 |
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
- Alderman EL, Fisher LD, Litwin P, et al.
- Results of coronary artery surgery in patients with poor left ventricular function (CASS).Circulation 1983;68:785-95.
View this and
related citations using 
- Arnsdorf MF, Bump TE.
- Management of arrhythmias in heart failure. Cardiol Clin 1989;7:145-69.
View this and related citations using 
- Bonow RO, Udelson JE.
- Left ventricular diastolic dysfunction as a cause of congestive heart failure: mechanisms and management. Ann Intern Med 1992;117:502-10.
View
this and related citations using
- Bounous EP, Mark DB, Pollock BG, et al.
- Surgical survival benefits for coronary disease patients with left-ventricular dysfunction.Circulation 1988 Sep;78(3 Pt 2):I151-7.
View
this and related citations using
- The Cardiac Arrhythmia Suppression Trial (CAST) Investigators.
- Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N
Engl J Med 1989;321:406-12.
View this and related citations using
- Chakko CS, Woska D, Martinez H, et al.
- Clinical, radiographic, and hemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care. Am J
Med 1991;90:353-9.
View this and related citations using
- Christakis GT, Ivanov J, Weisel R, et al.
- The changing pattern of coronary artery bypass surgery. Circulation 1989;80(3 Pt 1):I151-61.
View this and related citations using
- Coats AJ, Adamopoulos S, Meyer TE, et al.
- Effects of physical training in chronic heart failure. Lancet 1990;335(8681):63-6.
View this and related citations using
- Cody RJ.
- Management of refractory congestive heart failure. Am J Cardiol 1992;69:141G-149.
View this and related citations using
- Cohn JN, Archibald DG, Ziesche S, et al.
- Effect of vasodilator therapy on mortality in chronic congestive heart failure: results of a Veterans Administration Cooperative Study. N Engl J
Med 1986;314:1547-52.
View this and related citations using
- Cohn JN, Johnson G, Ziesche S, et al.
- A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991;325:303-10.
View
this and related citations using
- CONSENSUS Trial Study Group.
- Effects of enalapril on mortality in severe congestive heart failure. N Engl J Med 1987;316:1429-35.
View this and related citations
using
- Dougherty AH, Naccarelli GV, Gray EL, et al.
- Congestive heart failure with normal systolic function. Am J Cardiol 1984;54:778-82.
View this and related citations using
- Dracup K, Walden JA, Stevenson LW, et al.
- Quality of life in patients with advanced heart failure. J Heart Lung Transplant 1992;2:273-9.
View this and related citations using
- Dubach P, Froelicher VF.
- Cardiac rehabilitation for heart failure patients. Cardiology 1989;76:368-73.
View this and related citations using
- Echeverria HH, Bilsker MS, Myerburg RJ, et al.
- Congestive heart failure: echocardiographic insights. Am J Med 1983;75:750-5.
View this and related citations using
- Falk RH.
- A plea for a clinical trial of anticoagulation in dilated cardiomyopathy [editorial]. Am J Cardiol 1990;65:14-5.
View this and related
citations using
- Fleg JL, Hinton PC, Lakatta EG, et al.
- Physician utilization of laboratory procedures to monitor outpatients with congestive heart failure. Arch Intern Med 1989;149:393-6.
View
this and related citations using
- Ghali JK, Kadakia S, Cooper R, et al.
- Precipitating factors leading to decompensation of heart failure. Traits among urban blacks. Arch Intern Med 1988;148:2013-6.
View this
and related citations using
- Ghali JK, Kadakia S, Cooper RS, et al.
- Bedside diagnosis of preserved versus impaired left-ventricular systolic function in heart failure. Am J Cardiol 1991;67:1002-6.
View
this and related citations using
- Hannan EL, Kilburn H Jr, O'Donnell JF, et al.
- Adult open heart surgery in New York State. An analysis of risk factors and hospital mortality rates. JAMA 1990 Dec 5;264:2768-74.
View
this and related citations using
- Hartzler GO, Rutherford BD, McConahay DR, et al.
- "High-risk" percutaneous transluminal coronary angioplasty.Am J Cardiol1988;61:33G-37G.
View this and related citations using
- Jaeschke R, Oxman AD, Guyatt GH.
- To what extent do congestive heart failure patients in sinus rhythm benefit from digoxin therapy? A systematic overview and meta-analysis. Am J
Med 1990;88:279-86.
View this and related citations using
- Kannel WB.
- Epidemiological aspects of heart failure. Cardiol Clin 1989;7:1-9.
View this and related citations using
- Kotler TS, Diamond GA.
- Exercise thallium-201 scintigraphy in the diagnosis and prognosis of coronary artery disease. Ann Intern Med 1990;113:684-702.
View this
and related citations using
- Küpper AJ, Fintelman H, Huige MC, et al.
- Cross-over comparison of the fixed combination of hydrochlorothiazide and triamterene and the free combination of furosemide and triamterene in the
maintenance treatment of congestive heart failure. Eur J Clin Pharmacol 1986;30:341-3.
View this and related citations using
- Marantz PR, Tobin JN, Wassertheil-Smoller S, et al.
- The relationship between left-ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation 1988;77:607-12.
View
this and related citations using
- Mattleman SJ, Hakki A, Iskandrian AS, et al.
- Reliability of bedside evaluation in determining left-ventricular ejection fraction determined by radionuclide ventriculography. J Am Coll Cardiol
1983;1:417-20.
View this and related citations using
- Molgaard H, Kristensen BO, Baandrup U.
- Importance of abstention from alcohol in alcoholic heart disease. Int J Cardiol 1990;26:373-5.
View this and related citations using
- On bedresting in heart failure [editorial].
- Lancet 1990 Oct;336(8721):975-6.
View this and related citations using
- Perlman LV, Isenberg E, Donovan I, et al.
- Public health nurses and the prevention of recurrences of congestive heart failure. Geriatrics 1969;24:82-9.
View this and related
citations using
- Pfeffer MA, Braunwald E, Moyé LA, et al.
- Effect of captopril on mortality and morbidity in patients with left-ventricular dysfunction after myocardial infarction: results of the survival and
ventricular enlargement trial. N Engl J Med 1992;327:669-77.
View this and related citations using
- SOLVD Investigators.
- Effect of enalapril on survival in patients with reduced left-ventricular ejection fractions and congestive heart failure. N Engl J Med
1991;325:293-302.
- SOLVD Investigators.
- Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left-ventricular ejection fractions. N
Engl J Med 1992;327:10;685-91.
- Vinson JM, Rich MW, Sperry JC, et al.
- Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc 1990;38:1290-5.
View this and related citations
using
More than 2 million Americans have heart failure, and about 400,000 new cases are diagnosed each year. Mortality is high, with 5-year mortality in the
range of 50 percent. Many of the almost 1 million hospitalizations each year for heart failure might be prevented by improved evaluation and care.
This
Quick Reference Guide for Clinicians summarizes major recommendations in Heart Failure: Evaluation and Care of Patients with Left-Ventricular
Systolic Dysfunction. Clinical Practice Guideline No. 11. The document was prepared by RAND, a nonprofit research and policy organization, and a
private-sector panel of experts and consumers. Guideline recommendations are intended for use by a broad range of health care practitioners.
The
guideline recommendations are based on a combination of evidence obtained through extensive literature reviews and on expert judgment where evidence was
lacking. Specific recommendations are made in the following areas:
- Prevention of heart failure with asymptomatic left-ventricular systolic dysfunction.
- Approaches to diagnosis and initial evaluation of suspected heart failure.
- Hospital admission and discharge criteria.
- Pharmacological management.
- Patient counseling and education.
- Exercise and rehabilitation.
- Evaluation for myocardial revascularization.
- Patient monitoring and followup evaluation.
This document is in the public domain and may be used and reprinted without special permission. AHCPR appreciates citation as to source, and the
suggested format is provided below:
Konstam M, Dracup K, Baker D, et al. Heart Failure: Management of Patients With Left-Ventricular Systolic
Dysfunction. Quick Reference Guide for Clinicians No. 11. AHCPR Publication No. 94-0613. Rockville, MD: Agency for Health Care Policy and Research,
Public Health Service, U.S. Department of Health and Human Services. June 1994.
| Test Recommendation |
Finding |
Suspected Diagnosis |
| Electrocardiogram |
Acute ST-T wave changes Atrial fibrillation, other tachyarrhythmia |
Myocardial ischemia Thyroid disease or heart failure due to rapid ventricular rate |
| |
Bradyarrhythmias |
Heart failure due to low heart rate |
| |
Previous MI (e.g., Q waves) |
Heart failure due to reduced left-ventricular performance |
| |
Low voltage |
Pericardial effusion |
| |
Left-ventricular hypertrophy |
Diastolic dysfunction |
| Complete blood count |
Anemia |
Heart failure due to or aggravated by decreased oxygen-carrying capacity |
| Urinalysis |
Proteinuria |
Nephrotic syndrome |
| |
Red blood cells or cellular casts |
Glomerulonephritis |
| Serum creatinine |
Elevated |
Volume overload due to renal failure |
| Serum albumin |
Decreased |
Increased extravascular volume due to hypoalbuminemia |
| T4 and TSH (obtain only if atrial fibrillation, evidence of thyroid disease, or patient age >65) |
Abnormal T4 or TSH |
Heart failure due to or aggravated by hypo/hyperthyroidism |
Note: TSH = Thyroid-stimulating hormone, MI = myocardial infraction.
| Test |
Advantages |
Disadvantages |
| Echocardiogram |
Permits concomitant assessment of valvular disease, left-ventricular hypertrophy, and left-atrial size Less expensive than radionuclide
ventriculography in most areas Able to detect pericardial effusion and ventricular thrombus More generally available |
Difficult to perform in patients with lung disease Usually only semi-quantitative estimate of ejection fraction provided Technically
inadequate in up to 18% of patients under optimal circumstances |
| Radionuclide ventriculogram |
More precise and reliable measurement of EF Better assessment of right-ventricular function |
Requires venipuncture and radiation exposure Limited assessment of valvular heart disease and left-ventricular hypertrophy |
General Counseling
- Explanation of heart failure and the reason for symptoms
- Cause or probable cause of heart failure
- Expected symptoms
- Symptoms of worsening heart failure
- What to do if symptoms worsen
- Self-monitoring with daily weights
- Explanation of treatment/care plan
- Clarification of patient's responsibilities
- Importance of cessation of tobacco use
- Role of family members or other caregivers in the treatment/care plan
- Availability and value of qualified local support group
- Importance of obtaining vaccinations against influenza and pneumococcal disease
|
Prognosis
- Life expectancy
- Advance directives
- Advice for family members in the event of sudden death
|
Activity Recommendations
- Recreation, leisure, and work activity
- Exercise
- Sex, sexual difficulties, and coping strategies
|
Dietary Recommendations
- Sodium restriction
- Avoidance of excessive fluid intake
- Fluid restriction (if required)
- Alcohol restriction
|
Medications
- Effects of medications on quality of life and survival
- Dosing
- Likely side effects and what to do if they occur
- Coping mechanisms for complicated medical regimens
- Availability of lower cost medications or financial assistance
|
| Importance of Compliance With the Treatment/Care Plan |
| Drug |
Initial Dose (mg) |
Target Dose (mg) |
Recommended Maximal Dose (mg) |
Major Adverse Reactions |
| Thiazide Diuretics |
| Hydrochlorothiazide |
25 QD |
As needed |
50 QD |
Postural hypotension, hypokalemia, hyperglycemia, hyperuricemia, rash. Rare severe reaction includes pancreatitis, bone marrow
suppression, and anaphylaxis. |
| Chlorthalidone |
25 QD |
As needed |
50 QD |
|
| Loop Diuretics |
| Furosemide |
10-40 QD |
As needed |
240 BID |
Same as thiazide diuretics. |
| Bumetanide |
0.5- 1.0 QD |
As needed |
10 QD |
|
| Ethacrynic acid |
50 QD |
As needed |
200 BID |
|
| Thiazide-Related Diuretic |
| Metalazone |
2.5[a] |
As needed |
10 QD |
Same as thiazide diuretics. |
| Potassium-Sparing Diuretics |
| Spironolactone |
25 QD |
As needed |
100 BID |
Hyperkalemia, especially if administered with ACE inhibitor; rash; gynecomastia (spironolactone only). |
| Triamterene |
50 QD |
As needed |
100 BID |
|
| Amiloride |
5 QD |
As needed |
40 QD |
|
| ACE Inhibitors |
| Enalapril |
2.5 BID |
10 BID |
20 BID |
Hypotension, hyperkalemia, renal insufficiency, cough, skin rash, angioedema, neutropenia. |
| Captopril |
6.25-12.5 TID |
50 TID |
100 TID |
|
| Lisinopril |
5 QD |
20 QD |
40 QD |
|
| Quinapril |
5 BID |
20 BID |
20 BID |
|
| Digoxin |
See pages 58-60 |
See pages 58-60 |
See pages 58-60 |
Cardiotoxicity, confusion, nausea, anorexia, visual disturbances. |
| Hydralazine |
10-25 TID |
75 TID |
100 TID |
Headache, nausea, dizziness, tachycardia, lupus-like syndrome. |
| Isosorbide Dinitrate |
10 TID |
40 TID |
80 TID |
Headache, hypotension, flushing. |
[a] Given as a single test dose initially.
Note:
ACE = angiotensin-converting enzyme,
BID = twice a day, QD = once a day,
TID = three times
a day.
[Figures]
Click On The
Picture for a full sized view of the Algorithm
LV = left-ventricular, MI = myocardial infarction.
***** This Line Follows Each Range of Selected Text *****
 
|
