Managing Heart Failure in Primary Care

Last Updated: November 14, 2024

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Heart failure (HF) is a serious, life-long condition. With early diagnosis, lifestyle changes and proper management however, people living with heart failure can have a good quality of life.1

This tool is designed to educate and support primary care practitioners in diagnosing and implementing treatment for adult patients (≥ 18 years) with heart failure.

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Initial assessment and diagnosis New

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When HF is suspected, a diagnosis should be confirmed by:4

  • Assessing for symptoms and signs of HF caused by a structural or functional cardiac abnormality
  • Corroborated by at least one of the following:
    • Objective evidence of cardiogenic pulmonary or systemic congestion (e.g. findings from chest radiograph (x-ray) or echocardiogram)
    • Elevated natriuretic peptide (NP) levels where available

Once a HF diagnosis is confirmed, the HF type based on ejection fraction (EF) and symptom severity should be identified to inform subsequent management approaches and treatment goals. Etiology must also be investigated to understand underlying causes and guide subsequent treatment.

Diagnosis4–6

When HF is suspected, the following steps should be conducted to confirm a diagnosis

Investigate symptoms to determine the presence of:
  • Dyspnea
  • Fatigue
  • Edema
  • Confusion (particularly in older adults)
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Unintentional weight gain (e.g., > 2 kg in 2 days)*
Collect or review clinical history to determine:
  • Symptoms (dyspnea, fatigue, edema/leg swelling, confusion (particularly in seniors), orthopnea, paroxysmal nocturnal dyspnea, unintentional weight gain [e.g., > 2 kg in 2 days])*
  • Prior cardiac disease (coronary artery disease, valvular heart disease, atrial fibrillation)
  • Risk factors (hypertension, ischemic heart disease, valvular heart disease, diabetes, heavy alcohol or substance use, chemotherapy or radiation therapy, family history of cardiomyopathy, smoking, hyperlipidemia)
  • Comorbidities and functional and cognitive limitations
Conduct a physical examination to determine the presence of:
  • Lung crackles
  • Elevated jugular venous pressure (JVP)
  • Positive abdominal jugular reflux
  • Peripheral edema
  • Abnormal heart sounds (S3/S4)
  • Low blood pressure (BP) †
  • Heart rate > 100 beats/minute †

*While dyspnea, fatigue and edema are the classic presenting symptoms, they are not sufficient on their own to confirm or rule out heart failure. Other less common symptoms are possible, including nocturnal cough, wheezing, bloating, loss of appetite, dizziness, syncope, delirium (particularly in seniors), nausea, abdominal discomfort, oliguria, anorexia and cyanosis.

†While low blood pressure and heart rate > 100 beats/minute may be presenting symptoms of heart failure, they are not sufficient on their own to confirm or rule out heart failure.

Refer for initial investigations
  • Lab work to assess complete blood count (CBC), electrolytes, renal function, urinalysis, glucose and thyroid function
  • Chest x-ray to assess heart size and pulmonary congestion and to detect other cardiac and pulmonary disease that may contribute to the patient’s symptoms
    • Findings that may suggest HF: cardiomegaly, pulmonary venous redistribution, pulmonary edema or pleural effusion
  • 12-lead electrocardiogram (ECG) to determine heart rhythm, heart rate, QRS duration, morphology and to detect possible etiologies
    • Findings that may suggest HF: Q waves, left ventricular hypertrophy, left bundle branch block, tachycardia or atrial fibrillation
Refer for echocardiogram
  • Assess cardiac structure and function, establish the presence or absence of cardiac abnormalities, quantify systolic function for planning and monitoring of treatment, and for prognostic stratification
    • Findings that may suggest HF: reduced left ventricular ejection fraction (EF), increased left ventricular end-systolic and end-diastolic diameter, left ventricular hypertrophy, wall motion abnormalities and diastolic dysfunction, increased right ventricular size, right ventricular dysfunction, valve dysfunction, elevated filling pressures
Refer for natriuretic peptides (NPs) measurement (if cost is not a barrier; NT-proBNP covered by OHIP)

  • N-terminal pro-brain natriuretic peptide (NT-proBNP)
    • Findings that may suggest HF: NT-proBNP > 125 pg/ml
  • Brain natriuretic peptide (BNP)
    • Findings that may suggest HF: BNP > 50 pg/ml (if available)
Refer to a specialist (internal medicine or cardiologist) for additional diagnostic investigations if needed
  • Cardiac catheterization
  • Cardiopulmonary exercise testing
  • Other (cardiac magnetic resonance [CMR], myocardial perfusion [MIBI] scan, multigated acquisition scan [MUGA], computed tomography [CT] scan)
Role of natriuretic peptides
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Role of natriuretic peptides

NPs are secreted from the heart in response to changes in pressure that occur when heart failure develops or worsens. NPs improve heart failure symptoms through natural diuresis, vasodilation and inhibition of the renin-angiotensin-aldosterone system and the sympathetic nervous system.

Two key NPs, brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are used to assist with diagnosis, prognostic stratification and management of HF4. However,  BNP and NT-proBNP have different cut-points/values so they cannot be used interchangeably.

BNP (brain natriuretic peptide)4,6-8
  • Active hormone
  • Not covered by OHIP (private insurance may cover the cost)
  • If using to measure efficacy for angiotensin receptor-neprilysin inhibitors (ARNis), results are less reliable for monitoring the first year of therapy
NT-proBNP (N-terminal pro-brain natriuretic peptide)4,6-8
  • Biologically inactive (metabolite of BNP)
  • Higher levels in the bloodstream
  • Covered by OHIP
  • If using to measure efficacy for ARNis, results are more reliable in the first year of therapy
Role of NPs in heart failure4
Diagnosis*

In the setting of diagnostic uncertainty, either BNP or NT-proBNP can rule out HF with a high degree of confidence

NP cut-points (primary care)

NT-proBNP > 125 pg/mL

BNP > 50 pg/mL§

* Strong recommendation, high-quality evidence; † Recommendations are based on Canadian Cardiovascular Society guidelines4 other sources recommend a cut-off of < 356,9

Determining heart failure type by ejection fraction and symptom severity4

For patients with confirmed HF, determine the HF type by ejection fraction (EF) (via an echocardiogram) and symptom severity using the New York Heart Association (NYHA) functional classification to guide the subsequent management approach.

Heart failure types by ejection fraction4,6

Symptom severity using the New York Heart Association functional classification4
I: Asymptomatic – No limitation of physical activity.
II: Mild symptoms – Slight limitation of physical activity.
III: Moderate symptoms – Marked limitation of physical activity.
IV: Severe symptoms – Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest

Determining etiology of heart failure4 

For patients with confirmed HF, determine etiology to understand underlying causes and guide subsequent treatment. HF may have mixed etiologies. Noninvasive imaging should be considered to determine the presence or absence of coronary artery disease.

Common
  • Coronary artery disease
  • Left ventricular hypertrophy
  • Valve disease
  • Tachyarrhythmia
Less common
  • Genetic (e.g., hereditary cardiomyopathy, hemochromatosis, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy)
  • Toxic agents (e.g., chemotherapy, radiation, steroids, heavy metals, alcohol, amphetamines, cocaine)
  • Pregnancy (e.g., pre-eclampsia, gestational diabetes, peripartum cardiomyopathy)
  • Inflammatory/infectious/immune (e.g., myocarditis, sarcoidosis, autoimmune diseases)
  • Metabolic (e.g., diabetes, thyroid disease, adrenal insufficiency, pheochromocytoma, Cushing’s disease)
  • Nutritional (e.g., deficiencies of thiamine or selenium, malnutrition, obesity)
  • Infiltrative diseases (e.g., amyloidosis, glycogen storage diseases, Fabry disease)

Advance care planning and palliative care

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HF is often underestimated in terms of its severity as a lifelong, life-limiting illness.

When compared to advanced cancer (which is more recognized as a life-limiting illness) the trajectory of HF is quite different. HF patients typically experience a gradual decline in function over years, with intermittent serious episodes that often require hospitalization.

Conversations with patients and caregivers about advance care planning and palliative care should take place early on in their heart failure journey and should be revisited regularly.10 Patients should be made aware of what the trajectory of HF could look like and the possible variations.3,10

Input from a person living with heart failure
When and how to approach advance care planning and palliative care discussions
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Input from a person living with heart failure

“My initial reaction is never, but I realize that’s unrealistic, so we move onto option two. I would say early on. If we’re creating sort of a treatment plan, I don’t know when I’m going to be at a point where I can’t care for myself anymore. I don’t have that information. But, I think, let’s make it part of the long term plan. Let’s get it on the table and discuss it and see where it fits into the projection of what the next 2 and 5 and God willing 8 years of your life are going to look like. Again, it’s not a comfortable subject but I don’t think it’ll go away if I ignore it. So, let’s deal with it.” – person living with heart failure

3

Advance care planning3,10,11

Family physicians and primary care nurse practitioners have a role in discussions to help prepare patients and their loved ones for the future.  This is especially true when people have serious illness, such as heart failure.

  • Preparing happens over time. It isn’t a one-time conversation.
  • Preparing is not about making decisions now for the future.

Three outcomes to aim for to help your patients prepare:

  1. Identify their automatic substitute decision-maker (SDM). This is the person, recognized by the law, who would give or withhold consent for treatment or care when a person is mentally incapable of making treatment or care decisions. If someone wishes someone other than their automatic SDM, help them appoint an Attorney for Personal Care. It is important that all family members and caregivers in a patient’s circle of care know who the SDM is.
  2. Explore their illness understanding and help them learn what to expect in the future. For example, most people do not know what to expect with heart failure, that it can get worse over time and often results in a shortened life expectancy. See talking points about explaining heart failure, the trajectory of HF and what to expect in the future.
  3. Explore their goals, values, wishes, worries and fears and discuss these with their SDM.
Talking points10
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Talking tips

Explain HF to people using plain language and reduce the use of medical language.

“Can I explain what is happening? Your heart is a muscle and works as a pump. Its job is to squeeze and pump blood around your lungs and your body. When it does this, it brings oxygen and nutrition to all the parts of your body.”

“For you, the muscle is weak, so the pump isn’t working to push blood into your body. That means that not enough blood is getting to your body, your organs such as your kidneys, your muscles and even to your brain.”

“This is why you can feel weak and tired – there isn’t enough blood getting from your heart to the rest of your body. That is also why your kidneys aren’t working as well – your kidneys need the blood to work properly.”

Discuss with patients and their caregivers the HF trajectory. Describe it according to the specific patient you are meeting with.

“This is the common way that heart failure works. Initially, you were diagnosed and then we started the treatments. Things were stable for a period of time. Over time though, we know that the heart gets weaker and we start to see ups and downs like this where a person gets quite sick and needs to be in the hospital. With a change in medications or sometimes with a procedure like a pacemaker, they can get stronger again.

We always try to find ways to make someone feel better and return to being able to do their regular activities. Unfortunately, over time we aren’t always able to make things better and at some point the heart is so weak that it means a person may be approaching end-of-life because of their heart failure.” 

If very advanced HF: “I’m worried that for you, we are closer to this end of the situation. We will keep trying to make you feel well, but we don’t have a lot of ways to change the medications or any surgery to fix the heart.”

If less advanced HF: “I am hopeful we are a way off from this end of the graph, but I think it is important for us to be open and honest about this information. What do you think? How would you like to continue talking about this as I care for you over time?”

Bring up ACP in a neutral way

“Before we finish today, I’ve been asking people if they have heard of something called advance care planning. Can I tell you a bit about it?”

FAQs about advance care planning10,11

People often want to know what they can expect in the future to be prepared and involved in their health care. Offer to be their guide. It is not about “bad news”; it is about being active in their health care and being in control. It is about living well with a chronic illness and for many people this includes knowledge and information.

Your role is to offer to provide information and to guide them through the illness. If someone does not want this information or to participate in preparing for the future, acknowledge that and offer again in the future.

  • Introduce the importance of preparing for the future: “many people I take care of find it helpful to do some preparing for the future…”
  • If someone is interested, give them information to review on their own or with their caregivers and family
  • Break up the conversation over time. You don’t have to have these conversations in one visit.
  • Have a documentation template so that you can update it as your conversation goes forward.
  • Engage interprofessional staff to support these conversations.

Yes. Everyone in Ontario automatically has an SDM found on a hierarchy as defined in the Health Care Consent Act. If the patient has no relatives or an appointed SDM, the Public Guardian and Trustee (PGT) will act as a SDM if a patient is unable to make healthcare decisions. Patients can choose to have ACP conversations with their healthcare providers. Healthcare provider can share this information with the PGT if healthcare decisions are required.

Reassure patients that they can continue to update their wishes as their goals and priorities change over time. In Ontario, a patient’s most recent wishes should be considered by their SDM when making a decision. Encourage patients to talk with their SDM regularly to ensure that they are aware of their most recent wishes.

Resources

Palliative and supportive care

For all patients with HF, family physicians and primary care nurse practitioners should initiate and have regular discussions regarding palliative and supportive care, including: 4,8

  • Clear conveyance of prognosis
  • Clarifying goals of care
  • Clarifying preferences around the treatment of pain and other symptoms (physical, psychosocial and spiritual)

Palliative care provides an extra layer of support and symptom relief for patients who have a serious illness, such as advanced heart failure, to improve their quality of life. Support may include:

  • Education about HF (e.g., what to expect how to prepare for the future and future decision-making)
  • Support such as home-care assistance, caregiver support and other resources for people with advanced illness
  • Home-based palliative care or hospice care if concordant with a person’s goals

FAQs about palliative care10

Focus on the role of palliative care –  a team-based approach that focuses on providing support and symptom relief to improve a person’s quality of life. Explain that palliative care is not about dying. It is about improving the quality of life of patients experiencing serious illnesses like HF.

There is no specific right time. The important step is to assess your patient’s symptoms and needs (e.g., information needs, decision-support, psychosocial needs) as well as their goals and values, and align the discussion of palliative care accordingly. Palliative care has a role across the stages of heart failure, starting early in the disease course, and continuing through to end of life planning and managing caregiver bereavement.

Palliative care specialists may be engaged if:

  • A patient’s symptoms are challenging to manage despite optimizing HF therapy
  • A patient wishes a palliative approach to care
  • A patient needs additional support with decision-making about advanced treatments and goals of care

Palliative care providers should be involved in symptom management early (if possible) to ease the transition.

Management

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Providers, together with patients and caregivers, should decide on and implement a combination of non-pharmacological and lifestyle, pharmacological and self-care strategies to manage HF and the symptoms.

Overall management12

Support patients to Initiate and optimize non-pharmacological and lifestyle management 
Initiate standard quadruple therapy
Treat any underlying etiologies of HF
Initiate and document advance care planning and palliative care discussions

Assess clinical criteria for additional individualized therapy (e.g., HF modifying medications)

HR > 70 bpm and sinus rhythm

  • Consider referral to a community cardiologist or  Heart Function clinic to start ivabradine
    Ivabradine is a medication that works by slowing the heartbeat to reduce the workload on the heart and thus improving the EF.
    • Initial dose: 2.5-5 mg bid
    • Target dose: 7.5 mg bid.

Black patients on optimal quadruple therapy OR patients unable to tolerate ARNi/ACEi/ARB

  • Consider referral to community cardiologist or  Heart Function clinic to start hydralazine-isosorbide dinitrateHydralazine-isosorbide dinitrate is a combination of medications that work together to relax the blood vessels and increase the supply of blood and oxygen to the heart, thus reducing the heart workload.
    • Initial dose: 10-37.5 mg tid/10-20 mg tid
    • Target dose: 75-100 mg tid or qid/40 mg tid.

Suboptimal rate control for atrial fibrillation OR persistent symptoms despite optimized quadruple therapy

  • Consider referral to community cardiologist or  Heart Function clinic to start digoxinDigoxin is a combination of medications that work together to improve the strength and efficiency of the heart, thus leading to better blood circulation and reduced swelling of hands and ankles.
    • Initial dose: 0.0625-0.125 mg daily
    • Target dose: N/A, monitor for toxicity

 

Reassess left ventricle EF, symptoms and clinical risk to determine need for device therapy or surgical interventions

LVEF ≤ 35% and NYHA I-IV (ambulatory)

  • Consider refer to cardiology or cardiology device therapy clinic for
    implantable cardioverter-defibrillator
    Implantable cardioverter-defibrillators are the first line in the prevention of sudden death and all-cause mortality. They are often used in patients with a history of sustained ventricular tachycardia or ventricular fibrillation, cardiac arrest or unexplained syncope in the presence of left ventricular systolic dysfunction with symptomatic HF     or cardiac resynchronization therapy
    Cardiac resynchronization therapy attempts to synchronize the activation of the ventricles and atrioventricular activation sequence leading to improvements in left ventricular function. This therapy is often used in patients with sinus rhythm and prolonged QRS duration or those who require chronic right ventricular pacing.

LVEF > 35%, NYHA I, and low risk

  • Continue present management, reassess as needed

NYHA III/IV, advanced HF or high risk

    • Consider:
      • Referral to cardiology or cardiac transplant clinic for cardiac transplant
      • Referral for palliative and supportive care

Non-pharmacological and lifestyle management4

Patients should be supported to implement non-pharmacological management strategies including diet and lifestyle modifications.

Salt intake
  • Support patients to limit their salt intake to between approximately 2-3 grams/day, adapting the exact quantity to the clinical situation, severity of symptoms and baseline consumption
  • Educate patients on how to read food labels and understand the sodium content of foods, and remind them that reducing salt intake is more than just avoiding adding salt on top of food
  • The evidence base to support dietary salt restrictions is limited.
Physical activity
  • Support patients with NYHA I-III to gradually increase regular physical activity to improve HF symptoms, quality of life and physical activity capacity (physical activity intolerance is recognized as a hallmark of HF)
  • Physical activity in patients with NYHA IV should be supervised by experts
  • Consider referral to cardiac rehabilitation centre
Alcohol consumption
  • Encourage all patients to limit alcohol consumption
  • Alcohol consumption should be avoided altogether if it is believed to be responsible or contributing to heart failure.
Fluid intake
  • Only impose strict limits on fluid intake (2L/day) for patients with a clear fluid overload, demonstrated sensitivity to fluid intake or hyponatremia
  • The evidence base to support fluid restrictions is limited and severely limiting intake may have adverse consequences.
Smoking cessation
  • All attempts should be done to promote smoking cessation (smoking has been linked to the progression of coronary artery disease)
  • Nicotine replacement therapy and other smoking cessation therapies are acceptable
  • Refer patients for counselling
Weight monitoring
  • Encourage patients to weigh themselves every morning (after voiding and before breakfast) and record their weights
  • Patients should report weight increases of ≥ 2lbs per 24 hours or > 5lbs per week
  • Weight monitoring is only one component of monitoring. See Monitoring section below

Pharmacological management

HFrEF – Quadruple therapy

Patients with HFrEF should be started and maintained on quadruple therapy, including one evidence-based medication from each of the following classes, titrated to target doses or maximally tolerated doses12

  • Angiotensin receptor neprilysin inhibitor (ARNI) or angiotensin converting enzyme inhibitor (ACEI)/ angiotensin receptor blocker (ARB)
  • Beta-blocker
  • Mineralocorticoid receptor antagonist (MRA)
  • Sodium-glucose cotransporter inhibitor (SGLT2i)

Consider referral to or consultation with a specialist if:

  • Ongoing or worsening symptoms despite optimized quadruple therapy
  • Difficulty titrating medications due to renal impairment or hypotension
  • Access to Cardiologist or Heart Function Clinic to co-manage patients to ensure optimization of therapy and appropriate monitoring

Therapy should be continued if patients are classified as HFimpEF (ejection fraction increases to ≥ 40% after treatment), even if patients become asymptomatic. If quadruple therapy must be discontinued during hospitalization, it should be restarted and further optimized as soon as possible.

Initiation and titration

Because of the lifetime benefit of quadruple therapy, parallel initiation is now preferred to sequential initiation to avoid unnecessary delays in starting therapy. Therapy should be started at a low dose and titrated every 2-4 weeks to target or at a maximally tolerated dose over 3-6 months, while monitoring for safety and considering individual patient factors.5,12,13

Medications4,5,12,14–16, 34

Click here to view the medication options in table format.

Adapted from the CCS/CHFS Heart Failure Guideline12

Converting a patient from ACEi/ARB to ARNi5

ARNi treatment is recommended as first-line therapy, so stable HFrEF NYHA II-IV patients without recent symptomatic hypotension should be switched from an ACEi/ARB to an ARNi (if SBP > 100mmHg, eGFR > 30 mL/min and K+ < 5.2mmol/L).

Therapies with limited benefit or to avoid8
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Therapies with limited benefit or to avoid

The following therapies have limited evidence to support their use in managing HF or may contribute to the worsening of HF. They should be avoided or withdrawn.

No benefit

  • Dihydropyridine calcium channel blockers
  • Vitamins, nutritional supplements or hormonal therapy (unless to correct specific deficiencies)
  • Nitrates or phosphodiesterase-5 inhibitors (among patients with HFpEF)

Potentially harmful

  • Nondihydropyridine calcium channel blockers (may depress cardiac function and worsen HF)
  • IC antiarrhythmic medications and dronedarone (may increase risk of mortality)
  • Thiazolidinediones (may increase risk of worsening HF symptoms and hospitalization)
  • Dipeptidyl peptidase-4 inhibitors including saxagliptin and alogliptin (not recommended in patients with HF and type 2 diabetes as they may increase risk of hospitalization)
  • NSAIDs (may worsen HF symptoms)

 

HFmrEF

There is currently limited evidence about specific pharmacological therapy for people with HFmrEF.

HFpEF

There is currently limited evidence about specific pharmacological therapy for people with HFpEF (although guidelines are expected to be updated soon). There is emerging evidence that SGLT2is may be beneficial across the spectrum of heart failure. ARNI/ARB and MRAs may be considered in selected patients (particularly those with EF at the lower end of the spectrum) to reduce hospitalization from heart failure (HHF). ACEis and beta-blockers are not recommended (evidence does not support benefit in HFpEF).4,8

Pharmacological management of HFpEF should focus on:4,8,34

  • Identifying and treating underlying etiological factors for HF (e.g., hypertension)
  • Managing HF symptoms (e.g., loop diuretics to control symptoms of congestion and peripheral edema)
  • Identifying and treating comorbid conditions that might exacerbate the HF (e.g., atrial fibrillation)
HFimpEF

Do not withdraw treatment even if the patient’s condition becomes HFimpEF (unless experiencing intolerable side effects). Stopping medications can cause deterioration.10

Monitoring

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Providers and patients should monitor the following regularly:

  • Vital signs (e.g., BP, HR, O2 saturation and body weight) on a regular basis until they stabilize (body weight daily
  • Clinical signs and symptoms of congestion and hypoperfusion (worsening heart failure) regularly
  • Encourage patients to take part in the monitoring process. Patients should identify and document their early, individualized signs and symptoms of worsening HF.
  • Ensure patients know who to contact if they detect warning signs and symptoms of worsening HF.

The extent of monitoring required depends on the severity of patients’ HF and response to therapy.

Warning signs and symptoms of worsening heart failure4,9,32

Caution

Patients should be encouraged to contact their primary care practitioners

  • Edema (swelling) in ankles, feet, legs or abdomen
  • Weight gain (≥ 2lbs per 24 hours or > 5lbs per week)
  • Shortness of breath (while lying down or with activity)
  • Cough, wheezing
  • Fatigue, tiredness
  • Change in ability to do routine daily activities
  • Gastrointestinal symptoms that last more than 2 days
Medical Alert

Patients should proceed to their nearest emergency room/department or call 911 and notify their primary care practitioners

  • Shortness of breath (while sitting still)
  • Chest pain
  • Confusion
  • Changes in heart rate and blood pressure
  • Heart palpitations
  • Dizziness
  • Fainting

Coordination of care New

The coordination of care and information across these care team members is integral to supporting patients with HF.4,8,12,33 This coordination of care and information requires bidirectional follow-up between team members (e.g., discharge plans, care plans, community paramedicine/remote monitoring programs, pharmacy, dietician, home and community care support services) and should involve active engagement of patients and their caregivers.10

Timely clinical follow-up with patients should occur within 7 days of hospital discharge.8

When to refer4,8,10,12,33

References