Congestive Cardiac Failure (CCF)
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition
Description
General Measures
Medicine Treatment
Referral
I50.0
DESCRIPTION
CCF is a clinical syndrome and has several causes. The cause and immediate precipitating factor(s) of the CCF must be identified and treated to prevent further harm.
Potentially reversible causes include:
- hypertension
- thiamine deficiency
- thyroid disease
- ischaemic heart disease
- valvular heart disease
- haemochromatosis
- constrictive pericarditis
- tachycardia
GENERAL MEASURES
Patient and family education.
Monitor body weight to assess changes in fluid balance.
Limit fluid intake to 1–1.5 L/day if fluid overloaded despite diuretic therapy.
Limit alcohol intake to a maximum 2 drinks per day if at all.
LoE:IIIblix
Salt restriction (dietician guided when possible).
Regular exercise within limits of symptoms.
Avoid NSAIDs as these may exacerbate fluid retention.
Counsel that pregnancy may exacerbate heart failure and some medicines used in treatment of heart failure are contraindicated in pregnancy e.g. ACE-inhibitors, angiotensin-receptor blockers, spironolactone. Advise on contraception or refer for such advice.
LoE:IVblx
MEDICINE TREATMENT
Where heart failure is due to left ventricular systolic dysfunction, mortality is significantly reduced by the use of ACE-inhibitors, beta-blockers and spironolactone and every effort should be made to ensure eligible patients receive all these agents in appropriate doses.
|
Note: All the guideline evidence presented here relates to treatment of patients in whom heart failure syndrome is due to left ventricular systolic dysfunction and cannot necessarily be extrapolated to patients in whom heart failure is due to other causes of the syndrome |
Digoxin has only been shown to improve symptoms and reduce hospitalisation.
LoE:Ialxi
Diuretic
Mild volume overload (mild CCF) and normal renal function, thiazide diuretic:
LoE:IIIblxii
- Hydrochlorothiazide, oral, 25–50 mg daily.
- Caution in patients with gout.
- Less effective in impaired renal function.
- Caution in patients with a history or family history of skin cancer; and counsel all patients on sun avoidance and sun protection.
LoE:IIIblxiii
Significant volume overload or abnormal renal or hepatic function, loop diuretic:
- Furosemide, oral, daily.
- Initial dose: 40 mg/day.
- Higher dosages may be needed, especially if comorbid renal failure.
- Advise patients to weigh themselves daily and adjust the dose if necessary.
LoE:IVb
Note:
Unless patient is clinically fluid overloaded, reduce the dose of diuretics before adding an ACE-inhibitor. After introduction of an ACE-inhibitor, try to reduce diuretic dose and consider a change to hydrochlorothiazide.
Routine use of potassium supplements with diuretics is not recommended. They should be used short term only, to correct documented low serum potassium level.
LoE:Ialxiv
Renin-angiotensin-aldosterone system (RAAS) blockers:
- ACE-inhibitor, e.g.:
- Enalapril, oral, 2.5 mg 12 hourly, titrated to 10 mg 12 hourly
- In the absence of significant side-effects always try to increase the dose to the level shown to improve prognosis (i.e.10 mg 12 hourly).
LoE:Ialxv
If ACE-inhibitor intolerant, i.e. intractable cough:
- Angiotensin receptor blocker (ARB), e.g.:
- Losartan, oral, 50–100 mg daily. Specialist initiated.
Spironolactone
Use with an ACE-inhibitor and furosemide in patients presenting with Class III or IV heart failure.
Do not use if eGFR < 30 mL/minute.
Monitoring of potassium levels is essential if spironolactone is used with an ACE-inhibitor or other potassium sparing agent or in the elderly.
- Spironolactone, oral, 25–50 mg once daily.
LoE:IVblxvi
Beta-blockers
For all stable patients with heart failure who tolerate it:
- Carvedilol, oral. If not tolerated, i.e. worsening of cardiac failure symptoms, reduce the dose to the previously tolerated dose.
- Initial dose: 3.125 mg 12 hourly.
- Increase at 2-weekly intervals by doubling the daily dose until a maximum of 25 mg 12 hourly, if tolerated.
- Up-titration should take several weeks or months.
- If > 85 kg: maximum of 50 mg 12 hourly.
LoE:Ialxvii, LoE:IIIblxviii
Digoxin
Patients in sinus rhythm remaining symptomatic despite the abovementioned agents (Specialist consultation):
- Digoxin, oral, 0.125 mg daily, adjust according to rate response and trough plasma level.
- Digoxin trough plasma levels (before the morning dose) should be maintained between 0.6-1 nmol/L.
- Patients at high risk of digoxin toxicity: the elderly, patients with renal dysfunction, hypokalaemia and patients with lean body mass.
LoE:IIIblxix
Anticoagulants
Heparin: for DVT prophylaxis for patients admitted to hospital, unless contraindicated: See Venous thrombo-embolism.
Warfarin: See Narrow QRS complex (supraventricular) tachydysrhythmias.
Anti-dysrhythmic medicines
- Only for potentially life-threatening ventricular dysrythmias. See Cardiac Dysrhythmias.
- Always exclude electrolyte abnormalities and medicine toxicity first.
Thiamine
Consider as a trial of therapy in all unexplained heart failure:
- Thiamine, oral/IM, 100 mg daily for 4 weeks.
Prophylaxis (Z29.2)
- Annual influenza vaccine. See Adult vaccination.
REFERRAL
- Where specialized treatment and diagnostic work-up is needed and to identify treatable and reversible causes.
- All patients with audible cardiac murmurs should undergo specialist evaluation, as should all patients with potentially reversible causes of the heart failure syndrome and those with persistent and severe symptoms and signs of fluid overload despite adequate doses of diuretic.
- Patients who have LBBB on the ECG are potential candidates for cardiac resynchronization therapy, and should be discussed with a specialist. An ECG should be recorded at baseline and repeated at 6-monthly intervals.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.0_01 November 2024
Chapter 3: Cardiovascular System_3.4 Congestive Cardiac Failure (CCF)