Heart Failure: Management of Patients With Left-Ventricular Systolic Dysfunction
Quick Reference Guideline Number 11
AHCPR Publication No. 94-0613: June 1994
National Library of Medicine DOCLINE Information: MED/94282113

Highlights of Patient Management

Initial Evaluation

All patients who complain of paroxysmal nocturnal dyspnea, orthopnea, or new-onset dyspnea on exertion should undergo evaluation for heart failure unless history and physical examination clearly indicate a noncardiac cause for their symptoms, such as pulmonary disease.

Although the physical examination can provide important information about the etiology of patients' symptoms and about appropriate initial treatment, physical signs are not highly sensitive for detecting heart failure. Therefore, patients with symptoms highly suggestive of heart failure should undergo echocardiography or radionuclide ventriculography to measure left-ventricular ejection fraction (EF) (see below) even if physical signs of heart failure are absent. Patients with less specific symptoms (i.e., fatigue, lower extremity edema) should only undergo such testing if there are physical or radiographic signs of heart failure.

Conversely, many physical findings of heart failure are not highly specific. Elevated jugular venous pressure and a third heart sound are the most specific findings and are virtually diagnostic in patients with compatible symptoms. Pulmonary rales or peripheral edema are relatively nonspecific findings, however. The presence of these signs does not require measurement of left-ventricular ejection fraction if other symptoms, signs, and radiographic findings of heart failure (e.g., cardiomegaly and pulmonary vascular congestion) are absent or if they can be attributed to other causes.

Table 1 summarizes the tests that should be performed to evaluate patients with new-onset signs or symptoms of heart failure for underlying causes.

A variety of conditions can mimic or provoke heart failure, including pulmonary disease, myocardial infarction (MI), arrhythmias, anemia, renal failure, nephrotic syndrome, and thyroid disease. These conditions should be considered in every patient with suspected new-onset heart failure. This guideline does not address the management of patients with these conditions.

Hospital Management

• Clinical or electrocardiographic evidence of acute myocardial ischemia.
• Pulmonary edema or severe respiratory distress.
• Oxygen saturation below 90 percent (not due to pulmonary disease).
• Severe complicating medical illness (e.g., pneumonia).
• Anasarca.
• Symptomatic hypotension or syncope.
• Heart failure refractory to outpatient therapy.
• Inadequate social support for safe outpatient management.

• Symptoms of heart failure have been adequately controlled.
• All reversible causes of morbidity have been treated or stabilized.
• Patients and caregivers have been educated about medications, diet, activity, and exercise recommendations, and symptoms of worsening heart failure.
• Adequate outpatient support and follow up care have been arranged.

Clinical Volume Overload

Left-Ventricular Function

Measurement of left-ventricular performance is a critical step in the evaluation and management of almost all patients with suspected or clinically apparent heart failure. The combined use of history, physical examination, chest radiography, and electrocardiography does not appear to be reliable in determining whether a patient's symptoms and physical findings are due to dilated cardiomyopathy, left-ventricular diastolic dysfunction, valvular heart disease, or a noncardiac etiology. Therefore, echocardiography or radionuclide ventriculography can substantially improve diagnostic accuracy.

Patients with suspected heart failure should undergo echocardiography or radionuclide ventriculography to measure left-ventricular ejection fraction (if information about ventricular function is not available from previous tests). Table 2 summarizes the advantages and disadvantages of echocardiography and radionuclide ventriculography in the evaluation of left-ventricular performance.

Most patients with signs and symptoms of heart failure are found to have EF's less than 40 percent. Patients with an EF of 40 percent or greater may still have heart failure on the basis of valvular disease or stiffness of the ventricular wall (diastolic dysfunction). The recommendations contained in this Quick Reference Guide for Clinicians are designed for patients with heart failure due to left-ventricular systolic dysfunction, i.e., EF's less than 35-40 percent.

Screening for arrhythmias, such as ambulatory electrocardiographic (Holter) recording, is not warranted as part of the evaluation of patients with heart failure. Patients with a history of syncope or near-syncope should be referred immediately to a cardiologist with expertise in arrhythmias.

General Counseling

Patients with heart failure should be informed about their diagnoses including the prognosis, symptoms of worsening heart failure, and what to do if these symptoms occur. Information should also be provided concerning the benefits of regular activity, dietary restrictions, necessary medications, and the importance of compliance with recommendations. It is vital that patients understand their disease and be involved in developing the plan for their care. In addition, family members and other responsible caregivers should be included in counseling and decision making sessions.

Activity. Regular exercise such as walking or cycling should be encouraged for all patients with stable heart failure. Even short periods of bedrest result in reduced exercise tolerance and aerobic capacity, muscular atrophy, and weakness. Recent studies show that patients with heart failure can exercise safely, and regular exercise may improve functional status and decrease symptoms.

An explanation of the importance of exercise can help prevent patients from becoming afraid to perform daily activities that might provoke some shortness of breath. Patients should be advised to stay as active as possible.

There is insufficient evidence at this time to recommend the routine use of formal rehabilitation programs for patients with heart failure, although patients who are anxious about exercising on their own or are dyspneic at a low work level may benefit from such programs.

Diet. Dietary sodium should be restricted to as close to 2 grams per day as possible. In no case should sodium intake exceed 3 grams daily. Alcohol use should be discouraged. Patients who drink alcohol should be advised to consume no more than one drink per day. One drink equals a glass of beer or wine, or a mixed drink or cocktail containing no more than 1 ounce of alcohol. Patients with heart failure should be advised to avoid excessive fluid intake. However, fluid restriction is not advisable unless patients develop hyponatremia. Patients should be advised to keep a diary of their daily weights and to advise the clinicians if a weight gain of 3-5 pounds or more occurs within 1 week or since the previous visit with the clinician.

Medications. Medications are prescribed for patients with heart failure for two basic reasons: (1) to reduce mortality (angiotensin-converting enzyme [ACE] inhibitors, isosorbide dinitrate/ hydralazine) and (2) to reduce symptoms and improve functional status (ACE inhibitors, diuretics, digoxin). Patients should be provided with complete and accurate information concerning the medications they are being asked to take, including the reasons the medications are being prescribed, dosing requirements, and possible side effects.

Compliance. Because noncompliance is a major cause of morbidity and unnecessary hospital admissions for heart failure, educational programs or support groups can be very helpful in the care of patients with heart failure. Noncompliance may reduce life expectancy (e.g., if patients are not taking beneficial medications) and is also a major cause of hospitalizations. Practitioners should be aware of the problem of noncompliance and its causes and should discuss the importance of compliance at follow-up visits and assist patients in removing barriers to compliance (e.g., cost, side effects, or complexity of the medical regimen).

Prognosis. Patients with heart failure must understand the serious implications of this diagnosis, including a 5-year mortality rate approaching 50 percent in some studies. Patients should be encouraged to complete advance directives regarding their health care preferences. Patients, families, and caregivers must be provided with the accurate information necessary to make decisions and plans for the future, while maintaining hope and emphasizing that good quality of life is still possible.

Table 3 summarizes many of the topics that should be discussed during counseling.

Initial Pharmacological Management

Table 4 summarizes the usual dosing and potential adverse effects of the pharmacological agents commonly used to treat patients with heart failure.

Diuretics. Diuretics are extremely useful for reducing symptoms of volume overload, including orthopnea and paroxysmal nocturnal dyspnea. As noted above under "Clinical Volume Overload" (Algorithm Node 5), diuretics should be started immediately when patients present with symptoms or signs of volume overload.

Although initiation of diuretics is important in these patients, it is also important to avoid overdiuresis before starting ACE inhibitors. Volume depletion may lead to hypotension or renal insufficiency when ACE inhibitors are started or when the doses of these agents are increased to full therapeutic levels. After the ACE inhibitor is increased to full therapeutic levels, additional diuretic therapy may be necessary to optimize the patient's status.

ACE Inhibitors. Because of their beneficial effects on mortality risk and functional status, ACE inhibitors should be prescribed for all patients with left-ventricular systolic dysfunction unless specific contraindications exist (i.e., history of intolerance or adverse reactions to these agents, serum potassium >5.5, or symptomatic hypotension). Patients with contraindications to ACE inhibitors or who cannot tolerate them should be placed on isosorbide dinitrate/hydralazine.

ACE inhibitors may be considered as sole therapy in patients who present with fatigue or mild dyspnea on exertion and who do not have any signs or symptoms of volume overload. Diuretics should be added if symptoms persist in these patients despite ACE inhibitors or if volume overload develops at a later time.

Digoxin. Digoxin increases the force of ventricular contraction in patients with left-ventricular systolic dysfunction. Although physical functioning and symptoms may be improved with digoxin, its effect on mortality is not known. Digoxin should be initiated along with ACE inhibitors and diuretics in patients with severe heart failure. Patients with mild-to-moderate heart failure will often become asymptomatic on optimal doses of ACE inhibitors and diuretics; these patients do not require digoxin. Digoxin should be added to the therapeutic regimen of those patients whose symptoms persist despite optimal doses of ACE inhibitors and diuretics. Digoxin dosing and precautions are discussed in the Clinical Practice Guideline.

Anticoagulation. Routine anticoagulation is not recommended. Patients with a history of systemic or pulmonary embolism or recent atrial fibrillation should be anticoagulated to a prothrombin time ratio of 1.2-1.8 times each individual control time (International Normalization Ratio of 2.0-3.0). Although there has never been a controlled trial of anticoagulation for patients with heart failure, the risks of routine treatment, including intracranial or gastrointestinal hemorrhage, do not appear warranted given the relatively low incidence of significant thromboembolic events in this population.

Revascularization

Coronary artery disease is currently the most common cause of heart failure in the United States, and some patients may benefit from revascularization. In particular, patients with viable myocardium subserved by substantially stenotic vessels may reasonably be expected to obtain longevity benefits and, perhaps, improved quality of life if the stenosis is successfully relieved. On the other hand, revascularization entails significant morbidity and mortality. Before studies are initiated to determine if patients are candidates for revascularization (i.e., have viable myocardium subserved by stenotic arteries), it is important to determine first if any conditions exist that may preclude intervention or that could raise the risk of revascularization above any potential benefit. These may include:

• Patient would not consider surgery or is unable to give informed consent.
• Severe comorbid diseases, especially renal failure, pulmonary disease, or cerebrovascular disease (e.g., severe stroke).
• Very low ejection fraction (i.e., <20%).
• Illnesses with a projected life expectancy less than or equal to 1 year. These include advanced cancer, severe lung or liver disease, chronic renal disease, advanced diabetes mellitus, and advanced collagen vascular disease.
• Technical factors, including previous myocardial revascularization or other cardiac procedure, history of chest irradiation, and diffuse distal coronary artery atherosclerosis.

Patients without contraindication to revascularization should be advised of the possibility of revascularization, including its potential benefits and harms.

Three parameters are important:

1. likelihood of surgically correctable lesions,
2. expected benefits of revascularization, and
3. expected risks and potential harms of revascularization.

Counseling should be based on patients' particular characteristics, particularly on an assessment of patients' risk factors for coronary artery disease. Patients can be classified into three major subgroups:

1. patients who have neither angina nor a history of myocardial infarction,
2. patients without significant angina (angina that limits exercise or occurs frequently at rest), but who have a history of MI, and
3. patients with significant angina pectoris.

No Angina and No MI.

The likelihood of coronary disease in heart failure patients without angina or history of myocardial infarction varies depending on patient risk factors (e.g., age, sex, smoking history, hyperlipidemia, hypertension, family history of premature coronary artery disease, and diabetes).

Patients should be counseled concerning the expected benefits and risks of evaluation for ischemia, including the fact that there is no evidence from controlled trials to show that revascularization benefits heart failure patients in the absence of angina.

It is unclear whether patients without a history of MI or significant angina should be routinely evaluated for ischemia. The decision about whether to perform physiological tests for ischemia or coronary angiography should be based on a consideration of patients' risk factors for coronary artery disease and the likelihood of alternative etiologies (e.g., alcoholic cardiomyopathy).

No Angina and History of MI.

Available evidence suggests that as many as half of patients who suffer a myocardial infarction have clinically important myocardial ischemia in areas supplied by other coronary arteries. There are no data, however, to show that revascularization of these areas is beneficial, in terms of increased life expectancy or enhanced quality of life, in the absence of angina. Nevertheless, patients with large areas of ischemia may possibly benefit from revascularization.

Patients without angina but with a history of MI should undergo a physiological test for ischemia and should undergo cardiac catheterization if ischemic regions are detected. This strategy will miss a small number of patients with false negative physiological tests. However, in view of the lack of evidence that these patients benefit from surgery, together with a consideration of the morbidity, mortality, and the cost of catheterizing all patients in this group, this drawback is considered relatively minor. Although there are a number of acceptable physiological tests for ischemia, the most widely available and accepted procedure for determining the presence of ischemic myocardium is myocardial perfusion scintigraphy, such as thallium scanning, with poststress, redistribution, and rest reinjection imaging.

Angina.

The potential benefit of revascularization is clearest and probably greatest in individuals with severe or limiting angina or angina-equivalent (e.g., recurrent acute episodes of pulmonary edema despite appropriate medical management). Available evidence suggests that about 75 percent of heart failure patients with significant concomitant angina have operable disease. Although the three randomized trials of coronary artery bypass graft (CABG) surgery excluded patients with heart failure or severe left-ventricular dysfunction, several cohort studies and registries suggest that patients with angina and impaired left-ventricular function have improved functional status and survival if they undergo bypass surgery.

Heart failure patients without contraindications to revascularization and who have exercise-limiting angina, angina that occurs frequently at rest, or recurrent episodes of acute pulmonary edema should be advised to undergo coronary artery angiography as the initial test for significant coronary lesions. Some patients may need physiological testing for ischemia to interpret the significance of the findings from coronary artery angiography.

Counseling and Decision.

Based on the results of physiological testing and/or cardiac catheterization, the physician should give the patient a refined estimate of the risks and benefits of revascularization. The patient can then decide if he or she desires revascularization. No data are available that address the question of how much ischemia should be present to justify the risk of revascularization for the chance of an improvement in survival. In general, patients with severely depressed ejection fractions (EF <20 PERCENT) should undergo revascularization only if large areas of ischemia are detected. patients with less severely depressed ejection fractions may be willing to risk surgery for more modest-sized ischemic areas. The lack of data in this area makes it difficult to justify revascularization for small ischemic areas, except when severe angina is present.

Continue Medical Management.

If (1) a patient is not a candidate for revascularization, (2) studies show insufficient evidence of reversible ischemia, or (3) surgery has been performed but the patient still has residual left-ventricular dysfunction, then the medical therapy started under "Initial Pharmacological Management" (Algorithm Node 9) should be continued. As stated previously, an assessment of compliance is recommended at each visit. Use of a home health nurse or visiting nurse may be helpful for this purpose.

Revascularize.

Coronary artery bypass grafting is the only revascularization procedure that has been shown to prolong life in patients with angina and left-ventricular dysfunction. The effect of coronary artery angioplasty on survival of heart failure patients has not been studied, nor are the risks of angioplasty in heart failure patients known at this time. The choice between CABG and angioplasty will depend on numerous considerations, including multiple technical factors (e.g., coronary anatomy), relative risk of the two procedures in individual patients, and patient preferences. A discussion of these factors lies beyond the scope of this Quick Reference Guide for Clinicians.

Follow-up

Careful history and physical examination should be the main guide to determining outcomes and directing therapy. A thorough history should include questions regarding physical functioning, mental health, sleep disturbance, sexual function, cognitive function, and ability to perform usual work and social activities.

On followup visits, patients should be asked about the presence of orthopnea, paroxysmal nocturnal dyspnea, edema, and dyspnea on exertion. It is important to remember that patients are likely to experience changes in symptoms before there is evidence of deterioration by physical examination.

Patients should be encouraged to keep a record of their daily weights and to bring that record with them when visiting their practitioner. Patients should be instructed to call if they experience an unexplained weight gain greater than 3-5 pounds since their last clinical evaluation.

Family members or other caregivers can often contribute important additional information about the patient's status and compliance when asked similar questions. In some cases, it may be desirable to interview family members or other caregivers apart from the patient in order to validate the patient's report. If discrepancies do occur, additional measures need to be instituted for clarification.

In addition to questions about symptoms and activities, providers should ask about other aspects of patients' health-related quality of life, including sleep, sexual function, mental health (or outlook on life), appetite, and social activities. A worsening in any of these parameters may indicate the need to adjust therapy. To ensure optimal care for heart failure, the provider must view the disease in the broad context of the patient's life and see how the patient is coping with the disease. Consultation with psychologists, dieticians, health educators, and clinical nurse specialists may be necessary to deal with specific problems such as depression, difficulties adhering to complicated dietary or medical regimens, or poor functional status.

The Heart Failure Guideline Panel recommends against the use of other tests (e.g., echocardiography, exercise testing) for monitoring the response of heart failure patients to treatment. No data exist to suggest that the monitoring of these endpoints contributes information beyond that obtained by a careful history and physical examination. However, repeat testing may be useful in patients with a new heart murmur, a new myocardial infarction, or sudden deterioration despite compliance with medications. Repeat testing as part of the evaluation for transplantation may also be necessary.

Additional Pharmacological Management

If patients remain symptomatic on a combination of a diuretic, an ACE inhibitor, and digoxin, they should be seen at least once by a cardiologist.

Patients with persistent volume overload despite initial medical management may require more aggressive administration of the current diuretic (e.g., intravenous administration), more potent diuretics, or a combination of diuretics.

Patients with persistent dyspnea after optimal doses of diuretics, ACE inhibitors, and digoxin should be given a trial of hydralazine and/or nitrates. The addition of a vasodilator to an ACE inhibitor may also relieve symptoms. Direct vasodilators may be particularly helpful in patients with hypertension or evidence of severe mitral regurgitation. Even patients with blood pressure in the usual normal range may benefit by reducing their blood pressure with direct vasodilators. Alternatively, if a patient primarily has symptoms of pulmonary congestion or has a low systolic blood pressure, nitrates are preferred over arterial vasodilators.

There is some evidence that gradually incremental therapy with low dose beta blockers may produce long-term improvements in symptoms and in natural history in patients with heart failure. However, because beta blockers may also cause acute deterioration in patients with heart failure, this form of treatment should be considered experimental at this time.

Heart Transplantation

Consideration should be given to cardiac transplantation in patients with severe limitation and/or repeated hospitalization because of heart failure, despite aggressive medical therapy, and in whom revascularization is not likely to convey benefit. Patients with severe symptoms should be referred to a cardiologist to ensure that medical therapy is optimized prior to referral for possible transplantation. Practitioners should refer to existing documents concerning heart transplantation for further information on patient selection criteria.

Patients with poor systolic function whose symptoms are controlled on optimal medical management need not be referred for transplantation. Where appropriate, patients with severe symptoms uncontrolled by optimal medical management who are unable to obtain a heart transplant should be informed of the availability of experimental treatment protocols for which they may be eligible (e.g., new drugs, mechanical assist devices).

Prevention in Patients with Left-Ventricular Systolic Dysfunction

Asymptomatic patients who are found to have moderately or severely reduced left-ventricular systolic function (ejection fraction <35-40 PERCENT) should be treated with an ACE inhibitor to reduce the chance of developing clinical heart failure.

Probably the largest number of such patients will be those who have recently sustained a myocardial infarction. For this reason, the EF should be myocardial infarction. For this reason, the EF should be determined in most patients following a myocardial infarction unless they are at low risk for significant systolic dysfunction, i.e., unless they meet all of the following criteria:

1. No previous myocardial infarction.
2. Inferior infarction.
3. Relatively small increase in cardiac enzymes (i.e., <2-4 times normal).
4. No Q waves develop on electrocardiogram.
5. Uncomplicated clinical course (e.g., no arrhythmia or hypotension).

Other asymptomatic patients without infarctions may be found to have reduced EF on evaluation of heart murmurs or cardiomegaly. These patients should also be treated with ACE inhibitors.