Cardiac Failure
This Clinical Information Sheet (CIS) has been developed to assist RACF staff; medical practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the management of residential aged care patients with cardiac failure. It addresses issues that may occur in RACF, particularly:
Diagnosis of residents presenting with signs and symptoms of cardiac failure; Ongoing management; Management of acute exacerbations, and Palliative approach to end-stage cardiac failure.
This CIS covers:
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Cardiac Failure
In Australia it is estimated that 300,000 people suffer from cardiac failure, with about 30,000 new cases annually. The disease particularly affects older adults [1-4], with over 60% of Australian patients admitted to hospital for cardiac failure being aged 70 years or over [2]. Median survival time following a diagnosis of cardiac failure is about 3-4 years [5].
Cardiac failure is characterised by insufficient vascular perfusion to meet the body’s requirements as a result of a decline in cardiac pumping ability or relaxation of the left ventricle (LV). In response, the body initiates compensatory neurohormonal responses to maintain arterial blood pressure and blood flow to the vital organs. Over time, the increase in neuro hormones exacerbates cardiac failure by contributing to increased peripheral resistance, irreversible cardiac changes e.g. hypertrophy, fibrosis, ischaemia and fluid and electrolyte imbalances [2, 3].
Cardiac failure can be predominately left ventricular, with pulmonary congestion and dyspnoea, or predominately right ventricular with elevated venous pressure, peripheral oedema and hepatic congestion. Usually they occur together as biventricular or congestive cardiac failure [5].
Cardiac failure is categorised as either systolic or diastolic. Impaired systolic function due to myocardial damage, is the most common type of cardiac failure, particularly in older adults [1-3, 6]. Diastolic dysfunction occurs in those with longstanding hypertension or diabetes [7]. Management of systolic and diastolic cardiac failure may differ depending on the underlying causes [2, 3].
Assessment
The aim of assessment is to accurately determine:
Diagnosis and type of cardiac failure, if not already known; Underlying causes or precipitating factors; Stage of disease, and Adequacy of current management.
Underlying causes for cardiac failure include [4, 5, 8, 9]:
Coronary artery disease; Hypertension; Valvular heart disease; Hypertrophic cardiomyopathy; Hyperthyroidism, particularly with atrial fibrillation; Obstructive sleep apnoea; Excess alcohol intake (thiamine deficiency); Smoking; Obesity, and Physical inactivity.
Precipitating factors of an acute exacerbation or deterioration of cardiac failure, include [1, 5, 8, 9]:
Lack of compliance with treatment, e.g. medication, or dietary restriction (fluid, salt alcohol); Adverse effects of medication, e.g. NSAID, negatively inotropic drugs; Tachyarrthymias, e.g. atrial fibrillation or flutter, atrial or ventricular tachycardia; Bradyarrythmias, e.g. sinus bradycardia or heart block; Myocardial ischaemia or infarction, unstable angina; Infection e.g. bronchopneumonia, urinary tract infection; Severe anaemia; Hyperthyroidism, and Pulmonary embolism.
Stage of cardiac failure
Table One shows the stages of cardiac failure, described by the American College of Cardiology together with the American Heart Association. The level of treatment changes as patients progress from one stage to the next [1, 3, 4, 6, 10]; most will have Level C or D cardiac failure by the time they are admitted to a RACF.
Table One: Stages of cardiac failure [1, 3, 4, 6, 10]
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Stage
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A:high risk of heart failure
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B: asymptomatic heart failure
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C: symptomatic heart failure
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D: end-stage heart failure
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Common signs, symptoms and risk factors
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Hypertension.
Diabetes.
Coronary heart disease.
Family history of Cardiomyopathy.
|
Previous myocardial infarction.
Left ventricular dysfunction.
Valvular heart disease.
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Structural heart disease.
Dyspnoea.
Fatigue.
Decline in activity tolerance.
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Symptoms at rest despite maximum interventions.
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Clinical assessment
History and physical examination includes [2, 4]:
Presenting signs and symptoms; Ability to perform activities of daily living; Fluid volume status and orthostatic blood pressure changes; Weight to assess fluid retention, and Calculation of body mass index.
Signs and symptoms of cardiac failure include [1-3, 6, 8]:
Breathlessness (dyspnoea); Fatigue; Decreased activity tolerance;
Paroxysmal nocturnal dyspnoea (waking short of breath at night); Tachypnoea (rapid breathing); Bilateral crackles on inspiration (on auscultation); Tachycardia and/or irregular heart rate; Blood pressure abnormalities –can be high (causative) or low in late stages (a sign of severity); Jugular vein distension; Peripheral oedema (swollen feet, ankles, legs); Pale and/or sweating, and Ascites.
Dyspnoea and paroxysmal nocturnal dyspnoea (breathlessness causing waking at night) are associated with pulmonary congestion whilst fatigue and exercise intolerance indicate decreased heart output [2, 3].
Investigations
Clinical assessment, chest X-ray and ECG will usually identify diagnosis and underlying cause. Additional investigations may be required for diagnosis, assessment of severity and precipitating factors.
Chest X-ray
Chest X-ray findings in cardiac failure include an enlarged heart, pulmonary venous congestion, pleural effusions and alveolar oedema [3]. Chest X-ray can identify non-cardiac causes of breathlessness such as COPD, pulmonary fibrosis, bronchopneumonia and bronchiectasis.
Electrocardiogram (ECG)
ECG may identify underlying causes of cardiac failure such as arrhythmias, cardiac ischemia, past myocardial infarction, or left ventricular hypertrophy [7].
Echocardiogram
Echocardiogram measures the size and contractility of the ventricles, and provides an estimate of the ejection fraction (percentage of blood ejected with each beat). It can assess structure and function of heart valves. Transthoracic echocardiograms (TTE) are usually done, but occasionally a transoesophageal echo (TOE) will be required to gather more detailed information.
Most patients with cardiac failure will have an echocardiogram at least once. It is used to determine whether impaired left ventricular contraction (systolic dysfunction) or impaired relaxation (diastolic dysfunction) is leading to cardiac failure [7].
Where the echocardiogram establishes normal systolic function (ejection fraction), and valvular functions, consider diastolic heart failure, or differential diagnoses of fluid overload, pericardial effusion or constriction, pulmonary, renal or hepatic disease [1].
Blood tests
B-type natriuretic peptide levels (also known as brain natriuretic peptide levels, BNP) are raised in cardiac failure and can be helpful to determine diagnosis and severity of cardiac failure [2-4]. Diagnoses other than cardiac failure should be considered in those with a normal BNP [1]. BNP tests are currently expensive and not widely available.
Other useful blood tests include U&Es, creatinine, FBC, TFTs, LFTs, glucose, and lipids [1, 2, 4]. Table Two describes results commonly found in cardiac failure.
Table Two: Blood test results commonly found in cardiac failure [2]
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Blood Tests
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Findings in cardiac failure
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Full blood count (FBC)
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Mild anaemia may be present. (If severe, blood or iron transfusion may improve cardiac function.)
Mild thrombocytopenia may be present due to concurrent conditions e.g. liver dysfunction or adverse effect of medication e.g. diuretics.
Erythrocyte sedimentation rate (ESR) usually low -normal or low but may be elevated due to concurrent conditions e.g. infection.
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Electrolytes
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Electrolytes in mild - moderate cardiac failure usually normal.
In advanced cardiac failure you may find:
Dilutional hyponatraemia (low sodium) - related to fluid retention; Hyperkalemia (elevated potassium) - related to diuretic therapy, ACE; Inhibitors or impaired renal function; Hypokalaemia (low potassium) related to diuretic therapy; Low serum magnesium related to diuretic therapy, and Rise in serum creatinine.
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Iron
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Serum iron usually normal.
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Liver function tests (LFTs)
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Rise in levels of AST, ALT and LDH related to congestive hepatomegaly.
Rise in serum bilirubin.
Hypoalbuminaemia may indicate cardiac cirrhosis.
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Other investigations
Cardiac catheterisation, an invasive day surgery procedure, is rarely used in the diagnosis and assessment of cardiac failure in RACF residents. Radionuclide blood pool scanning can provide more detailed information than echocardiography but is very expensive and is not used often in Australia.
Management
Goals of management for residents with cardiac failure are to [1, 2, 4]:
Improve life expectancy and quality of life; Treat underlying causes or precipitating factors; Control symptoms and signs of cardiac failure; Manage co-morbidities; Prevent medication interactions/side effects, and Maintain comfort in end stage cardiac failure.
The resident’s GP should develop a cardiac failure management plan, together with RACF staff, the resident and family. The management plan should be reviewed regularly (as a minimum, annually) [1, 4, 8]. Specific goals depend upon the stage of cardiac failure; these should be clearly documented and incorporated into Advance Care Planning [1, 4, 9, 11, 12].
The management plan incorporates:
Stage of cardiac failure; Goals of care; Medication for maintenance and acute exacerbations; Lifestyle changes and resident education; Monitoring for clinical response and adverse effects (including weight, and blood tests); How to identify and respond to acute exacerbations, and Advance care plan.
Medication review
The resident’s overall medication regime should be reviewed annually, with an acute exacerbation, and when introducing a new line of therapy. Determine if medications can be reduced, ceased or altered to prevent drug interactions. Medications that may exacerbate cardiac failure include [1, 4, 8, 9, 13]:
Non steroidal anti inflammatory drugs (including Cox-2 inhibitors) are not recommended due to the increased risk of fluid retention and renal failure, particularly if used with ACE Inhibitor or loop diuretic [1, 9, 12]; Calcium channel blockers e.g. diltiazam, verapamil; Tricyclic anti-depressants; Anti-diabetic drugs called thiazolidinediones e.g. Rosiglitazone; Some antipsychotics e.g. thioridazine, and Products containing sodium e.g. ural, antacids.
Consider potential adverse effects and drug interactions at the time of prescribing medications. Monitor relevant clinical signs and pathology tests before changing medication and after an appropriate period. See the Clinical Information Sheet on Medication Management for further information.
Manage concurrent illness
Conditions associated with cardiac failure include [4, 12]:
Pulmonary disease
As cardiac failure can have an effect on the respiratory system, there is a risk that concurrent pulmonary disease may be overlooked. Residents with respiratory signs and symptoms (breathlessness, tachypnoea) or low oxygen saturation levels on exercise should be assessed to determine whether the cause is cardiac or pulmonary disease before treatment (including oxygen therapy) is initiated [1, 4, 10, 12-14].
If signs and symptoms persist despite initial management the following alternate diagnoses may be investigated [12]:
Pulmonary emboli (VQ scan, CT pulmonary angiogram); Pulmonary hypertension (echocardiogram); Silent myocardial infarction (echocardiogram, stress test); Obesity; and/or Sleep disordered breathing (sleep study).
Sleep-disordered breathing
Sleep-disordered breathing such as obstructive sleep apnoea is significantly related to an increase in the risk of cardiac failure [4]. In addition, people with late stage heart failure have a high prevalence of Cheyne–Stokes respirations with central sleep apnoea, which carries a poor prognosis and can cause severe sleep disturbance that is hard to treat and made worse by sedatives. A sleep assessment and/or polysomnography [2, 12] should be considered for residents with cardiac failure who display signs and symptoms of sleep disordered breathing.
Depression and anxiety
Depression is common in both the general population of older adults and patients with cardiac failure, therefore screening is highly recommended [2, 9, 12]. Treatment of depression with selective serotonin reuptake inhibitors (SSRIs) is preferable to tricyclic antidepressants as the latter have anticholinergic side-effects (e.g. increase in heart rate; increase in orthostatic hypotension) that impact upon cardiac failure and its management [12]. Research shows cognitive behaviour therapy (CBT) is effective in treating depression in residents with cardiac failure [2], however accessing a psychologist can be difficult and some residents will not have sufficient cognitive ability to undertake CBT. Anxiety is common in residents diagnosed with chronic diseases, and can decrease ability to be involved in care planning. Non-pharmacological strategies such as relaxation techniques, and meditation may be considered in the management of anxiety [9, 12].
Referral to a specialist physician may assist GP management of some residents, particularly those with diastolic cardiac failure or valve disease, or with the following co-morbidities [1, 13]: peripheral vascular disease, COPD or asthma, renal dysfunction, thyroid disease, anaemia, angina, atrial fibrillation or other symptomatic arrhythmia.
Advance care plan
The GP and RACF staff should discuss the disease process, symptoms to report, management and the resident’s preferences for future care, with the resident and his or her family/representatives, after diagnosis and as the condition progresses.
Decisions should be made regarding resuscitation in the event of cardiac arrest, and preferences for end-of-life care. An Advance Care Plan should be developed, and regularly reviewed particularly following an acute exacerbation and as part of end stage care [4, 11]. Refer to Clinical Information Sheet on Advance Care Planning for more information.
Maintenance
The aim of drug therapy is to improve life expectancy and control symptoms and signs of cardiac failure. Life expectancy has been shown to be prolonged by Angiotensin Converting Enzyme (ACE) inhibitors, beta-blockers and spironolactone.
ACE inhibitors, diuretics and beta blockers [1, 4, 8, 9, 13] are recommended for symptomatic cardiac failure (Stage 3) in most residents. ACE inhibitors have been shown to relieve signs and symptoms, decrease hospitalisations and increase survival in all stages of cardiac failure. [1-4, 8, 13]. Although diuretics have not been shown to decrease mortality, they are used in combination with ACE inhibitors to control symptoms and signs. Beta-blockers improve survival in stable chronic systolic heart failure, and diastolic cardiac failure, particularly when there is also atrial fibrillation [5].
Some residents may need Angiotensin II receptor agonists (if unable to tolerate ACE inhibitors), digoxin and/or spironolactone [1, 4, 8, 9, 13].
Optimal control may take several months with close monitoring of symptoms, weight, electrolytes and renal function.
Angiotensin converting enzyme (ACE) inhibitors
ACE inhibitors block the conversion of angiotensin I to angiotensin II and modulate neurohormonal responses, leading to a reduction in cardiac after load [3]. Despite their effectiveness, ACE inhibitors are under-prescribed due to the fear of hypotension or renal failure. Whilst most effective in severe cardiac failure, ACE inhibitors improve prognosis and are recommended for those at all stages of the disease, including asymptomatic patients with left ventricular fraction < 40% [1-4, 8, 13].
Residents should be commenced on low doses of ACE inhibitor (to decrease side effects) and the dose increased at 2 week intervals until the maximum tolerable dose is reached [1, 3, 8]. Side effects that may require a reduction in dose or cessation include [1, 3, 4, 13]:
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ACE Inhibitors [1, 3-5]
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Preparation
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Commencement dose
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Therapeutic range
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Captopril
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6.25mg three times daily
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50–100mg three times daily
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Enalapril
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2.5mg twice daily
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10–20mg twice daily
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Ramipril
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1.25mg once daily
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5-10mg once daily
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Perindopril(coversyl)
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2mg once daily
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2.5 to 10mg once daily
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Angiotensin II receptor agonists
Angiotensin II receptor agonists are recommended as second-line therapy for residents who are unable to tolerate ACE inhibitors because of cough or rash. Their use is contra-indicated for residents who developed worsening renal failure or angioedema when taking ACE inhibitors [1-4, 8].
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Angiotensin II receptor agonists [4]
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Preparation
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Commencement dose
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Maximum Dose
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Candesartan
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4mg to 8mg daily
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32mg daily
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Irbesartan
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75mg once daily
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75mg to 300mg once daily
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Diuretics
Whilst the use of diuretics has not been shown to increase survival [1, 3], fluid retention should be corrected to relieve symptoms and maximise the effects of ACE inhibitors [1, 3, 4, 8, 13]. Loop diuretics are generally used in combination with ACE inhibitors [1, 4, 8]. Elderly residents and those with known renal impairment require regular electrolyte and renal function tests [1, 8]. Potassium supplements or potassium sparing diuretic is usually not required in older adults with renal impairment. The most serious side effect of diuretics, requiring a reduction in dose or cessation, is hyperkalaemia (particularly if using potassium-sparing diuretics in combination with ACE inhibitors) [1, 4, 13].
Residents should be commenced on lower doses of loop diuretics and the dose increased at 2-4 week intervals [1]. The goal is to achieve equilibrium in fluid balance through active diuresis. Residents should be weighed weekly to monitor fluid retention [1, 4, 10, 13, 14], with an aim of achieving 0.5-1.0kg weight loss per day until fluid overload is corrected. RACF staff should inform the resident’s general practitioner if weight increases by 1.5kg or more over a one week period [8].
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Diuretics [4,5]
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Preparation
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Commencement dose
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Frusemide (Lasix)
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20-40mg daily
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Bumetanide
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O.5-1.0mg daily
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Ethacrynic acid
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50mg daily
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Flexible diuretic plan
A flexible diuretic plan is an option for residents who frequently suffer from fluid overload requiring an increase in diuretic doses. Using the resident’s daily weight as a guide, the medication orders may contain a guideline of dosage based on weight, with instructions for when diuretics should be returned to baseline dose [2, 4, 9].
Hyperkalemia
Hyperkalemia (high potassium levels) is a common problem, especially when a resident has just been discharged from hospital after an exacerbation of cardiac failure. Oral resonium – a medication that removes excess potassium from the blood - may be required and can reduce the need for urgent representation to the emergency department. U&Es should be monitored weekly initially. Resonium should be dispensed on hospital discharge, if hyperkalemia occurred in hospital, and administered on a sliding scale dependent upon U&E results.
Beta-blockers
Some beta blockers are approved for use in conjunction with ACE inhibitors in stabilised cardiac failure. They have been shown to decrease mortality and decrease hospitalisations [1, 2, 4, 8, 13]. Beta blockers reduce myocardial oxygen consumption through reducing the heart rate.
Beta blocker therapy can be difficult to manage and may require specialist consultation. Commence on low doses and increase at 2-4 week intervals until the maximum tolerable dose is reached [1, 3, 8]. Common side effects that may require a reduction in dose or cessation of beta blockers include [1, 4, 8, 13]:
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Beta-blockers [1, 3-5]
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Preparation
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Commencement dose
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Therapeutic range
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Bisoprolol
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1.25 mg once daily
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10 mg once daily
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Carvedilol
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3.125 mg twice daily
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25 mg twice daily
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Metoprolol (CR)
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12.5mg twice daily
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up to 100mg daily
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Digoxin
Digoxin has been shown to reduce the frequency of hospitalisation due to cardiac failure, although it is not related to a decrease in mortality [1, 3]. Digoxin is recommended for use in residents with systolic LVF who continue to have symptoms despite use of ACE inhibitors and diuretics, however it should be used with caution in residents with renal failure [1-4]. It is also indicated to control ventricular rate in atrial fibrillation.
If the resident has not been taking digoxin, give digoxin 62.5-500micrograms daily; according to age, plasma creatinine and plasma digoxin level [5].
Common side effects that may require a reduction in dose or cessation of digoxin include [4, 13]:
Spironolactone
Generally used as a potassium-sparing loop diuretic, spironolactone also has an effect in blocking cardiac aldosterone receptors that are involved in fibrosis and hypertrophy. Its use is related to improvement in signs , symptoms and mortality rate. The recommended dosage: 12.5 - 25 mg once daily [1] however this may be increased to 25-50mg daily in severe heart failure. Residents taking spironolactone should be monitored regularly for hyperkalaemia (particularly in those with concurrent renal impairment) [1, 2, 4].
Non-pharmacological Strategies
Smoking Cessation
Residents who smoke should be counselled to cease smoking [1-4, 12]. Nicotine causes vasodilation, and inhalation of smoke exacerbates respiratory disease and is associated with increase in respiratory infections [2, 3, 12].
Nutrition
Guidelines recommend reduction of dietary sodium to maintain fluid and electrolyte balance and decrease the need for diuretics. Research shows that the average western diet contains 8-10mg sodium. In cardiac failure sodium intake should be restricted to 2g per day [2-4, 8, 9, 12, 13].
Alterations in gastro-intestinal absorption and changes in appetite put those with cardiac failure at risk of nutritional complications [12]. Unintentional weight loss and/or muscle wasting should be carefully monitored (e.g. nitrogen balance, caloric input, prealbumin) and nutritional supplements aimed at maintaining the resident’s weight should be considered [12]. Determine if the resident is already taking over-the-counter nutritional supplements to prevent the risk of double-dosing [12].
Residents with co-existing diabetes mellitus, obesity or dyslipidaemia will require additional education and dietary modification (see Table Three) [3, 4, 12].
Table Three: Recommended dietary modifications [2, 12]
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Diagnosis
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Recommended dietary modifications
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Cardiac Failure
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Restriction of sodium.
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Hyperlipidaemia; atherosclerosis
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Fat and cholesterol restrictions.
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Diabetes mellitus
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Carbohydrate, protein and calorie restrictions.
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Renal impairment
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Restrict protein, potassium, and phosphorus.
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Obesity
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Weight loss.
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Weight loss; muscle wasting
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High-energy diet; small, frequent meals.
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Fluid restriction
Restriction of daily fluid intake may help reduce peripheral oedema [4, 9]. Recommended fluid restrictions range from 1.0 litre (severe heart failure) to1.5 litres per day [1, 3, 12], however the risk of dehydration should be carefully considered [1] .
Weighing residents on a daily or weekly basis to monitor fluid retention is a more reliable measure than measuring fluid input and output [4, 9, 12]. The resident’s general practitioner should be informed if the resident’s weight increases by 1.5kg or more over a 24-hour period [8, 9], or over a week (repeat weight the next day as errors often occur).
Alcohol
Alcohol alters myocardial function and its use is associated with an increased rate of nutritional deficits, both of which can have adverse effects in cardiac failure [1, 2]. Ceasing [13] or limiting intake of alcohol is associated with an improved prognosis. Recommendations suggest males limit alcohol intake to a maximum of 2 standard drinks/day, and females to 1 standard drink/day [2, 9, 12].
Physical activity
Increase in exercise tolerance may be associated with a positive health benefit for residents with cardiac failure [1-4, 13]. Maintain or increasing activity levels also help prevent bone loss and muscle atrophy [3, 4].
Oxygen
Patients with acute pulmonary oedema will require oxygen for hypoxaemia. Carbon dioxide is usually not a problem unless the resident has cor pulmonale or very severe pulmonary oedema.
Immunisation
Pulmonary congestion associated with cardiac failure increases the risk of respiratory infections. Therefore pneumococcal and annual influenza vaccinations are recommended [1, 2, 9, 12, 13].
Complementary therapies
Use of complementary therapies is rising within the community. It is important that residents be provided with education on complementary therapies that are contraindicated in cardiac failure (see Table Four) [1, 12]. The effectiveness of complementary therapies in the management of cardiac failure has not been reviewed for this Clinical Information Sheet.
Table Four: Complementary therapies contraindicated in cardiac failure [1, 12]
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Preparation
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Effects related to cardiac failure
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Hawthorne (cratageus)
Ephedra (ma huang)
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Vasodilatory effect.
Associated with increased serum digoxin levels.
Associated with increased risk of hypotension and arrhythmias.
|
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Garlic
Ginger
Ginseng
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Antiplatelet effects and potential interactions with anticoagulant therapy.
|
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St John’s Wort
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Antiplatelet effects and potential interactions with anticoagulant therapy.
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Acute Exacerbations
Management of acute exacerbations of cardiac failure focus on assessing and treating precipitating factors, as well as adjustments to the resident’s medication regime, fluid allowance, and daily weight until signs and symptoms improve [2, 4, 8]. In most instances this care can be provided within the RACF.
Residents with severe cardiac failure who choose to have active treatment, may require transfer to acute care for intensive therapy [2]. Management includes [5]:
Bed rest, and LMW heparin for DVT prophylaxis; Increased doses of ACE inhibitors and frusemide; Low dose spironolactone, and/or Careful combinations of thiazide diuretics, beta-blockers, digoxin and nitrates.
Acute pulmonary oedema is a medical emergency, requiring transfer to acute care. Treat immediately with oxygen 4 to 6 L/min via a mask, plus frusemide 20 to 80 mg IV, repeated in 20 minutes if necessary [5]. If response to frusemide is inadequate consider morphine 2.5mg IV [5]. If pulmonary oedema is severe or not responding, or associated with ischemia or significant hypertension, add isosorbide dinitrate 5 to 20mg sublingually, repeat after 30 minutes if necessary [5].
In older adults, arrhythmias secondary to underlying heart disease can precipitate worsening cardiac failure. Arrhythmias occur with more frequency and severity in residents with severe cardiac failure and underlying heart disease. Sudden death in patients with heart failure is mostly due to ventricular fibrillation with or without ventricular tachycardia. Principles underlying treatment and prevention of arrhythmias are [5]:
Avoid potassium depletion from diuretic therapy (maintain potassium between 4-5 mmol/l); Avoid magnesium depletion from diuretic therapy; Use ACE inhibitors and beta blockers because of their proven effect in reducing arrhythmias and sudden death, and Avoid long-term cardiac stimulants and antiarrhythmic agents because of their proarrythmic potential.
An acute care plan would:
Assess causes of exacerbation such as cardiac ischemia or arrhythmia, infection, anaemia, thyroid disease and medications; Assess symptoms and signs, oxygen saturation, pulse, and respiratory rate; Monitor weight daily and U&E (including magnesium) frequently include PRN medications for residents with frequent acute exacerbations; Review and increase diuretic therapy, and Institute salt and fluid restrictions.
End-stage Cardiac Failure
There is a high mortality rate from cardiac failure, and sudden death occurs in 30-50% of cases [3, 11]. Indications of end-stage disease include frequent, regular exacerbation of symptoms despite maximum medical intervention; symptoms at rest; and frequent prolonged hospitalisation for more intensive therapy [4].
Signs and symptoms commonly experienced during the end stages of cardiac failure include [11]:
When the condition reaches its final stages, review the Advance Care Plan and consider using a palliative approach to care. The goals of palliative care are to control the resident’s symptoms; maintain the resident in a pain-free state; provide emotional, social and spiritual support for the resident and carers; and enable a dignified death [1, 11].
Specific treatments to optimize control of cardiac failure are aimed at relieving distressing signs and symptoms and should not be routinely abandoned in end-stage care. Suboptimal control can lead to decreased quality of life, distress and anxiety, and may interfere with the resident’s ability to perform closure tasks [11]. Discussion of managing cardiac and other end-of-life symptoms is found in the Clinical Information Sheet on End of Life Care.
Sources of Information
Where to go for more information
Heart Support Australia
Heart Support Australia provides information, support and counselling for people diagnosed with cardiac failure, their families and their carers. Support groups are operational around Australia.
Contact Heartline: 1300 36 27 87 (within Australia) to find your nearest group.
Cardiomyopathy Association of Australia
The Cardiomyopathy Association of Australia provides support for residents, family and professional carers of those diagnosed with cardiac failure related to cardiomyopathy. The organisation works to raise awareness of cardiomyopathy and provide up-to-date medical research on its management.
Website: http://www.cmaa.org.au
Contact Heartline: 1300 36 27 87 (within Australia) to find your nearest group
Sleep Apnoea Assessment
Sleep apnoea assessment is conducted at Austin Hospital and La Trobe Private Hospital.
Further reading
The following article is recommended:
National Institute for Clinical Excellence -The National Collaborating Centre for Chronic Conditions, NICE, Management of heart failure: Understanding NICE guidance – information for people with heart failure, their carers, and the public. 2003, Copyright National Institute for Clinical Excellence, NICE: London.
A document prepared by NICE to help residents, families and carers clearly understand the NICE guidelines.
References
National Institute for Clinical Excellence -The National Collaborating Centre for Chronic Conditions, NICE, Chronic Heart Failure -National clinical guideline for diagnosis and management in primary and secondary care. 2003, Royal College of Physicians: London. Cardiac Society of Australia and New Zealand, (CSANZ), Heart Foundation of Australia , (HFA), Guidelines on the Contemporary Management of the Patient with Chronic Heart Failure in Australia. 2002, The Cardiac Society of Australia and New Zealand, (CSANZ) and Heart Foundation of Australia, (HFA). Hobbs, R.,Boyle, A., Heart Failure, in http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/heartfailure/heartfailure.htm#table4, Cleveland Clinic, The. 2004 Hunt, S., Antman, E., Smith, S., Abraham, W., Chin, M., Feldman, W., Francis, G., Ganiats, T., Jessup, M., Konstam, M., ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. 2005, American College of Cardiology, (ACC); American Heart Association, (AHA); American College of Chest Physicians, (ACCP); International Society for Heart and Lung Transplantation, (ASHLT). eTG, Therapeutic Guidelines: Cardiac Failure, in http://www.tg.com.au (accessed August 2006), eTG. 2006 Chavey II, W., Blaum, C., Bkeske, B., Harrison, R, Kesterson, S. , Nicklas, J., Guideline for the Management of Heart Failure Caused by Systolic Dysfunction: Part I. Guideline Development, Etiology and Diagnosis. American Family Physician, 2001. 64(5). Goble, A.,Worcester, M., Heart Research Centre. Hospital Admission Risk Program (HARP): Chronic Heart Failure Management Report. 2003, Produced on behalf of Department of Human Services Victoria.: Melbourne. National Prescribing Service Limited, NPS, Improving outcomes for heart failure patients. Prescribing Practice Review, 2004. November. Security Health Plan, (SHP), Clinical Practice Guideline: Evaluation and Treatment of Heart Failure. 2005, Marshfield Clinic: Wisconsin. Scottish Intercollegiate Guidelines Network, SIGN, Diagnosis and Treatment of Heart Failure due to Left Ventricular Systolic Dysfunction - A National Clinical Guideline. 1999, Scottish Intercollegiate Guidelines Network, SIGN. Adams, K., Lindefeld, J., Arnold, J., Baker, D., Barnard, D., Baughman, K., Bochmer, J., Deedwania, P., Dunbar, S., Elkayam, U., Gheorghiade, M., Howlett, J., Konstam, M., Kronenberg, J., Rodcheffer, R., Sackner-Bemstein, J., Silver, M., Starling, R., Wagoner, L., HFSA 2006 Comprehensive Heart Failure Practice Guideline: Section 8 Disease Management in Heart Failure. Journal of Cardiac Failure, 2006. 12. Adams, K., Lindefeld, J., Arnold, J., Baker, D., Barnard, D., Baughman, K., Bochmer, J., Deedwania, P., Dunbar, S., Elkayam, U., Gheorghiade, M., Howlett, J., Konstam, M., Kronenberg, J., Rodcheffer, R., Sackner-Bemstein, J., Silver, M., Starling, R., Wagoner, L., HFSA 2006 Comprehensive Heart Failure Practice Guideline: Section 6 Nonparmacological Management and Health Care Maintenance with Chronic Heart Failure. Journal of Cardiac Failure, 2006. 12: p. e29-e37. National Heart Foundation of New Zealand, (NHFNZ), A guideline for the management of heart failure: health professionals guide. 2001, National Heart Foundation of New Zealand: Auckland (New Zealand); 2001 Dec. 30 p. p. 30. National Institute for Clinical Excellence -The National Collaborating Centre for Chronic Conditions, NICE, Management of heart failure: Understanding NICE guidance – information for people with heart failure, their carers, and the public. 2003, Copyright National Institute for Clinical Excellence, NICE: London. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
Background information on the management of Cardiac Failure provided in this Clinical Information Sheet is based on Level I evidence produced by expert opinions in the field, particularly The Cardiac Society of Australia and New Zealand and The Heart Foundation of Australia. Supporting evidence is based on additional Level I evidence sources including guidelines produced by the National Institute for Clinical Excellence (UK) and the Scottish Intercollegiate Guidelines Network (Scotland).
The following table outlines the level of evidence of each reference:
|
|
Reference |
Year |
Level of Evidence |
1. |
National Institute for Clinical Excellence -The National Collaborating Centre for Chronic Conditions, NICE, Chronic Heart Failure -National clinical guideline for diagnosis and management in primary and secondary care. 2003, Royal College of Physicians: London. |
2003 |
Level I evidence |
2. |
Cardiac Society of Australia and New Zealand, (CSANZ), Heart Foundation of Australia , (HFA), Guidelines on the Contemporary Management of the Patient with Chronic Heart Failure in Australia. 2002, The Cardiac Society of Australia and New Zealand, (CSANZ) and Heart Foundation of Australia, (HFA). |
2002 |
Level I evidence |
3. |
Hobbs, R.,Boyle, A., Heart Failure, in http://www.clevelandclinicmeded.com/diseasemanagement/cardiology/heartfailure/heartfailure.htm#table4, Cleveland Clinic, The. 2004 |
2004 |
Level IV C evidence |
4. |
Hunt, S., Antman, E., Smith, S., Abraham, W., Chin, M., Feldman, W., Francis, G., Ganiats, T., Jessup, M., Konstam, M., ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. 2005, American College of Cardiology, (ACC); American Heart Association, (AHA); American College of Chest Physicians, (ACCP); International Society for Heart and Lung Transplantation, (ASHLT). |
2005 |
Level I evidence |
5. |
eTG, Therapeutic Guidelines: Cardiac Failure, in http://www.tg.com.au (accessed August 2006), eTG. 2006 |
2006 |
Level I evidence |
6. |
Chavey II, W., Blaum, C., Bkeske, B., Harrison, R, Kesterson, S. , Nicklas, J., Guideline for the Management of Heart Failure Caused by Systolic Dysfunction: Part I. Guideline Development, Etiology and Diagnosis. American Family Physician, 2001. 64(5). |
2001 |
Level IV C evidence |
7. |
Goble, A.,Worcester, M., Heart Research Centre. Hospital Admission Risk Program (HARP): Chronic Heart Failure Management Report. 2003, Produced on behalf of Department of Human Services Victoria.: Melbourne. |
2003 |
Level IV C evidence |
8. |
National Prescribing Service Limited, NPS, Improving outcomes for heart failure patients. Prescribing Practice Review, 2004. November. |
2004 |
Level IV C evidence |
9. |
Security Health Plan, (SHP), Clinical Practice Guideline: Evaluation and Treatment of Heart Failure. 2005, Marshfield Clinic: Wisconsin. |
2005 |
Level IV C evidence |
10. |
Scottish Intercollegiate Guidelines Network, SIGN, Diagnosis and Treatment of Heart Failure due to Left Ventricular Systolic Dysfunction - A National Clinical Guideline. 1999, Scottish Intercollegiate Guidelines Network, SIGN. |
1999 |
Level IV C evidence |
11. |
Adams, K., Lindefeld, J., Arnold, J., Baker, D., Barnard, D., Baughman, K., Bochmer, J., Deedwania, P., Dunbar, S., Elkayam, U., Gheorghiade, M., Howlett, J., Konstam, M., Kronenberg, J., Rodcheffer, R., Sackner-Bemstein, J., Silver, M., Starling, R., Wagoner, L., HFSA 2006 Comprehensive Heart Failure Practice Guideline: Section 8 Disease Management in Heart Failure. Journal of Cardiac Failure, 2006. 12. |
2006 |
Level I evidence |
12. |
Adams, K., Lindefeld, J., Arnold, J., Baker, D., Barnard, D., Baughman, K., Bochmer, J., Deedwania, P., Dunbar, S., Elkayam, U., Gheorghiade, M., Howlett, J., Konstam, M., Kronenberg, J., Rodcheffer, R., Sackner-Bemstein, J., Silver, M., Starling, R., Wagoner, L., HFSA 2006 Comprehensive Heart Failure Practice Guideline: Section 6 Nonparmacological Management and Health Care Maintenance with Chronic Heart Failure. Journal of Cardiac Failure, 2006. 12: p. e29-e37. |
2006 |
Level I evidence |
13. |
National Heart Foundation of New Zealand, (NHFNZ), A guideline for the management of heart failure: health professionals guide. 2001, National Heart Foundation of New Zealand: Auckland (New Zealand); 2001 Dec. 30 p. p. 30. |
2001 |
Level I evidence |
14. |
National Institute for Clinical Excellence -The National Collaborating Centre for Chronic Conditions, NICE, Management of heart failure: Understanding NICE guidance – information for people with heart failure, their carers, and the public. 2003, Copyright National Institute for Clinical Excellence, NICE: London. |
2003 |
Level I evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [15] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
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