplantation are those
with severe symptoms of heart failure with no alternative form of
treatment and with a poor prognosis.

Ventricular Assist Devices and Artificial Heart

-   Current indications for left ventricular assist devices and
    artificial heart include bridging to transplantation, acute severe
    myocarditis, and in some patients permanent haemodynamic support
    (Class of recommendation IIa, level of evidence C).

-   Left ventricular assist devices are being implanted as a bridge to
    transplantation. Experience from long-term treatment is accumulating
    but these devices are not recommended for routine Long-term use
    (Class of recommendation IIb, level of evidence B) (Rose et al.,
    2001).

*Ultrafiltration*

-   Ultrafiltration may be used to treat fluid overload (pulmonary or
    peripheral oedema) refractory to diuretics (Rimondini et al, 1987).
    However, in most patients with severe heart failure, the relief is
    temporary (Dormans, Huige, & Gerlag, 1996).

**Choice and Timing of Pharmacological Therapy**

Please refer to the original guideline document for a discussion of the
choice and timing of pharmacological therapy in the various stages of
heart failure caused by systolic dysfunction.

**Management of Heart Failure with Preserved Left Ventricular Ejection
Fraction (PLVEF)**

Please refer to the original guideline document for a discussion on the
management of heart failure with preserved LVEF.

*Pharmacological Therapy of Heart Failure with PLVEF or Diastolic
Dysfunction*

The following recommendations are largely speculative because of the
limited data available in patients with PLVEF or diastolic dysfunction
(in general, Class of recommendation IIa, level of evidence C).

There is no clear evidence that patients with primary diastolic heart
failure benefit from any specific drug regimen.

1.  ACE inhibitors may improve relaxation and cardiac distensibility
    directly and may have tong-term effects through their
    anti-hypertensive effects and regression of hypertrophy and
    fibrosis.

2.  Diuretics may be necessary when episodes with fluid overload are
    present, but should be used cautiously so as not to lower preload
    excessively and thereby reduce stroke volume and cardiac output.

3.  Beta-blockade could be instituted to lower heart rate and increase
    the diastolic filling period.

4.  Verapamil-type calcium antagonists may be used for the same reason
    (Setaro et al., 1990). Some studies with verapamil have shown a
    functional improvement in patients with hypertrophic cardiomyopathy
    (Bonow et al., 1985).

5.  A high dose of an ARB may reduce hospitalizations (Yusuf et al.,
    2003).

**Heart Failure Treatment in the Elderly**

Please refer to the original guideline document for a discussion of
heart failure treatment in the elderly.

**Arrhythmias**

-   It is essential to recognize and correct precipitating factors for
    arrhythmias, improve cardiac function, and reduce neuro-endocrine
    activation with beta-blockade, ACE inhibition, and, possibly,
    aldosterone receptor antagonists (Class of recommendation I, Level
    of evidence C).

**Ventricular Arrhythmias**

-   In patients with ventricular arrhythmias, the use of anti-arrhythmic
    agents is only justified in patients with severe, symptomatic,
    sustained ventricular tachycardias and where amiodarone should be
    the preferred agent (Class of recommendation IIa, level of
    evidence B) (\"Effect of prophylactic amiodarone,\" 1997; Singh et
    al., 1995).

-   ICD implantation is indicated in patients with heart failure and
    with life threatening ventricular arrhythmias (i.e., ventricular
    fibrillation or sustained ventricular tachycardia) and in selected
    patients at high risk of sudden death (Class of recommendation I,
    level of evidence A) (Moss et al., 1996, 2002; \"A comparison of
    antiarrhythmic-drug therapy,\" 1997; Buxton et al., 1999, Priori et
    al., 2001).

**Atrial Fibrillation**

-   For persistent (non-self-terminating) atrial fibrillation,
    electrical cardioversion could be considered, although its success
    rate may depend on the duration of atrial fibrillation and left
    atrial size (Class of recommendation IIa, level of evidence B).

-   In patients with atrial fibrillation and heart failure and/or
    depressed left ventricular function, the use of anti-arrhythmic
    therapy to maintain sinus rhythm should be restricted to amiodarone
    (Class of recommendation I, level of evidence C) and, if available,
    to dofetilide (Class of recommendation IIa, level of evidence B)
    (Torp-Pederson et al., 1999).

-   In asymptomatic patients, beta-blockade, digitalis glycosides, or
    the combination may be considered for control of ventricular rate
    (Class of recommendation I, level of evidence B). In symptomatic
    patients with systolic dysfunction digitalis glycosides are the
    first choice (Class of recommendation IIa, level of evidence C). In
    PLVEF, verapamil can be considered (Class of recommendation IIa,
    level of evidence C).

-   Anti-coagulation in persistent atrial fibrillation with warfarin
    should always be considered unless contraindicated (Class of
    recommendation I, level of evidence C).

-   Management of acute atrial fibrillation is not depending on previous
    heart failure or not. Treatment strategy is depending on symptoms
    and haemodynamic stability. For options see Fuster et al., 2001.

**Symptomatic Systolic Left Ventricular Dysfunction and Concomitant
Angina or Hypertension**

Specific recommendations in addition to general treatment for heart
failure because of systolic left ventricular dysfunction. If angina is
present:

-   Optimize existing therapy, e.g., beta-blockade.

-   Add long-acting nitrates.

-   If not successful, add amlodipine or felodipine.

-   Consider coronary revascularization.

If hypertension is present:

-   Optimize the dose of ACE inhibitors, beta-blocking agents, and
    diuretics (Turnbull, 2003).

-   Add spironolactone or ARBs if not present already.

-   If not successful, try second generation dihydropyridine
    derivatives.

**Care and Follow-up**

-   An organized system of specialist heart failure care improves
    symptoms and reduces hospitalizations (Class of recommendation I,
    level of evidence A) and mortality (Class of recommendation IIa,
    level of evidence B) of patients with heart failure (Coletta et al.,
    2003; Rich, 1999; McAlister et al., 2001; Stewart, Pearson, &
    Horowitz, 1998; Stewart, Marley & Horowitz, 1999; Stromberg et al.,
    2003).

-   It is likely that the optimal model will depend on local
    circumstances and resources and whether the model is designed for
    specific sub-groups of patients (e.g., severity of heart failure,
    age, comorbidity, and left ventricular systolic dysfunction) or the
    whole heart failure population (Class of recommendation I, level of
    evidence C) (Weinberger, Oddone, & Henderson, 1996, Jaarsma et al.,
    1999; Ekman et al., 1998; McAlister et al., 2004).

**Table. Recommended Components of Care and Following Programmes (class
of recommendation I, level of evidence C**

+-----------------------------------------------------------------------+
| -   Use a multi-disciplinary team approach.                           |
|                                                                       |
| -   Vigilant follow-up, first follow up within 10 days of discharge   |
|                                                                       |
| -   Discharge planning                                                |
|                                                                       |
| -   Increased access to health care                                   |
|                                                                       |
| -   Optimizing medical therapy with guidelines                        |
|                                                                       |
| -   Early attention to signs and symptoms (e.g., telemonitoring)      |
|                                                                       |
| -   Flexible diuretic regimen                                         |
|                                                                       |
| -   Intense education and counselling                                 |
|                                                                       |
| -   Inpatient and outpatient (home-based)                             |
|                                                                       |
| -   Attention to behavioural strategies                               |
|                                                                       |
| -   Address barriers to compliance                                    |
+-----------------------------------------------------------------------+

**Definitions**:

**Levels of Evidence**

A.  Data derived from multiple randomized clinical trials or
    meta-analyses.

B.  Data derived from a single randomized clinical trial or large
    non-randomized studies.

C.  Consensus of opinion of the experts and/or small studies,
    retrospective studies, registries.

**Classes of Recommendations**

**Class I**: Evidence and/or general agreement that a given diagnostic
procedure/treatment is beneficial, useful, and effective

**Class II**: Conflicting evidence and/or a divergence of opinion about
the usefulness/efficacy of the treatment

**Class IIa**: Weight of evidence/opinion is in favour of
usefulness/efficacy

**Class IIb**: Usefulness/efficacy is less well established by
evidence/opinion

**Class III**\*: Evidence or general agreement that the treatment is not
useful/effective and in some cases may be harmful

\*Use of Class III evidence is discouraged by the European Society of
Cardiology (ESC)

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for the
diagnosis of heart failure or left ventricular dysfunction.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=7301)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

For the diagnosis, evidence is incomplete and in general based on
consensus of expert opinions. As in the 2001 version, it was decided not
to use evidence grading in this part.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Accurate diagnosis of chronic heart failure, including establishing
    the proper epidemiology and prognosis, can aid in optimizing
    treatment.

-   Appropriate treatment of heart failure may prevent disease
    progression, maintain or improve quality of life, and increase
    survival.

#### POTENTIAL HARMS

**Angiotensin-converting Enzyme (ACE) Inhibitors**

Important adverse effects associated with ACE inhibitors are cough,
hypotension, renal insufficiency, hyperkalaemia, syncope, and
angioedema.

**Diuretics**

Major side effects of diuretics are provided in table 16 of the original
guideline document and include hypokalaemia, hypomagnesaemia,
hyponatraemia, hyperuiricaemia, glucose intolerance, acid-base
disturbance, hyperkalaemia, rash, and gynaecomastia.

**Beta-blockers**

During titration, beta-blockers may reduce heart rate excessively,
temporarily induce myocardial depression, and exacerbate symptoms of
heart failure.

**Positive Inotropic Agents**

Repeated or prolonged treatment with oral inotropic agents increases
mortality.

**Heart Transplantation**

Besides shortage of donor hearts, the main problem of heart
transplantation is rejection of the allograft, which is responsible for
a considerable percentage of deaths in the first postoperative year. The
long-term outcome is limited predominantly by the consequences of
immuno-suppression (infection, hypertension, renal failure, malignancy,
and by transplant coronary vascular disease).

**Heart Failure Treatment in the Elderly**

-   In elderly patients, hyperkalaemia is more frequently seen with a
    combination of aldosterone antagonist and ACE inhibitors or
    nonsteroidal anti-inflammatory drugs (NSAIDs) and Cox-2 inhibitors
    (coxibs).

-   Elderly patients may be more susceptible to adverse effects of
    digoxin.

-   Venodilating drugs, such as nitrates and the arterial dilator
    hydralazine and the combination of these drugs, should be
    administered carefully because of the risk of hypotension.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Angiotensin-converting enzyme (ACE) inhibitor treatment is
    contraindicated in the presence of bilateral renal artery stenosis
    and angioedema during previous ACE-inhibitor therapy.

-   Contraindications to the use of beta-blockers in patients with heart
    failure include asthma bronchiale, severe bronchial disease, and
    symptomatic bradycardia or hypotension.

-   Relative contraindications for starting a beta-blocker include
    asymptomatic bradycardia and/or low blood pressure.

-   Contraindications to the use of cardiac glycosides include
    bradycardia, second- and third-degree atrioventricular (AV) block,
    sick sinus syndrome, carotid sinus syndrome, Wolff-Parkinson-White
    syndrome, hypertrophic obstructive cardiomyopathy, hypokalaemia, and
    hyperkalaemia.

-   Diltiazem- and verapamil-type calcium antagonists are
    contraindicated in addition to beta-blockade for the treatment of
    heart failure caused by systolic dysfunction.

-   Contraindications for heart transplantation include:

    -   Present alcohol and/or drug abuse

    -   Lack of proper co-operation

    -   Serious mental disease which could not be properly controlled

    -   Treated cancer with remission and \<5 years follow-up

    -   Systemic disease with multi-organ involvement

    -   Uncontrolled infection

    -   Severe renal failure (creatinine clearance \<50 mL min) or
        creatinine \>250 micromoles/L, although some centres accept
        patients on haemodialysis

    -   Fixed high pulmonary vascular resistance (6--8 Wood units and
        mean transpulmonary gradient \>15 mm Hg and pulmonary artery
        systolic pressure \>60 mm Hg)

    -   Recent thromboembolic complication

    -   Unhealed peptic ulcer

    -   Evidence of significant liver impairment

    -   Other disease with a poor prognosis

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   National health policy as well as clinical judgement may dictate the
    order of priority of implementation. It is recognized that some
    interventions may not be affordable in some countries for all
    appropriate patients. The recommendations in these guidelines should
    therefore always be considered in the light of national policies and
    local regulatory requirements for the administration of any
    diagnostic procedure, medicine, or device.

-   Many definitions of chronic heart failure (CHF) exist, but only
    selective features of this complex syndrome are highlighted. None is
    entirely satisfactory. A simple objective definition of CHF is
    currently impossible as there is no cut-off value of cardiac or
    ventricular dysfunction or change in flow, pressure, dimension, or
    volume that can be used reliably to identify patients with heart
    failure. The diagnosis of heart failure relies on clinical judgment
    based on a history, physical examination, and appropriate
    investigations.

-   The ESC Guidelines represent the views of the ESC and were arrived
    at after careful consideration of the available evidence at the time
    they were written. Health professionals are encouraged to take them
    fully into account when exercising their clinical judgment. The
    guidelines do not, however, override the individual responsibility
    of health professionals to make appropriate decisions in the
    circumstances of the individual patients, in consultation with that
    patient, and where appropriate and necessary the patient\'s guardian
    or carer. It is also the health professional\'s responsibility to
    verify the rules and regulations applicable to drugs and devices at
    the time of prescription.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Foreign Language Translations\
Personal Digital Assistant (PDA) Downloads\
Pocket Guide/Reference Cards\
Slide Presentation

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\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M,
Tavazzi L, Smiseth OA, Gavazzi A, Haverich A, Hoes A, Jaarsma T,
Korewicki J, Levy S, Linde C, Lopez-Sendon JL, Nieminen MS, Pierard L,
Remme WJ. Guidelines for the diagnosis and treatment of chronic heart
failure: full text (update 2005): The Task Force for the Diagnosis and
Treatment of Chronic Heart Failure of the European Society of
Cardiology. Sophia Antipolis (FR): European Society of Cardiology (ESC);
2005. 45 p. \[358 references\]

#### ADAPTATION

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

#### DATE RELEASED

2001 Sep (revised 2005)

#### GUIDELINE DEVELOPER(S)

European Society of Cardiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

European Society of Cardiology

#### GUIDELINE COMMITTEE

Task Force for the Diagnosis and Treatment of Chronic Heart Failure

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: Karl Swedberg (*Chairperson*), Göteborg (Sweden)

*Writing Committee*: John Cleland, Hull (UK); Henry Dargie, Glasgow
(UK); Helmut Drexler, Hannover (Germany); Ferenc Follath, Zurich
(Switzerland); Michel Komajda, Paris (France); Luigi Tavazzi, Pavia
(Italy); Otto A. Smiseth, Oslo (Norway)

*Other Contributors*: Antonello Gavazzi, Bergamo (Italy); Axel Haverich,
Hannover (Germany); Arno Hoes, Utrecht (The Netherlands), Tiny Jaarsma,
Gronigen (The Netherlands); Jerczy Korewicki, Warsaw (Poland); Samuel
Lévy, Marseille (France); Cecilia Linde, Stockholm (Sweden); José-Luis
Lopez-Sendon, Madrid (Spain); Markku S. Nieminen, Helsinki (Finland);
Luc Piérard, Liège (Belgium); Willem J. Remme, Rhoon (The Netherlands)

*European Society of Cardiology (ESC) Committee for Practice Guidelines
Members*: Silvia G. Priori (Chairperson) (Italy); Jean-Jacques Blanc
(France); Andrzej Budaj (Poland); John Camm (UK); Veronica Dean
(France); Jaap Deckers (The Netherlands); Kenneth Dickstein (Norway);
John Lekakis (Greece); Keith McGregor (France); Marco Metra (Italy);
João Morais (Portugal); Ady Osterspey (Germany); Juan Tamargo (Spain);
José Luis Zamorano (Spain)

*Document Reviewers*: Marco Metra (CPG Review Coordinator) (Italy);
Michael Böhm (Germany); Alain Cohen-Solal (France); Martin Cowie (UK);
Ulf Dahlström (Sweden); Kenneth Dickstein (Norway); Gerasimos S.
Filippatos (Greece); Edoardo Gronda (Italy); Richard Hobbs (UK); John K.
Kjekshus (Norway); John McMurray (UK); Lars Rydén (Sweden); Gianfranco
Sinagra (Italy); Juan Tamargo (Spain); Michal Tendera (Poland); Dirk van
Veldhuisen (The Netherlands); Faiez Zannad (France)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Within the Task Force, statements of Conflicts of Interests were
collected, which are available at the European Society of Cardiology
(ESC) Office.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Remme WJ, Swedberg K, Task
Force for the Diagnosis and Treatment of Chronic Heart Failure, European
Society of Cardiology. Guidelines for the diagnosis and treatment of
chronic heart failure. Eur Heart J 2001 Sep;22(17):1527-60.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [European Society of Cardiology
(ESC) Web
site](http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/chronic-heart-failure.aspx).

Print copies: Available from Oxford University Press, Great Clarendon
Street, Oxford, OX2 6DP, UK, Tel: +44 (0) 1865 353263, Fax: +44 (0) 1865
353774, Web site: <http://www.eurheartj.org/>.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Guidelines for the diagnosis and treatment of chronic heart failure:
    executive summary (update 2005): The Task Force for the Diagnosis
    and Treatment of Chronic Heart Failure of the European Society of
    Cardiology. Eur Heart J 2005;26:1115-1140. Electronic copies:
    Available from the [European Society of Cardiology (ESC) Web
    site](http://www.escardio.org/admin/GuidelinesReferences/guidelines-CHF-ES.pdf).

-   Diagnosis and treatment of chronic heart failure (update 2005).
    Pocket guidelines. (Available in English, Italian, Spanish, French,
    and German). Sophia Antipolis (France): European Society of
    Cardiology, 2005. Electronic copies: An order form for ESC pocket
    guidelines is available in Portable Document Format (PDF) from the
    [European Society of Cardiology (ESC) Web
    site](http://www.escardio.org/admin/GuidelinesReferences/CHF-pocket.aspx).
    Also available for PDA download from the [European Society of
    Cardiology (ESC) Web site](http://www.pocketgram.net/escardio/).

-   ESC guidelines for the diagnosis and treatment of chronic heart
    failure - 2005. Educational slides. Sophia Antipolis (France):
    European Society of Cardiology, 2005. Electronic copies: Available
    in Microsoft PowerPoint from the [European Society of Cardiology
    (ESC) Web
    site](http://www.escardio.org/admin/GuidelinesReferences/guidelines-CHF-slides.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on April 2, 2002. This NGC summary
was updated by ECRI on March 2, 2006. The updated information was
verified by the guideline developer on April 10, 2006. This summary was
updated by ECRI on March 6, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on Coumadin (warfarin sodium). 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).

#### COPYRIGHT STATEMENT

This summary is based on the original guideline, which is subject to the
guideline developer\'s restrictions.

### DISCLAIMER

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Date Modified: 11/10/2008