Heart Failure - Diagnosis and Management

Effective Date: July 26, 2023

Recommendations and Topics

• Scope
• Key Recommendations
• Definition
• Epidemiology
• Diagnosis
• Management
• Reassessment and Follow-up
• Indications for Referral
• Palliative Care and End of Life Care
• Resources

This guideline provides recommendations for the diagnosis and management of people aged ≥ 19 years with suspected or confirmed heart failure in the ambulatory primary care setting. Given that heart failure is associated with reduced life expectancy, advanced care planning and palliative care are also addressed.

For specific guidance on heart failure in acute care settings refer to the Canadian Cardiovascular Society Heart Failure guidelines.

• Echocardiogram (ECHO) is the gold standard for assessing structural and/or functional cardiac abnormalities and determining ejection fraction to guide treatment planning.
• BNP and NT-proBNP tests have a high sensitivity for the detection of heart failure (HF) and can help with diagnosis while waiting for echocardiogram.
• There are cornerstone therapies that improve clinical outcomes (e.g., reduced hospitalizations, and mortality, improved quality of life) in patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) necessitating their rapid implementation in eligible patients.
• NEW: It is recommended that in the absence of contraindications, patients with HFrEF be treated with combination therapy including one medication from each of the following categories: Angiotensin receptor-neprilysin inhibitors (ARNI) [or Angiotensin-converting enzyme inhibitors (ACEI)/Angiotensin receptor blockers (ARB)]; beta-blockers (β-blockers); Mineralocorticoid receptor antagonists (MRA); and Sodium-glucose cotransporter-2 inhibitors (SGLT2i). These four medications should be initiated and titrated in parallel as quickly as possible.
• Patient and caregiver education about the importance of self-monitoring and early identification of disease decompensation is crucial to avoid hospitalization and to inform acute treatment.
• Consider referral to a heart function clinic or a multi-disciplinary chronic disease management clinic, where available.
• Initiate advance care planning discussions early in the disease course.
• Incorporate a palliative approach as the disease progresses and/or as per patient preference.

The new universal definition of heart failure (HF):

• Signs and/or symptoms caused by a structural and/or functional cardiac abnormality based on ECHO findings AND
• Elevated natriuretic peptide levels (BNP or NT-proBNP*) OR objective evidence of cardiogenic, pulmonary or systemic congestion.¹

^{* B -Type natriuretic peptide or N‐terminal pro B‐type natriuretic peptide prohormone of BNP}

Diagnosis begins with a suspicion of HF based on clinical history (risk factors, symptoms) and physical examination, and is then confirmed with natriuretic peptide testing and ECHO.^2,3 See Figure 1: Diagnosis of Heart Failure.

Edema, fatigue, and dyspnea are typical but not specific symptoms of HF; atypical presentations may need to be considered, particularly for women, elderly and obese patients.^4,5

Initial investigations should be targeted to confirm or exclude HF, and to identify systemic disorders that might affect its development or progression (e.g., thyroid dysfunction).

Echocardiography

ECHO should be performed in all patients with suspected HF to assess cardiac structure, quantify systolic and diastolic function, and to facilitate treatment planning and prognostication. There is regional variation in timely access to ECHO in BC. Delays in obtaining ECHO should not delay initiation of treatment in cases where HF is likely.

Though not a replacement for ECHO, an estimate of left ventricular function may be obtained through alternate imaging modalities:

• Thallium and Sestamibi (MIBI) scan – especially in those patients where ischemia may be the underlying etiology.
• Multi Gated Acquisition Scan (MUGA) or radionuclide angiography – especially for patients with chronic obstructive pulmonary disease or obesity, which may affect ECHO image quality.

Ejection Fraction

Left ventricular ejection fraction (LVEF) is the primary measure of left ventricular systolic function. Normal LVEF is approximately 60%. Management of HF is based upon LVEF.

^{*Adapted from Bozkurt B et al. Eur J Heart Fail. 2021;23:352}

New York Heart Association (NYHA) Functional Classifications

Determine NYHA functional classification in order to guide therapy and determine prognosis.

Management

Heart Failure with Reduced Ejection Fraction (LVEF ≤ 40%)

• Patients with HFrEF should be treated early with a combination of four medications, one from each of the following classes: angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker (β-blocker), MRA, and SGLT2 inhibitor (SLGTi). This GDMT/quadruple therapy has been shown to have substantial and sustained reductions in mortality, HF hospitalizations, and symptom burden, even at low doses.^5,10–17
• It is preferable to titrate medication doses simultaneously and as quickly as possible (“in-parallel” approach), rather than titrating one medication before initiating an additional agent (“strict sequential” approach).¹⁸
• The principles behind treatment are to: treat early, use combination of all four medications, up titrate rapidly, and aim for target dose of each medication.
• Consider IV iron therapy for patients with HFrEF who meet all of the following criteria: ejection fraction ≤ 40%, serum ferritin < 100 μg/L or between 100-299 μg/L, and TSAT < 20%.¹⁸
• See Appendix C: Commonly Used Drugs for in Heart Failure Care for dosages, Pharmacare coverage and therapeutic considerations for drug classes used in the management of patients with HF. The appendix also includes titration and renal function considerations. Consider consultation with your local specialist or a RACE line clinician when further guidance is needed.

Heart Failure with Mildly Reduced Ejection Fraction (EF 41-49%) and Heart Failure with Preserved Ejection Fraction (EF ≥ 50%)

• To improve symptoms:
  • Use minimal effective diuretic dose to achieve and maintain euvolemia.
• To improve outcomes:
  • Initiate an SGLT2i (e.g., empagliflozin and dapagliflozin). SGLT2i therapy reduces hospitalizations as well as all- cause and cardiovascular mortality across age, sex, race, HF and EF classification.^5,19,20
  • Consider MRA (in all eligible patients) to reduce HF hospitalization.²¹
  • In select patients, consider initiating an angiotensin receptor-neprilysin inhibitor (ARNI). In large randomized clinical trials, patients with HFmrEF had fewer hospitalizations when treated with an ARNI compared to an Angiotensin Converting Enzyme Inhibitors (ACEI).

Reassessment and Follow-up

• For all patients, regardless of their EF status, periodic assessment of renal function and potassium is recommended. Renal function and electrolytes should be checked with each adjustment of diuretic, MRA, and/or ACEI/ARB/ARNI dose.
• For patients with HFrEF, EF should be reassessed after maximally tolerated GDMT has been achieved, and before deciding on further treatment options.
• Once clinically optimized, routine surveillance with ECHO is not indicated unless the patient’s clinical status changes. A follow-up ECHO may be warranted in 3-5 years.

Clinical follow-up frequency recommendations:

1-4 weeks or as clinically indicated:

• Those classified with NYHA III or IV symptoms, recent HF hospitalization, during titration of HF medications, new onset heart failure, complications of HF therapy (e.g., rising creatinine, hypotension), needing to down-titrate
• or discontinue ß-blockers or ACEI/ARB, severe concomitant and active illness (e.g., COPD, frailty), frequent implantable cardioverter defibrillator (ICD) firings.

1-6 Months:

• Those with no clear features of high or low risk.

6-12 months:

• NYHA I or II.
• No hospitalizations in past year.
• No recent changes in medications, receiving optimal medical/device HF therapies.

Worsening HF:

• By the time a person reports worsening symptoms of fluid overload or has overt signs of fluid overload on clinical exam, they may have been progressing over days or even weeks. They should be addressed as soon as possible to avoid further decline, hospitalization or even death.
• Identify triggers and treat appropriately. Treat volume overload, optimize therapies and reinforce education.
• If a patient fails to improve, consider referral to a heart failure clinic and/or specialist, including RACE.

Indications for Referral 

Refer to a Cardiologist/Internist:

• Persistent symptoms or signs of HF despite attempts TO OPTIMIZE medical therapy.
• To aid in diagnosis and management of HF where valvular disease or coronary disease is a significant contributing factor.
• If a rare underlying etiology is suspected.
• For assistance with diagnosis or management, refer the patient to a heart function clinic or a multi-disciplinary chronic disease management clinic, if available.

Refer to a Heart Function Clinic, if available, for:

• Management after a recent admission or repeated admissions to hospital.
• Assessment of asymptomatic left ventricular dysfunction.
• Assistance with multidisciplinary HF care including education on lifestyle management skills.
• Consideration for procedural interventions including PCI, surgery, and implantable devices.
• See Cardiac Services BC for Heart Function Clinics in BC

Device Management:

• Decisions about device management (e.g., implantable cardioverter defibrillator [ICD], cardiac resynchronization therapy [CRT]) are complex and involve a cardiologist/internist/cardiac electrophysiologist/Heart Function Clinic.
• Appropriate ICD utilization is associated with improved mortality, but does not improve quality of life. By contrast, CRT is associated with improved mortality and quality of life (i.e., improved symptom status and functional capacity) in properly selected individuals.¹⁸

ICD may be considered in patients with one of the following:

• History of hemodynamically significant sustained ventricular arrhythmia;
• Ischemic cardiomyopathy and LVEF ≤ 35% (measured at least 1 month after acute myocardial infarction, or 3 months post coronary artery revascularization); or
• Non-ischemic cardiomyopathy and LVEF ≤ 35% (measured at least 9 months after optimal medical therapy).
• ICD should not be considered in patients with active NYHA Class IV symptoms.

CRT may be considered in patients with NYHA class II – IV symptoms despite maximally tolerated HF therapies, with a QRS duration ≥ 130 ms, and LVEF ≤ 35%.

Palliative Care and End of Life Care

Palliative care offers the potential to improve quality of life for cardiac patients with advanced disease. Unfortunately, many patients perceive palliative care in a negative context, equating it with hospice care. As a result, very few cardiac patients receive appropriate palliative care. For those who do, it typically occurs quite late in the disease trajectory, limiting the benefit. Do not delay advance care planning conversations or palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment.

A palliative care approach addresses management of pain, dyspnea, other symptoms, and prioritizes quality of life. This may include support for the patient’s family and caregivers.

Some resources include:

• Supportive Cardiology Tool – a clinician tool which focuses on delivery of care from the primary care perspective.
• What Really Matters Now, a comprehensive resource for patients with advanced heart failure.
• BCGuidelines.ca: Palliative Care for the Patient with Incurable Cancer or Advanced Disease.
• HealthLinKBC: Palliative Care and MOST forms

*Adapted from Slawnych, New Dimensions in Palliative Care Cardiology, CJC, 2018²²

Resources

References

1. Bozkurt B, Coats AJ, Tsutsui H, Abdelhamid M, Adamopoulos S, Albert N. Universal Definition and Classification of Heart Failure: A Report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. Journal of Cardiac Failure 2021 Apr. 1;27(4):387–413.
2. Roger VL. Epidemiology of Heart Failure. Circulation Research. 2021 May 14;128(10):1421–34.
3. Chamberlain AM, Boyd CM, Manemann SM, Dunlay SM, Gerber Y, Killian JM, et al. Risk Factors for Heart Failure in the Community: Differences by Age and Ejection Fraction. Am J Med. 2020 Jun;133(6):e237–48.
4. Ezekowitz JA, O’Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, et al. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Canadian Journal of Cardiology. 2017 Nov;33(11):1342–433.
5. 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure: Executive Summary - ScienceDirect [Internet]. [cited 2022 Jun 8]. Available from: https://www-sciencedirect-com.ezproxy.hlth.gov.bc.ca/science/article/abs/pii/S1071916422000756
6. Yu DSF, Li PWC, Li SX, Smith RD, Yue SCS, Yan BPY. Effectiveness and Cost-effectiveness of an Empowerment-Based Self-care Education Program on Health Outcomes Among Patients With Heart Failure: A Randomized Clinical Trial. JAMA Netw Open. 2022 Apr 1;5(4):e225982.
7. He Y, Ling Y, Guo W, Li Q, Yu S, Huang H, et al. Prevalence and Prognosis of HFimpEF Developed From Patients With Heart Failure With Reduced Ejection Fraction: Systematic Review and Meta-Analysis. Frontiers in Cardiovascular Medicine [Internet]. 2021 [cited 2023 Apr 18];8. Available from: https://www.frontiersin.org/articles/10.3389/fcvm.2021.757596
8. Halliday BP, Wassall R, Lota AS, Khalique Z, Gregson J, Newsome S, et al. Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial. The Lancet. 2019 Jan 5;393(10166):61–73.
9. Stolfo D, Sinagra G, Savarese G. Evidence-based Therapy in Older Patients with Heart Failure with Reduced Ejection Fraction. Card Fail Rev. 2022 Apr 28;8:e16/
10. Miller RJH, Howlett JG, Fine NM. A Novel Approach to Medical Management of Heart Failure With Reduced Ejection Fraction. Can J Cardiol. 2021 Apr;37(4):632–43.
11. Zannad F, Ferreira JP, Pocock SJ, Anker SD, Butler J, Filippatos G, et al. SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR-Reduced and DAPA-HF trials. The Lancet. 2020 Sep 19;396(10254):819–29.
12. Vaduganathan M, Claggett BL, Jhund PS, Cunningham JW, Pedro Ferreira J, Zannad F, et al. Estimating lifetime benefits of comprehensive disease-modifying pharmacological therapies in patients with heart failure with reduced ejection fraction: a comparative analysis of three randomised controlled trials. The Lancet. 2020 Jul 11;396(10244):121–8.
13. Sodium–Glucose Cotransporter-2 Inhibitors in Patients With Heart Failure: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 0, No 0 [Internet]. [cited 2022 May 20]. Available from: https://www.acpjournals.org/doi/10.7326/M21-4284?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed
14. Cardoso R, Graffunder FP, Ternes CMP, Fernandes A, Rocha AV, Fernandes G, et al. SGLT2 inhibitors decrease cardiovascular death and heart failure hospitalizations in patients with heart failure: A systematic review and meta-analysis. eClinicalMedicine [Internet]. 2021 Jun 1 [cited 2022 Apr 14];36. Available from: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00213-3/fulltext
15. McMurray JJV, Packer M. How Should We Sequence the Treatments for Heart Failure and a Reduced Ejection Fraction?: A Redefinition of Evidence-Based Medicine. Circulation. 2021 Mar 2;143(9):875–7.
16. Sharma A, Verma S, Bhatt DL, Connelly KA, Swiggum E, Vaduganathan M, et al. Optimizing Foundational Therapies in Patients With HFrEF. JACC: Basic to Translational Science. 2022 Mar;S2452302X21003594.
17. Bauersachs J. Heart failure drug treatment: the fantastic four. European Heart Journal. 2021 Feb 7;42(6):681–3.
18. McDonald M, Virani S, Chan M, Ducharme A, Ezekowitz JA, Giannetti N, et al. CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction. Canadian Journal of Cardiology. 2021 Apr 1;37(4):531–46.
19. Ghionzoli N, Gentile F, Del Franco AM, Castiglione V, Aimo A, Giannoni A, et al. Current and emerging drug targets in heart failure treatment. Heart Fail Rev. 2022 Jul 1;27(4):1119–36.
20. Karamichalakis N, Xanthopoulos A, Triposkiadis F, Paraskevaidis I, Tsougos E. Reshaping Treatment of Heart Failure with Preserved Ejection Fraction. Journal of Clinical Medicine. 2022 Jan;11(13):3706.
21. Kjeldsen SE, von Lueder TG, Smiseth OA, Wachtell K, Mistry N, Westheim AS, et al. Medical Therapies for Heart Failure With Preserved Ejection Fraction. Hypertension. 2020 Jan;75(1):23–32.
22. Slawnych M. New Dimensions in Palliative Care Cardiology. Canadian Journal of Cardiology. 2018 Jul 1;34(7):914–24.

Abbreviations:

ACEI                Angiotensin-converting enzyme inhibitors

ARNI                Angiotensin Receptor-neprilysin Inhibitor

BNP                 B -Type Natriuretic Peptide

CRT                 Cardiac Resynchronization Therapy

CVD                 Cardiovascular Disease

ECG                 Electrocardiogram

ECHO              Echocardiogram

GDMT              Guideline Directed Medical Therapy

HF                    Heart Failure

HFmrEF           HF Mild Reduced Ejection Fraction

HFpEF             HF Preserved Ejection Fraction

HFrEF              HF Reduced Ejection Fraction

ICD                  Implantable Cardioverter Defibrillator

LVEF                Left Ventricular Ejection Fraction

MIBI                 Thallium and Sestamibi scan

MRA                Mineralocorticoid Receptor Antagonist

MUGA              Multi Gated Acquisition Scan

NT-proBNP      N‐terminal pro B‐type natriuretic peptide 

NYHA               New York Heart Association

SGLT2i             Sodium-Glucose Cotransporter-2 Inhibitor

TSH                 Thyroid Stimulating Hormone

• CardiacServicesBC (www.cardiacbc.ca): Multiple patient handouts available.
• HealthLinkBC: Heart Failure Overview
• HealthLinkBC: Heart Failure: Taking Medicines Properly
• HealthLinBC: Monitoring and Medicines for Heart Failure
• Island Health Community Virtual Care: Community Virtual Care provides support to people with a range of medical conditions. Registered nurses help you to manage your condition from the comfort of your home. All the tools needed are loaned to you at no cost.
• Canadian Heart Failure Society: Living Well with Heart Failure
• Canadian Heart Failure Society: How to manage your heart failure medication ON SICK DAYS?
• RxFiles: SADMANS medications in heart failure
• Heartlife Foundation: Patients
• Heart Failure Medications: A Patient and Caregiver Guide
• Heart and Stroke Foundation: Heart Failure

Diagnostic Fee Code

428 Heart Failure

Appendices

• Appendix A: Health Behavior Modifications and Self-monitoring Recommendations
• ​Appendix B: Heart Failure Zones Reference Guide
• Appendix C: Commonly used Drugs in Heart Failure Care

This guideline was developed by the Guidelines and Protocols Advisory Committee in collaboration with the Provincial Laboratory Medicine Services and adopted under the Medical Services Act and the Laboratory Services Act.

The principles of the Guidelines and Protocols Advisory Committee are to: Encourage appropriate responses to common medical situations Recommend actions that are sufficient and efficient, neither excessive nor deficient Permit exceptions when justified by clinical circumstances. Contact Information Guidelines and Protocols Advisory Committee PO PO Box 9642 STN PROV GOVT Victoria BC V8W 9P1 E-mail: hlth.guidelines@gov.bc.ca Web site: www.BCGuidelines.ca Disclaimer The Clinical Practice Guidelines (the guidelines) have been developed by the guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.