Managing heart failure in primary care

Last Updated: December 9, 2022

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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

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

What is heart failure?

Pathophysiology of heart failure

Heart failure (HF) is a condition in which the heart is unable to pump enough blood to meet the needs of the body.2

HF results from damage to ventricular function (i.e., ventricular filling or ventricular ejection of blood), most often caused by coronary artery disease, hypertension or diabetes.2,3

Damage to the ventricles leads to hormonal reactions that cause narrowing of the blood vessels resulting in restricted blood flow, fluid retention and anatomical changes. Without treatment these reactions can further contribute to heart damage and dysfunction.3

Therapy can work to interrupt this cycle to improve function and reduce remodeling of the heart.3 

Initial assessment and diagnosis

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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.

Diagnosis

When HF is suspected, the following steps should be conducted to confirm a diagnosis.4–6

Diagnosing heart failure

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:
  • Functional limitations
  • Prior cardiac disease (coronary artery disease, valvular heart disease, atrial fibrillation)
  • Risk factors (hypertension, ischemic heart disease, valvular heart disease, diabetes, alcohol or substance use, chemotherapy or radiation therapy, family history of cardiomyopathy, smoking, hyperlipidemia)
  • Contributing factors (recent flu-like illness)
  • Comorbidities
  • Prescribed and over-the-counter medications, vitamins or supplements
  • Substance use
Conduct a physical examination to determine the presence of:
  • Lung crackles upon inspiration
  • Elevated jugular venous pressure
  • Positive abdominal jugular reflux
  • Peripheral pitting edema
  • Abnormal sounds on cardiac auscultation
  • 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
  • Transthoracic doppler 2D echocardiogram to 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: decreased 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)

Providers should consider test access, cost, and timing when determining which test to use:

  • Resources may be limited in some communities
  • Echocardiograms can take a significant amount of time to arrange an appointment for and complete in some communities
  • NT-proBNP is currently covered by OHIP whereas BNP is not
  • Refer to specialist for investigation or for patients with low EF, high symptom burden or recent hospitalization for HF
Talking points
Click to view
Role of natriuretic peptides
Click to view

Determining heart failure type by ejection fraction and symptom severity4

For patients with confirmed HF, determine the HF type by EF (via an echocardiogram) and symptom severity using the New York Heart Association 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
  • Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath)

II

Mild symptoms

  • Slight limitation of physical activity
  • Comfortable at rest
  • Ordinary physical activity results in fatigue, palpitation, dyspnea

III

Moderate symptoms

  • Marked limitation of physical activity
  • Comfortable at rest
  • Less than ordinary activity causes fatigue, palpitation, or dyspnea

IV

Severe symptoms

  • Unable to carry on any physical activity without discomfort
  • Symptoms of heart failure at rest
  • If any physical activity is undertaken, discomfort increases

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
  • Assess for multimorbidity, frailty (Clinical Frailty Scale), cognitive impairment (MoCA), dementia and depression (PHQ-9), all of which might affect treatment, adherence to therapy, follow-up or prognosis
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 New

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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

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
Click to view

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
  • Information, tools and resources for patients and caregivers related to advance care planning in Ontario: Advance Care Planning Ontario
  • Documentation templates, step-by-step conversation guides and resources for providers related to advance care planning in Ontario: Hospice Palliative Care Ontario

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 as well as self-care
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
  • Understand and measure salt in ingredients
  • The evidence base to support dietary salt restrictions is limited
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 the syndrome
Physical activity
  • Support patients with NYHA HF types 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 HF type IV should be supervised by experts
  • Consider referral to cardiac rehabilitation centre
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 weigh increases of ≥ 2lbs per 24 hours or > 5lbs per week
  • Weight monitoring is only one component of monitoring. See Monitoring section below
Talking points10
Click to view

Self-care

Work in partnership with patients and caregivers to create an individualized self-care plan that empowers them to take an active role in their HF management.2,10

Care plans should include information about:

  • health behaviours (e.g. dietary choices, physical activity)
  • reducing risk factors
  • taking medications as prescribed
  • monitoring for early symptoms of worsening heart failure
  • responding to worsening symptoms of heart failure

Practical tips:

  • Many patients will benefit from having clear instructions instead of multiple options based on a given situation.
  • An individualized approach that emphasizes how to apply this information into their daily life is needed for patients to develop the necessary self-care skills. Discuss potential options with the patient and caregiver using a shared decision-making approach.
  • Self-care is a skill and requires learning over time. Reinforcement is often necessary.
  • Help build self-care confidence by reinforcing positive behaviours, setting mutual realistic goals and celebrating successes.
  • Support health literacy through conversation by assessing a patient’s understanding of their illness.
  • Use plain language.
  • Self-care monitoring and management planning may be positioned into green-yellow- and red zones. A sample may be found here.
Talking points10
Click to view

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 doses:12

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

For patients with newly diagnosed HF10,12,13

INITIATE: ARNi, beta-blocker, SGLT2i, MRA

For patients with stable HF10,12,13

CONTINUE: beta-blocker, MRA

INITIATE: SGLT2i

SWITCH: ACEi/ARB to ARNi

For patients with worsening HF10,12,13

OPTIMIZE: beta-blocker, MRA

INITIATE with support from a specialist: SGLT2i

SWITCH with from support from a specialist: ACEi/ARB to ARNi

Consider referral to or consultation with a specialist if:

  • Ongoing or worsening symptoms despite optimized quad therapy
  • Difficulty titrating medications due to renal impairment or hypotension
Medications4,5,12,14–16, 34
ARNis / ACEis / ARBs
Scroll (left-right) for details
  • ARNi
    Sacubitril-valsartan17*

    Coverage

    • ODB ✓ – LU 497
    • NIHB ✓ – LU

    Starting dose

    • 50-100 mg BID (50 mg strength includes 24.3 mg sacubitril and 25.7 mg valsartan; 100 mg strength includes 48.6 mg sacubitril and 51.4 mg valsartan)

    Target dose

    • 200 mg BID (200 mg strength includes 97.2 mg sacubitril and 102.8 mg valsartan)

    Benefits

    • ↓ CV mortality or HF hospitalization
    • ↓ CV mortality
    • ↓ HF hospitalization *
    • ↓ All-cause mortality*
    • ↓ HF symptoms

    Harms and monitoring

    • Closely monitor BP for symptomatic hypotension
    • Electrolytes for hyperkalemia
    • Closely monitor renal function for elevated creatinine
    • Acute kidney injury, angioedema, cough, dizziness and diuretic dosing for hypovolemia
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • ACEi
    Enalapril18*

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 1.25-2.5 mg BID

    Target dose

    • 10 mg BID/20 mg BID in NYHA IV

    Benefits

    • ↓ CV mortality
    • CV mortality
    • ↓ HF hospitalization
    • ↓ HF symptoms

    Harms and monitoring

    • Monitor BP for symptomatic hypotension
    • Electrolytes for hyperkalemia
    • Closely monitor renal function for elevated creatinine
    • Acute kidney injury, angioedema and cough
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • ACEi
    Lisinopril19*

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 2.5-5 mg daily

    Target dose

    • 20-35 mg daily

    Benefits

    • ↓ CV mortality
    • CV mortality
    • ↓ HF hospitalization
    • ↓ HF symptoms

    Harms and monitoring

    • Monitor BP for symptomatic hypotension
    • Electrolytes for hyperkalemia
    • Closely monitor renal function for elevated creatinine
    • Acute kidney injury, angioedema and cough

     

    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • ACEi
    Perindopril20

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 2-4 mg daily

    Target dose

    • 4-8 mg daily

    Benefits

    • ↓ CV mortality
    • CV mortality
    • ↓ HF hospitalization
    • ↓ HF symptoms

    Harms and monitoring

    • Monitor BP for symptomatic hypotension
    • Electrolytes for hyperkalemia
    • Closely monitor renal function for elevated creatinine
    • Acute kidney injury, angioedema and cough

     

    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • ACEi
    Ramipril21*

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 1.25-2.5 mg BID

    Target dose

    • 5 mg BID

    Benefits

    • ↓ CV mortality
    • CV mortality
    • ↓ HF hospitalization
    • ↓ HF symptoms

    Harms and monitoring

    • Monitor BP for symptomatic hypotension
    • Electrolytes for hyperkalemia
    • Closely monitor renal function for elevated creatinine
    • Acute kidney injury, angioedema and cough

     

    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • ACEi
    Trandolapril22*

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 1-2 mg daily

    Target dose

    • 4 mg daily

    Benefits

    • ↓ CV mortality
    • CV mortality
    • ↓ HF hospitalization
    • ↓ HF symptoms

    Harms and monitoring

    • Monitor BP for symptomatic hypotension
    • Electrolytes for hyperkalemia
    • Closely monitor renal function for elevated creatinine
    • Acute kidney injury, angioedema and cough
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • ARB
    Candesartan23*

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 4-8 mg daily

    Target dose

    • 32 mg daily

    Benefits

    • ↓ CV mortality or HF hospitalization
    • *↓ CV mortality
    • ↓HF hospitalization
    • *↓ All-cause mortality

    Harms and monitoring

    • Closely monitor BP for symptomatic hypotension
    • Risk of orthostatic hypotension
    • Electrolytes for hyperkalemia
    • Closely monitor renal function for elevated creatinine
    • Acute kidney injury, angioedema and cough
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • ARB
    Valsartan24*

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 40 mg BID

    Target dose

    • 160 mg BID

    Benefits

    • ↓ CV mortality or HF hospitalization
    • *↓ CV mortality
    • ↓HF hospitalization
    • *↓ All-cause mortality

    Harms and monitoring

    • Closely monitor BP for symptomatic hypotension
    • Risk of orthostatic hypotension
    • Electrolytes for hyperkalemia
    • Closely monitor renal function for elevated creatinine
    • Acute kidney injury, angioedema and cough
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
Beta-blockers
Scroll (left-right) for details
  • Beta-blocker
    Bisoprolol26*

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 1.25 mg daily

    Target dose

    • 10 mg daily

    Benefits

    • ↓ All-cause mortality
    • ↓ HF hospitalization

    Harms and monitoring

    • Monitor renal function, heart rate, BP, transient fluid retention, fatigue
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • Beta-blocker
    Carvedilol25*

    Coverage

    Starting dose

    • 3.125 mg BID

    Target dose

    • 25 mg BID/50 mg BID (>85 kg)

    Benefits

    • ↓ All-cause mortality
    • ↓ HF hospitalization

    Harms and monitoring

    • Monitor renal function, heart rate, BP, transient fluid retention, fatigue
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
MRAs
Scroll (left-right) for details
  • MRA
    Spironolactone27*

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 12.5 mg daily

    Target dose

    • 25*-50 mg daily

    Benefits

    • ↓ All-cause mortality
    • ↓ CV mortality
    • ↓HF hospitalizations

    Harms and monitoring

    • Closely monitor potassium, renal function, diuretic dosing
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • MRA
    Eplerenone28*

    Coverage

    • ODB ✓ – LU 458
    • NIHB ✓ – LU

    Starting dose

    • 25 mg daily

    Target dose

    • 50 mg daily

    Benefits

    • ↓ All-cause mortality
    • ↓ CV mortality
    • ↓HF hospitalizations

    Harms and monitoring

    • Closely monitor potassium, renal function, diuretic dosing
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
SGLT2is
Scroll (left-right) for details
  • SGLT2i
    Dapagliflozin29*

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 10 mg daily

    Target dose

    • 10 mg daily

    Benefits

    • ↓ HF symptoms
    • ↑ Quality of life
    • ↓ CV mortality
    • ↓ HF hospitalization

    (for patients with or without concomitant type 2 diabetes)

    Harms and monitoring

    • Closely monitor renal function, electrolytes, BP, genital mycotic infections, risk of hypoglycemia (not a significant concern unless patients have diabetes and are taking sulfonylureas or insulin)
    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • SGLT2i
    Empagliflozin30*

    Coverage1

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 10 mg daily

    Target dose

    • 10*-25 mg daily

    Benefits

    • ↓ HF symptoms
    • ↑ Quality of life
    • ↓ CV mortality
    • ↓ HF hospitalization

    (for patients with or without concomitant type 2 diabetes)

    Harms and monitoring

    • Closely monitor renal function, electrolytes, BP, genital mycotic infections, risk of hypoglycemia (not a significant concern unless patients have diabetes and are taking sulfonylureas or insulin)

     

    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation
  • SGLT2i
    Canagliflozin31

    Coverage

    • ODB ✓
    • NIHB ✓

    Starting dose

    • 100 mg daily

    Target dose

    • 100-300 mg daily

    Benefits

    • ↓ HF symptoms
    • ↑ Quality of life
    • ↓ CV mortality
    • ↓ HF hospitalization

    (for patients with or without concomitant type 2 diabetes)

    Harms and monitoring

    • Closely monitor renal function, electrolytes, BP, genital mycotic infections, risk of hypoglycemia (not a significant concern unless patients have diabetes and are taking sulfonylureas or insulin)

     

    View parameters for initiation, laboratory and clinical monitoring, and when to consider dose reduction / discontinuation

*=recommended in the management of HFrEF12, BP = blood pressure, eGFR = estimated glomerular filtration rate, K+ = potassium, LU = limited use, SCr = serum creatinine; SBP = systolic blood pressure

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
Click to view
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. ARNIs, ARBs and MRAs may be considered in selected patients (particularly those with EF at the lower end of the spectrum) to reduce 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 New

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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

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

Identify patients with worsening heart failure by monitoring for warning signs and symptoms. If symptoms worsen, work to identify the possible etiologies and address those before initiating additional therapies.

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.

Caution

Patients should be encouraged to contact their family physicians or primary care nurse practitioner, or person most responsible for their HF care

  • 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 provider

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

Managing warning signs and symptoms of worsening heart failure4

Patients presenting with worsening signs and symptoms of HF need to have medication adjusted within 24-48 hours.

Warning signs and medications

Edema can be managed through:

  • Pharmacological
    • Optimized HF quadruple therapy
    • Loop diuretics
  • Non-pharmacological
    • Reducing salt intake
    • Attention to skin care

Diuretics

Diuretics should be titrated to a minimum effective dose to maintain euvolemiaEuvolemia = at dry weight with no/mild HF symptoms with dry weight referring to ideal weight without extra fluid accumulation/congestion and reassessed at every visit.

To achieve this, patients may require one of the following (in order of escalation):

  • No furosemide
  • PRN furosemide
  • Scheduled low-dose furosemide
  • Scheduled high dose furosemide +/- metolazone (if considering initiating metolazone engage a specialist)

If dry weight is not achieved:

  • Increase the furosemide dose by 20 to 40mg increments
  • Consider bid dosing (breakfast and lunch)
  • Consider the addition of metolazone 2.5mg daily x 3 days if 2+ increases in furosemide do not provide relief

If dry weight is achieved and HF symptoms are resolved:

  • Consider reducing to the previous furosemide dose

Reassess HF symptoms and bloodwork in 2 to 7 days and adjust furosemide dose.

The management of hypotension is dependent on whether it is asymptomatic or symptomatic.

If asymptomatic hypotension:

  • Encourage patients to monitor BP and report any symptoms of hypotension (e.g., syncope, presyncope, dizziness, lightheaded, confusion, blurred vision)
  • MRAs and SGLT2i have minimal impact on BP

For mild symptomatic hypotension:

  • Start by assessing other BP meds that don’t lower mortality or HF hospitalization
    • Diuretics
    • Nitrates
    • Calcium channel blockers
  • Separate times of administration (e.g., once daily ACEi before noon and beta blocker at bedtime)
  • Use cardio-selective beta blocker, take carvedilol with food (to reduce rate but not the extent of absorption)
  • Take beta blocker with food (to slow absorption)

If none of the above work for symptomatic hypotension:

  •   Consider referral to or consult with a specialist

Resting HR of 50-60bpm is reasonable if the patient is not experiencing symptomatic bradycardia. Pacemakers will be set to thresholds to prevent bradycardia and tachycardia.

If asymptomatic bradycardia:

  • Encourage the patient to monitor HR and report any symptoms of bradycardia (e.g., HR < 60bpm, syncope, presyncope, dizziness, lightheaded, confusion, blurred vision)
  • If concerned about bradycardia, consider referral to or consult with a specialist

If symptomatic bradycardia:

  • Consider referral to or consult with a specialist

 

Potassium might fluctuate due to HF meds (i.e., ACEi, ARB, ARNi, MRA). Conditions such as diabetes, renal impairment and older age can increase potassium. Check potassium at baseline and 1 to 2 weeks after starting or titrating medications.

If hyperkalemia (> 5.0 mmol/L) present, then consider the following strategies to decrease potassium levels:

  • Encourage a low potassium diet
  • Encourage the elimination of salt substitutes which often use potassium
  • Stop or reduce potassium supplements
  • Confirm patient not taking NSAIDs/COX-2 inhibitors
  • Confirm patient not taking ACEi + ARB + ARNi combination
  • Monitor and assess for hypovolemia that may be due to diuretics, ARNi and SGLT2i, as this can lead to hyperkalemia
  • Consider reducing MRA dose

If potassium 5.6 to 5.9 mmol/L (i.e., moderate hyperkalemia), then consider the following strategies:

  • Lower the dose of ACEi, ARB, ARNi or MRA by 50%
  • If sudden increase in potassium, stop most recently added ACEi, ARB, ARNi or MRA medication
  • Recheck potassium and renal function within 3 days. If still elevated, stop one of the ACEi, ARB, ARNi or MRA medication
    • If still elevated after stopping an ACEi, ARB, ARNi or MRA medication, consider potassium binder (e.g., sodium polystyrene)
    • Consider rechallenge after potassium stabilized
    • Document if not able to rechallenge

If potassium > 5.9 mmol/L (i.e., severe hyperkalemia), then consider the following strategies:

  • Patient should be sent to the emergency room

If hypokalemia (< 3.5 mmol/L) present, then consider the following strategies to increase potassium levels:

  • Taper diuretic to achieve a euvolemic state
  • Increase dose of ACEi/ARB/ARNi (balancing risk of hypotension)
  • Start or increase dose of MRA
  • Correct hypomagnesemia with magnesium oxide supplementation
  • Potassium supplementation until potassium ≥ 3.5 mmol/L, then re-evaluate continuous requirement

A slight decline in renal function is expected after starting an ACEi, ARB, ARNi or SGLT2i but will improve over time.

Consider the following strategies to reduce the risk of acute kidney injury:

  • Check serum creatinine and urea at baseline and 1-2 weeks after starting or titrating ACEi, ARB, ARNi or SGLT2i
  • Reassess diuretics and reduce dose by 30-50% if euvolemic
  • Ensure patients are not taking NSAIDs/COX-2 inhibitors or a combination of ACEi + ARB

If serum creatinine increases by > 30% from baseline or eGFR decreases by > 30% from baseline, then:

  • Reasses diuretics and lower or stop to maintain euvolemic state
  • Reduce ACEi, ARB or ARNi by 50% and recheck serum creatinine and blood urea nitrogen in 1-2 weeks and rechallenge if clinically appropriate
    •  Document if unable to rechallenge or lower dose required
  • Monitor potassium as renal dysfunction can increase the risk of hyperkalemia

A cough can be a sign of HF congestion and as such is isimportant to document the presence or absence of a cough before initiating an ACEi, ARB or ARNi. ACEi and ARBs have an incidence of cough at 10-20% and < 1%, respectively. A dry cough can be a burdensome side effect for patients (e.g., impacts daily routines like sleep).

If a bothersome cough develops, consider switching a patient to an ARB.

Hyponatremia is a common electrolyte disorder frequently experienced by patients with worsening or advanced heart failure.

Consider the following strategies to increase sodium levels:

  • Taper diuretic to achieve a euvolemic state
  • Lower or stop thiazide diuretic (e.g., metolazone) dose and increase loop diuretic (e.g., furosemide) dose (thiazide diuretics can lower sodium more than loop diuretics)
  • Review other medications that can cause hyponatremia (e.g., SSRIs) and adjust as needed
  • Avoid increasing dietary Na+ or NaCl tablets as they can lead to fluid retention making HF symptoms worse
  • Consider referral to or consult with a specialist as this is a poor prognostic marker

Diuretic use can increase uric acid buildup leading to gout.

If hyperuricemia present without gout:

  • Monitor the patient

If symptomatic gout:

  • Treat with colchicine (preferred) or prednisone
  • Avoid NSAIDs

If patient is experiencing ≥ 2 attacks/year manage with prophylaxis:

  • Allopurinol preferred

Consider the following strategies to manage dyspnea:

  • Pharmacological
    • Optimized HF quadruple therapy
  • Nonpharmacological
    • Rehabilitation/physical activity
    • Energy conservation techniques
    • Supplemental oxygen only if hypoxia
    • Fan to circulate air
  • Referral to or consult with a specialist

Consider the following strategies to manage fatigue:

  • Pharmacological
    • Optimized HF quadruple therapy
  • Nonpharmacological
    • Rehabilitation/physical activity
    • Consider depression, sleep-disordered breathing, or other comorbidities
  • Referral to or consult with a specialist

Consider the following strategies to support patients who experience a loss in ability to do routine daily activities:

  • Pharmacological
    • Optimized HF quadruple therapy
  • Nonpharmacological
    • Rehabilitation/physical activity
    • Occupational therapy
    • Social work
  • Supporting an application for short- or long-term disability income support if unable to work or if work hours are reduced
    • Identify the relevant disability support programs. The Prosper Benefits Wayfinder produces an individualized list of income supports. Key programs include:
    • Conduct a thorough assessment of symptoms and functional impairments: disability support programs generally look toward impact on day-to-day life and function as opposed to medical proof of diagnosis
    • Engage other supports for complicated cases or where a patient has been denied disability or other income support benefits:

Consider the following strategies to manage pain:

  • Pharmacological
    • Non-opioid medications (e.g., acetaminophen, anticonvulsants, antidepressants, topical rubefacients)
    • Avoid nonsteroidal anti-inflammatory drugs
  • Nonpharmacological
    • Physical activity or therapy
    • Psychological therapy

Rule out fluid overload, ascites, digoxin toxicity or medication side effects (e.g., MRAs) if gastrointestinal symptoms are present. Once ruled out, consider non-cardiac contributors.

If treating constipation, sennosides and PEG 17 are okay. Avoid adding fibre if fluid is restricted.

Consider the following strategies to manage depression:

  • Pharmacological
    • Optimized HF quadruple therapy
    • Selective serotonin reuptake inhibitors (sertraline, citalopram)
    • Avoid tricyclic antidepressants
  • Nonpharmacological
    • Psychological therapy
    • Cognitive behaviour therapy
    • Rehabilitation/physical activity

Consider the following strategies to manage anxiety:

  • Pharmacological
    • Selective serotonin reuptake inhibitors (sertraline, citalopram)
    • Avoid tricyclic antidepressants
    • Benzodiazepines
  • Nonpharmacological
    • Psychological therapy
    • Cognitive behaviour therapy
    • Breathing exercises
    • Relaxation therapy

Rule out concomitant depression, anxiety, agitated delirium, nocturi and sleep apnea. Once ruled out, consider the following strategies to manage sleep disturbances:

  • Pharmacological
    • Optimized HF quadruple therapy
    • Consider and treat concomitant depression, anxiety, agitated delirium, nocturia, sleep apnea
  • Nonpharmacological
    • Attention to sleep hygiene

Coordination of care

Patients with HF should receive care from providers across a variety of expertise (e.g., physician, nurse, pharmacist, dietitian) or a multidisciplinary team (if available in patient’s region) to facilitate the implementation of management approaches and support self-care to reduce the risk of rehospitalization for HF, improve quality of life and reduce mortality. 

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

HF multidisciplinary clinic
  • Advanced HF
  • Multiple (unstable) comorbidities
  • Recurrent hospitalization for HF
Cardiologist
  • New diagnosis (co-management can be beneficial if feasible)
  • Multiple (but stable) comorbidities
  • High symptom burden
  • Recent hospitalization for HF
  • Additional diagnostic investigations required (e.g., cardiac catheterization, cardiopulmonary exercise testing, CMR, MIBI scan, MUGA, CT scan)
  • Support for etiological investigation
  • The I-Need-HelpI, Intravenous inotropes
    N, New York Heart Association (NYHA) class IIIB to IV or persistently elevated natriuretic peptides
    E, End-organ dysfunction
    E, EF ≤35%
    D, Defibrillator shocks
    H, Hospitalizations >1
    E, Edema despite escalating diuretics
    L, Low systolic BP ≤90, high heart rate
    P, Prognostic medication; progressive intolerance or down-titration of GDMT
    acronym can be used to determine when patients should be referred
Nephrologist
  • Declining renal function
  • Persistent or difficult to manage electrolyte abnormalities (e.g., hyperkalemia)
Cardiac rehabilitation program
  • Any patient with stable HF
  • Any patient with cardiac history
Palliative and supportive care
  • Challenging to manage symptoms despite optimized HF therapy
  • Patient wishes a palliative care approach
  • Patient needs additional support with decision-making about advanced treatments and goals of care

References