Neobook — clinical reference

I50.0-1/I50.9

DESCRIPTION

CCF is a clinical syndrome and has several causes. The cause and immediate precipitating factor(s) must be identified and treated to prevent further damage to the heart.

Symptoms of CCF include:

Progressive effort intolerance (worsening breathlessness, or fatigue with physical activity such as walking uphill, climbing stairs, sweeping or carrying a heavy load). If severe, breathlessness, or fatigue, may occur when doing activities of daily living such as dressing and washing and may even occur at rest
Orthopnoea (breathless when lying down flat)
Paroxysmal nocturnal dyspnoea (PND) (sudden awakening with breathlessness)
Ankle (or body) swelling
Fatigue

Signs of CCF include:

Dyspnoea (breathlessness)
Tachypnoea
- Men: breathing rate > 18 breaths/minute
- Women: breathing rate > 20 breaths/minute
Ankle swelling with pitting oedema
Tachycardia
Raised jugular venous pressure
Inspiratory basal crackles or wheezing on auscultation of the lungs
Enlarged liver, often tender

GENERAL MEASURES

Monitor body weight to assess changes in fluid balance
Salt (sodium chloride) restriction to less than 2–3 g/day
Regular exercise within limits of symptoms

MEDICINE TREATMENT

All patients need to be assessed by a doctor for initiation or change of treatment.

Many of the medicines used can affect renal function and electrolytes
Monitor sodium, potassium and serum creatinine

STEP 1: Diuretic plus ACE-inhibitor

Mild volume overload (mild CCF) and normal renal function – thiazide diuretic

Hydrochlorothiazide, oral, 25–50 mg daily
- Caution in patients with gout
- Less effective in impaired renal function
- Higher doses can cause hyponatremia
- Caution in patients with a history or family history of skin cancer; and counsel all patients on sun avoidance and sun protection

LoE:IIb³⁷

Significant volume overload or abnormal renal function – loop diuretic

Furosemide, oral, daily (Doctor initiated)
- Initial dose: 40 mg
- If dose > 80 mg/day is required, change dose interval to 12 hourly
- Higher doses may be needed if co-morbid kidney impairment is present
- Once CCF has improved, consider switching to hydrochlorothiazide
- Monitor electrolytes and creatinine

Acute pulmonary oedema

Furosemide, IV. See: Pulmonary oedema, acute

Note

- Use a lower diuretic dose when given in combination with an ACE-inhibitor

- Routine use of potassium supplements with diuretics is not recommended. They should only be used short-term to correct documented low serum potassium level

All patients with CCF, unless contraindicated or poorly tolerated

ACE-inhibitor, e.g.:
Enalapril, oral, 2.5 mg 12 hourly, up to maximum of 10 mg twice daily
- Titrate dosages gradually upwards until an optimal dose is achieved
- Absolute contraindications include: (refer to package insert)
  - Cardiogenic shock
  - Bilateral renal artery stenosis, or stenosis of an artery to a dominant/ single kidney
  - Aortic valve stenosis and hypertrophic obstructive cardiomyopathy
  - Pregnancy
  - History of angioedema associated with previous ACE-inhibitor or angiotensin II receptor blocker (ARB) therapy

STEP 2: After titration of ACE-inhibitor, add carvedilol (alpha 1 and non-selective beta-blocker) unless contra-indicated (Refer to package insert for full prescribing information).

Note

Do not use atenolol for cardiac failure

LoE:IIIb³⁸

Carvedilol, oral (Doctor initiated)
- Starting dose: 3.125 mg twice daily
- Increase dose at two-weekly intervals by doubling the daily dose until a maximum of 25 mg twice daily, if tolerated
- If >85 kg and target heart rate has not been achieved, titrate to a maximum of 50 mg twice daily, if tolerated.
- If not tolerated, i.e. worsening of cardiac failure manifestations, reduce the dose to the previously tolerated dose
- Up-titration can take several months
- Should treatment be discontinued for > 14 days, reinstate therapy as above
- Absolute contraindications include: (Refer to package insert)
  - Cardiogenic shock, bradycardia, various forms of heart block
  - Severe fluid overload
  - Hypotension
  - Asthma

Spironolactone, oral, 25mg daily (Doctor initiated)

LoE:IIIb³⁹

CAUTION

Spironolactone can cause severe hyperkalemia and should only be used when serum potassium and renal function can be monitored

Check potassium levels within one month of starting therapy and thereafter, as per clinical need

Routine monitoring of potassium levels is essential if spironolactone is used with an ACE-inhibitor, other potassium sparing agent or in the elderly

Avoid concomitant potassium supplements and use of NSAIDs

Do not use in kidney failure (Do not use if eGFR < 30 mL/min)

STEP 3:

Spironolactone, oral, 25mg daily (Doctor initiated)

LoE:IVb⁴⁰

Carvedilol, oral (Doctor initiated)
- Starting dose: 3.125 mg twice daily
- Increase dose at two-weekly intervals by doubling the daily dose until a maximum of 25 mg twice daily, if tolerated
- If >85 kg and target heart rate has not been achieved, titrate to a maximum of 50 mg twice daily, if tolerated
- If not tolerated, i.e. worsening of cardiac failure manifestations, reduce the dose to the previously tolerated dose
- Up-titration can take several months
- Should treatment be discontinued for > 14 days, reinstate therapy as above
- Absolute contraindications include: (Refer to package insert)
  - Cardiogenic shock, bradycardia, various forms of heart block
  - Severe fluid overload
  - Hypotension
  - Asthma

STEP 4:

Symptomatic CCF despite above-mentioned therapy

Refer to hospital for step up therapy with digoxin

CAUTION

Patients with CCF on diuretics may become hypokalaemic

Digoxin therapy should not be initiated if the patient is hypokalaemic

REFERRAL

Urgent

Patients with prosthetic heart valve
Suspected infective endocarditis
Fainting spells

Non urgent

Initial assessment and initiation of treatment
Poor response to treatment

Click here for the pdf.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_1 November 2024

Chapter 4: Cardiovascular Conditions_4.6.1 Cardiac Failure, Congestive (CCF), Adults

Cardiac Failure, Congestive (CCF), Adults

Drugs mentioned

ICD-10 codes