CONGESTIVE CARDIAC FAILURE (CCF)

DESCRIPTION

CCF is a clinical syndrome and has several causes.  The cause and immediate precipitating factor(s) of the CCF must be identified and treated to prevent further damage to the heart.

Potentially reversible causes include:
»     anaemia,                                            »	thiamine deficiency,
»     thyroid disease,                                 »	ischaemic heart disease,
»     valvular heart disease,                    » »     constrictive pericarditis.	haemochromatosis, and

GENERAL MEASURES

Patient and family education.

Monitor body weight to assess changes in fluid balance.

Limit fluid intake to 1–1.5 L/day if fluid overloaded despite diuretic therapy.

Salt restriction.

Regular exercise within limits of symptoms.

Avoid NSAIDs as these may exacerbate fluid retention.

Counsel regarding the risk of pregnancy and the use of oral contraceptives.

MEDICINE TREATMENT

Mortality is significantly reduced by the use of ACE inhibitors, ß-blockers and spironolactone in heart failure.

Digoxin has been shown to reduce hospitalisation only.

Diuretic

Mild volume overload (mild CCF) and normal renal function, thiazide diuretic:

• Hydrochlorothiazide, oral, 25–50 mg daily. o Caution in patients with gout.
  • Contraindicated in impaired renal function.

Significant volume overload or abnormal renal or hepatic function, loop diuretic:

• Furosemide, oral, daily.
  • Initial dose: 40 mg/day.
  • Higher dosages may be needed, especially if also renal failure.

Note:

Unless patient is clinically fluid overloaded, reduce the dose of diuretics before adding an ACE inhibitor.

After introduction of an ACE inhibitor, try to reduce diuretic dose and consider a change to hydrochlorothiazide.

Routine use of potassium supplements with diuretics is not recommended. They should be used short term only, to correct documented low serum potassium level.

ACE inhibitor, e.g.:

• Enalapril, oral, 2.5 mg 12 hourly up to 10 mg 12 hourly.

If ACE inhibitor intolerant, i.e. intractable cough:

        Angiotensin receptor blocker (ARB), e.g.:

• Losartan, oral, 50–100 mg daily. (Specialist initiated)

Spironolactone

Use with an ACE inhibitor in patients presenting with Class III or IV heart failure.

Do not use if GFR <30 mL/minute.

Monitoring of potassium levels is essential if spironolactone is used with an ACE inhibitor or other potassium sparing agent or in the elderly.

• Spironolactone, oral, 25 mg once daily.

ß-blockers

For all stable patients with heart failure who tolerate it.

Patients should not be fluid overloaded or have low blood pressure before initiation of therapy.

• Carvedilol, oral.
  • Initial dose: 3.125 mg daily. o Increase after two weeks to 3.125 g 12 hourly, if tolerated. o Increase at two-weekly intervals by doubling the daily dose until a maximum of 25 mg 12 hourly, if tolerated. o If not tolerated, i.e. worsening of cardiac failure symptoms, reduce the dose to the previously tolerated dose.
  • Up-titration can take several months.Digoxin

    Symptomatic CCF owing to systolic dysfunction.

    • Digoxin, oral, 0.125 mg daily. Specialist initiated.
      • Digoxin trough blood levels (before the morning dose) should be maintained between 0.65 and 1.5 nmol/L
      • Patients at high risk of digoxin toxicity are:

    »     the elderly,

    »     patients with poor renal function,

    »     hypokalaemia, and

    »     patients with low body weight.

     

    Anticoagulants 

    Heparin for DVT prophylaxis.

    For patients admitted to hospital, unless contraindicated:

    • Unfractionated heparin, SC, 5 000 units 8 hourly.

     

    Warfarin: See section 3.3.1: Narrow QRS complex (supraventricular) tachydysrhythmias.

    • Warfarin, oral, 5 mg daily.
      • Control with INR to therapeutic range, i.e. between 2.0 and 2.5.

     

    Anti-dysrhythmic drugs

    See Section 3.3: Cardiac Dysrhythmias.

    Only for potentially life-threatening ventricular dysrythmias.

    Always exclude electrolyte abnormalities and drug toxicity first.

    Thiamine

    Consider in all unexplained heart failure.

    • Thiamine, oral/IM, 100 mg daily.

    REFERRAL

    » Where specialised treatment and diagnostic work-up is needed and to identify treatable and reversible causes.