1. Cardiac echo should be obtained in all patients with heart failure to differentiate between systolic and diastolic dysfunction.
2.  Standard Therapy should be started first for all patients with LV systolic dysfunction (EF < 40%).
   1. ACE inhibitors should be used in all patients (even if asymptomatic) unless contraindicated.
      • The dosage should be equivalent to Enalapril 10 mg. BID or Captopril 50 mg. TID.
      • Patients who are truly intolerant to ACE inhibitors should be considered for treatment with an Angiotensin Receptor Blocker.
   2. Diuretics should be used as needed to control fluid retention.
   3. Digoxin should be considered for patients who have symptoms of heart failure caused by LV dysfuntion while on ACE inhibitors and diuretics.
3. B-blocker therapy should be routinely administered to clinically stable patients with LV dysfunction and heart failure symptoms on standard therapy.
   • B-blocker therapy should also be strongly considered for patients who are asymptomatic on standard therapy.
   • B-blocker therapy should be initiated at low doses and up-titrated slowly to the target dose, generally no sooner than at two week intervals.
4. Spironolactone, at a dose of 12.5 mg. to 25 mg. daily, should be considered for patients who are symptomatic on standard therapy.
   • Patients treated in this manner should have a potassium < 5.0 and creatinine < 2.5. 
   • To prevent hyperkalemia, potassium should be monitored after the first week and at regular intervals thereafter.
5.  Lab monitoring with sodium, potassium, magnesium, BUN and creatinine should be done every 3 months until clinical stability is demonstrated at which time a longer interval is acceptable.
   • potassium should be maintained at 4.0 or greater.
6.  NSAID use can cause sodium retention and should be avoided as much as possible in heart failure patients.  Aspirin in a dose of 325 mg. a day or less is acceptable.
7. Weight should be measured daily (first morning weight after urinating and before eating).  Generally weight gain of greater than 2 pounds in one day or 5 pounds in one week requires intervention.  The Mercy CHF Tel-Assurance program can be utilized by calling 643-2775.
8.  Follow up with the physician, CHF case manager, or home health nurse should be arranged within 1 week after discharge for all hospitalized heart failure patients to ensure stability, compliance and educational needs.

References:

1. Heart Center Society of America Guidelines for the Management of Patients With Heart Failure Due to LV Systolic Dysfunction – Pharmacological Approaches.  Jan. 2000   (available at www.hfsa.org)
2. Heart Failure: Evaluation and Care of Patients with Left Ventricular Systolic Dysfunction.  Clinical Practice Guideline No. 11.  June 1994  (available at www.ahcpr.gov)

Variation from this guideline is always acceptable, if in the opinion of the attending physician, individual circumstances require it.