Special Article
The Canadian Cardiovascular Society Heart Failure Companion: Bridging Guidelines to Your Practice

https://doi.org/10.1016/j.cjca.2015.06.019Get rights and content

Abstract

The Canadian Cardiovascular Society Heart Failure (HF) Guidelines Program has generated annual HF updates, including formal recommendations and supporting Practical Tips since 2006. Many clinicians indicate they routinely use the Canadian Cardiovascular Society HF Guidelines in their daily practice. However, many questions surrounding the actual implementation of the Guidelines into their daily practice remain. A consensus-based approach was used, including feedback from the Primary and Secondary HF Panels. This companion is intended to answer several key questions brought forth by HF practitioners such as appropriate timelines for initial assessments and subsequent reassessments of patients, the order in which medications should be added, how newer medications should be included in treatment algorithms, and when left ventricular function should be reassessed. A new treatment algorithm for HF with reduced ejection fraction is included. Several other practical issues are addressed such as an approach to management of hyperkalemia/hypokalemia, treatment of gout, when medications can be stopped, and whether a target blood pressure or heart rate is suggested. Finally, elements and teaching of self-care are described. This tool will hopefully function to allow better integration of the HF Guidelines into clinical practice.

Résumé

Le programme des lignes directrices de la Société canadienne de cardiologie en matière d’insuffisance cardiaque (IC) a généré des mises à jour annuelles sur l’IC, y compris des recommandations formelles et des conseils pratiques depuis 2006. De nombreux cliniciens indiquent qu'ils utilisent régulièrement les lignes directrices de la Société canadienne de cardiologie en matière d’IC dans leur pratique quotidienne. Cependant, de nombreuses questions entourant la mise en œuvre effective de ces lignes directrices dans leur pratique quotidienne demeurent. Une approche fondée sur le consensus a été utilisée, y compris les rétroactions des Panels d’IC primaire et secondaire. Ce vade-mecum est destiné à répondre à plusieurs questions clés élaborées par les praticiens spécialistes de l’IC tels que les délais appropriés pour les évaluations initiales des patients et les réévaluations subséquentes, l'ordre dans lequel les médicaments doivent être ajoutés, comment les nouveaux médicaments devraient être inclus dans les algorithmes de traitement, et quand la fonction ventriculaire gauche doit de nouveau être évaluée. Un nouvel algorithme de traitement de l'IC avec une fraction d'éjection réduite est inclus. Plusieurs autres questions pratiques sont abordées telles une approche de gestion de l'hyperkaliémie hypokaliémie, le traitement de la goutte, le moment où les médicaments peuvent être arrêtés, et si une cible de pression artérielle ou d’un rythme cardiaque est suggérée. Enfin, un enseignement et des éléments de l’autosoins sont décrits. Cet outil devrait permettre une meilleure intégration des lignes directrices en matière d’IC dans la pratique clinique.

Section snippets

Who Is This Document Primarily Intended to Reach? What Is the Format?

This document addresses the most commonly asked practical questions that arise from those (in primary and secondary care) who use these HF Guidelines and is written with the main HF care provider in mind. Many of the suggestions and comments made in this article might also be of interest to those who treat a large volume of HF patients or who practice in a HF clinic setting. We have adopted a question and answer approach to the structure of this document and have indicated where published

How Soon Should I See a Newly Referred HF Patient?

Table 1 shows situational wait time benchmarks for HF referrals to a specialist.15 More than 86% of survey respondents agreed that routine referrals should be seen within 4 weeks and 16% suggested this ideally be < 14 days.14

How Often Should My HF Patient Be Seen?

There are few published data regarding the optimal frequency of outpatient visits for patients with HF. Most clinical trials that involved stable HF patients scheduled visits every 3-4 months, with the assumption that primary and specialist care was in place. Patients who are not stable or are in the process of medical optimization should be seen more frequently. Table 2 shows the time frames for which > 70% of our respondents believe patients should be seen for HF care (by whomever provides

Who Can I Discharge From My HF Clinic?

Panelists were split on this issue, with nearly 30% questioning whether those in the low-risk category required ongoing follow-up in HF clinics.14 However, all agreed that they should not be discharged without establishment of coordinated follow-up involving primary and specialist care. Many of our panelists also believe that stable patients could be followed in satellite clinics attended by a combination of nurses and experienced internists or family doctors. All of our respondents listed a

How Quickly and in What Order Should Standard HF Therapy Be Titrated for Most Patients?

Standard treatment of HF due to LV systolic dysfunction (LVEF < 40%) now consists of triple therapy with an angiotensin-converting enzyme inhibitor (ACEi) (or an angiotensin receptor blocker [ARB] if ACEi not tolerated), β-blockers and, mineralocorticoid receptor antagonists (MRA).8 However, many practitioners prefer specific aids, which might be used to help perform the mechanics of titration. The CCS has developed online aids for the titration of these medications that may be used by the

A Note on New Therapies

The astute reader will note 2 new medications in the updated Figure 2. Ivabradine and LCZ696 have been noted in previous HF Updates and are recommended for eligible patients. These medications should both be considered only after standard triple therapy has been completed. The optimal order of use for these medications is not known, however, the careful clinician can consider the following issues: (1) ivabradine is generally limited by HR, can be titrated over 2-4 weeks, and is generally well

Helpful Links for the Practitioner

The CCS HF Medication Titration app (Med-HF) and HF Guidelines app (iCCS) are available at: http://www.ccs.ca/index.php/en/resources/mobile-apps.19 These apps contain a detailed algorithm that can be used for all aspects of titration of evidence-based medications for HF including ACEi, ARB, MRA, and β-blockers. The iCCS Guidelines app can be used for inquiry into any part of the Guidelines updates. In addition, an online tool, the HF Guidelines Compendium, can be used to look up any subject

When Should I Measure Electrolytes, Serum Creatinine, and BUN?

In many HF clinics serum electrolytes, creatinine, and BUN are routinely measured every 1-3 months in stable patients. Otherwise, our panelists suggest they also be measured in the following settings:

  • •

    For patients with advanced symptoms, measure with each visit (or televisit).

  • •

    Within 5-7 days of any intensification/addition of diuretic therapy.

  • •

    Within 7-10 days of and initiation or change in ACEi, ARB, MRA, or nonsteroidal anti-inflammatory drug (NSAID) therapy. This can be shortened to 3-5 days

How Should I Manage Hyper- or Hypokalemia in My Patients?

Changes in diet, fluid balance, diuretic therapy, and drugs that affect renal function (ACEi, ARB, MRA) might affect serum potassium. For this reason, it is always important that the patient understands to avoid or encourage potassium intake in their diet, depending on their own potassium status. Hyperkalemia and hypokalemia are both commonly seen during the management of patients with HF. The former is most commonly seen in patients who receive > 1 ACEi, ARB, or MRA medication, or have

Should I Treat My HF Patients to a Specific HR or BP?

Current HF Guidelines are based on the concept that we use targets to identify when to initiate therapy. When an evidence-based therapy is initiated, it is titrated until the target dose is reached or intolerance occurs. However, a few comments can be made.

I Know I Should Get a Baseline Measure of LVEF, but Should I Measure It Again? If So, When Should It Be Measured?

It has been shown that LVEF might change substantially over time.35, 36 Indeed, approximately 25% of patients with initial LVEF < 40% (HF with reduced LVEF) might gain an increase to > 40%. These patients have an excellent prognosis. Conversely, 25% of patients with initial LVEF > 40% (HF with preserved EF [HFpEF]) might experience a decrease in LVEF < 40%.36, 37 Finally, in patients with initially low LVEF, it is necessary to document the response of EF to triple therapy to assess eligibility

What About Measurement of BNP or NT-proBNP?

Natriuretic peptides (NPs) are increasingly a part of the management of HF. In 2015, the CCS recommended the use of NPs in several clinical scenarios.9 It is important to recognize that access to NP is variable across Canada, and so use will vary from region to region and according to indication. The following clinical scenarios for which BNP will commonly be measured are noted in the following list of scenarios. Scenarios 1-3 are more strongly advocated in the Guidelines.

  • (1)

    All patients on

Can HF Medications Ever Be Stopped? If So, Then When?

Guideline-directed medical therapy (GDMT) for patients with HF and reduced EF (< 40%) has dramatically changed the long-term natural history of the disease.8 These drugs include ACEi inhibitors, ARB, MRA, and β-blockers. In an African American subset of moderately severe HF patients, the combination of nitrates and/or hydralazine is also disease-modifying. In contrast to these drugs, several other agents such as loop diuretics, thiazide diuretics, nitrates (alone), digoxin, and other drugs have

What About HFpEF?

Unfortunately, we still do not have proof that any specific medication will prolong life in patients with HFpEF.9 However, evidence is increasing that we can reduce symptoms and improve quality of life in this condition, and recent studies suggest that MRA might be useful in those with increased NP level.9 As mentioned in previous updates, our suggestions for treating HFpEF remain:

  • (1)

    The same recommendations for initial referral, repeat assessment, and measurement of LVEF and NP are identical

How Should I Manage an Acute Episode of Gout?

Gout is a common complication of loop diuretic therapy, and frequently occurs during HF decompensation. NSAID agents should be avoided as shown in Table 6.

Is My Patient a Candidate for Heart Surgery?

Surgical coronary revascularization, mitral (or even tricuspid) valve repair, and (in carefully selected cases) LV aneurysm resection might have a profound effect on mortality, symptoms, and subsequent hospitalization.4, 44, 45 As such, patients with HF should always be assessed for conditions amenable to surgical therapy. This action is typically performed on initial diagnosis of HF, but should always be a consideration after any major change in the clinical HF syndrome (especially if there is

In What Ways Do I Care Differently for Frail Older Patients With HF?

Although the CCS HF Guidelines endorse that most of the recommendations for management of HF also apply to seniors, their successful implementation requires careful consideration of concurrent geriatric syndromes as stated in the 2006 HF update.2 Frailty is commonly understood as a state of increased vulnerability that generally occurs among older persons, and arises from the presence of multiple deficits across multiple systems.46

How Can Complaints of Urinary Frequency and Incontinence Be Addressed in Older HF Patients?

Urinary frequency, nocturia, and incontinence are common among older persons and are often attributed to the use of diuretics. This might affect patient adherence. However, urinary frequency or nocturia might occur because of increased intravascular volume from suboptimal HF control, nocturnal mobilization of peripheral edema in the recumbent position, and sleep apnea.47

A focused clinical history will help identify potential HF-related precipitants of urinary complaints:

  • •

    Ask about urinary

Why Are My Older HF Patients Continuously Readmitted Despite My Best Efforts?

Elderly patients with HF are more likely to suffer additional comorbid conditions in addition to HF.48, 49 Repeat hospitalization, approximately 50% of which is because of noncardiac causes, is thus more likely to occur in this group of patients.48, 50 In addition to a properly executed hospital discharge, extra care should be taken to identify potential causes of readmission, which if found, can be addressed directly or with prompt specialist referral47, 51:

  • •

    Screening for cognitive impairment

How Do I Teach Self-Care to My Patients?

Self-care in HF is often described in the context of behaviours necessary to maintain or promote health and lifestyle changes and manage the symptoms and effects of living with HF.57, 58 The basic elements of self-care are shown in Table 7.

Topics relevant to self-care in HF are well documented.58, 59 Although patient education is necessary, simply providing patients with the standardized information is insufficient for optimization of self-care.60, 61 The key points for optimization of

Conclusions

Guidelines form the basis for the provision of high-quality care for patients with HF, and underpin the development of best practices and the assessment of quality of care. The CCS has published comprehensive HF Guidelines and annual updates for the past 10 years. This Guidelines Companion has been developed in response to key practical questions that are unlikely to be answered by randomized controlled clinical trials. For the first time, we articulate answers to how soon and how often

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