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Home | Articles | Cardiac | Heart Failure

Heart Failure

Last updated 10th January 2024


  1. All patients admitted with symptoms of suspected heart failure should have a Heart Failure Care Bundle completed.
  2. and be referred to Heart Failure Nurse Service on 01387 244312 following cardiology review if proven evidence of LVSD


  1. Symptoms include breathlessness, fatigue, ankle swelling, also orthopnoea and PND
  2. Signs include oedema, basal creps and tachycardia, also third heart sound and displaced apex

Assess Breathlessness by NYHA Class

  1. Grade 1= have had HF, currently asymptomatic
  2. Grade 2= SOB on incline
  3. Grade 3= SOB on level or while washing & dressing
  4. Grade 4= SOB at rest

Causes and Triggers of Heart Failure

  1. Commonest cause in UK is CHD
  2. Valvular – note murmur of aortic stenosis may be soft in presence of LVSD
  3. Hypertension – suspect bilateral renovascular disease if creatinine increases with ACEI
  4. Alcohol abuse – important cause of dilated cardiomyopathy
  5. Triggers are often more rewarding to treat than causes

NB: Not All Breathlessness is Due to Heart Failure

  1. Other causes of acute breathlessness – exacerbation COAD or asthma, pneumonia, pneumothorax, PE
  2. Other causes of chronic breathlessness – COAD, asthma, pulmonary fibrosis, pleural effusion, bronchial carcinoma

Investigation of Suspected Heart Failure in Hospital

  1. FBC, U&E,BG, LFT, TFT, TnT (if acute), ECG & CXR
  2. LV Systolic dysfunction is rare with completely normal ECG
  3. NT ProBNP – see below.
  4. Echocardiogram – see below.

Role of NT ProBNP

  1. Request on admission unless already done in primary care or already known to the heart failure service.
  2. NT-proBNP >2000 pg/ml: highly likely that HF is cause of breathlessness. Needs urgent referral to cardiology.  Request Echo.
  3. NT-proBNP 400-2000 pg/ml: raised but not diagnostic for HF.  Request Echo.
  4. NT-proBNP <400 pg/ml in the absence of heart failure therapy means heart failure is an unlikely cause for the breathlessness. Echo not required.

Role of Echocardiography

  1. All patients with suspected HF should have transthoracic echoideally within 48 hours of admission
  2. Echo will elucidate the cause of HF – around 50% will have LV systolic dysfunction or HF with reduced EF (HF-rEF) and a similar proportion will have preserved LV systolic function (previously known as diastolic heart failure, currently known as HF with preserved EF or HF-pEF)
  3. LVEDd ≥5.5cm suggests LV dilatation; IVSd ≥1.2cm suggests LV hypertrophy; EF <40% suggests HF-rEF.

Treatment of Aute Pulmonary Oedema

  1. Morphine 5-10mg IV (Rx 2.5mg if COPD with CO2 retention) plus Maxolon 10mg IV
  2. Frusemide 40-80mg IV
  3. Sit upright
  4. 60 – 100% oxygen to maintain SpO2 >94%
  5. Consider IV nitrate 1-10mg/hr if not settling.
  6. Consider CPAP
  7. Thromboprophylaxis with Clexane 40mg sc od

Treatment of Chronic Heart Failure Due to LVSD

  1. Most patients will be given ramipril or lisinopril with diuretic unless contraindicated
  2. Rx candesartan if ACEI intolerant.
  3. Add bisoprolol or carvedilol once signs of HF have resolved.
  4. Starting dose bisoprolol is1.25mg od for one week increasing to 2.5mg od, 3.75mg od then 5mg od at weekly intervals.
  5. Starting dose for carvedilol is 3.125mg bd for two weeks increasing to 6.25 mg bd; then 12.5mg bd; then 25mg bd if tolerated.
  6. Nebivolol is alternative – same dosing schedule as for bisoprolol.
  7. Add spironolactone 25mg od-bd in NYHA 3 or 4
  8. Rx eplerenone 25mg od if post MI (and started within first 2 weeks of MI) or if gynaecomastia with Spironolactone
  9. Consider Sacubitril/Valsartan (Angiotensin receptor blocker/neprolysin inhibitor or ARNI) if symptoms persist once fully optimised to maximum tolerated ACEI/ARB/Beta-blocker/Spironolactone – click here for flowchart
  10. Consider dapagliflozin if symptoms persist once fully optimised to maximum tolerated ACEI/ARB/Beta-blocker/Spironolactone/ARNI – click here for flowchart
  11. Remember to fluid restrict, usually 1200-1500ml/day
  12. Advise on smoking, diet, alcohol & exercise
  13. Refer to HF nurses if LVSD confirmed
  14. May require additional cardiac investigations to determine underlying cause

Treatment of Angina and Heart Failure

  1. Treat heart failure first
  2. Then give carvedilol or bisoprolol as above
  3. Then Rx oral nitrate using asymmetric bd dose eg isosorbide mononitrate 20mg bd at 0800 & 1400hrs, or Amlodipine 5-10mg od
  4. All patients should be on aspirin, and on statin if appropriate but avoid diltiazem & verapamil

How to Introduce ACE Inhibitors

  1. Seek Consultant advice if SBP<100, Frusemide ≥80mg od, Na <130mmol/l, urea >12mmol/l, creatinine >170micromol/L
  2. Stop K supps, K sparing diuretics and, if possible, NSAIDs
  3. Start with low dose ACEI e.g. ramipril 2.5mg od, enalapril 2.5mg bd. lisinopril 2.5mg od
  4. Titrate to optimal dose at fortnightly intervals, aiming for ramipril 10mg od, enalapril 10mg bd. lisinopril 40mg od
  5. Check U&E at 1 week and 1 month after every dose change, more often if clinically indicated
  6. Use Frusemide up to 80mg bd for oedema if normal renal function; up to 160mg bd may be necessary in CRF. ‘Right’ dose is lowest possible to avoid fluid retention
  7. Commonest side effect of ACEI is cough, in which case consider switch to angiotensin receptor blocker.

Non Pharmacological Treatment of Heart Failure

One or more of the following may have a role to play in selected patients with heart failure – the heart Failure team will advise:

  1. Coronary revascularisation
  2. Heart transplantation
  3. LV Assist Device (LVAD)
  4. Cardiac Resynchronisation Therapy (CRT)
  5. Implantable Cardiac Defibrillator (ICD)
  6. Exercise training

Palliative Care

  1. In Scotland, heart failure is associated with one of the poorest five year survival rates, approximately 25% for both sexes.
  2. A palliative care approach, with focus on symptom relief and the discontinuation of nonessential treatments should be considered by all clinicians managing patients with chronic heart failure in the later stages of the disease.
  3. See Hippo for advice on when and how to deactivate implanted cardiac defibrillators


Content by Sue Bryant & Chris Isles