Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management

Abstract

Heart failure remains a common diagnosis, especially in older individuals. It continues to be associated with significant morbidity and mortality, but major advances in both diagnosis and management have occurred and will continue to improve symptoms and other outcomes in patients. The Canadian Cardiovascular Society published its first consensus conference recommendations on the diagnosis and management of heart failure in 1994, followed by two brief updates, and reconvened this consensus conference to provide a comprehensive review of current knowledge and management strategies. New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel who developed both recommendations and practical tips, which were reviewed by a secondary panel. The resulting document is intended to provide practical advice for specialists, family physicians, nurses, pharmacists and others who are involved in the care of heart failure patients. Management of heart failure begins with an accurate diagnosis, and requires rational combination drug therapy, individualization of care for each patient (based on their symptoms, clinical presentation and disease severity), appropriate mechanical interventions including revascularization and devices, collaborative efforts among health care professionals, and education and cooperation of the patient and their immediate caregivers. The goal is to translate best evidence-based therapies into clinical practice with a measureable impact on the health of heart failure patients in Canada.

Figure 1)

Algorithm for diagnosis of heart failure. *Useful in selected care settings (eg, emergency room); ^†Some laboratory tests are recommended at the time of initial evaluation if diagnostic suspicion is high (complete blood count, electrolytes, renal function, urinalysis, glucose, lipids, liver enzymes and function, and thyroid function) and others are recommended when clinically indicated (eg, ferritin, antinuclear antibody, rheumatoid factor, metanephrines or HIV); ^‡Includes both systolic and diastolic parameters (eg, ejection fraction, transmitral and pulmonary venous flow patterns, or mitral annulus velocities); ^§Heart failure with preserved systolic function may not be identified on a routine echocardiogram and clinical judgment is required if other indicators point strongly to heart failure as a diagnosis; ^¶Magnetic resonance imaging, multislice computed tomography or endomyocardial biopsy

Figure 2)

A simplified algorithm of heart failure management including drug and device therapy (see text for full recommendations). ACEI Angiotensin-converting enzyme inhibitor; ARB Angiotensin receptor blocker; Comb. Combination; CRT Cardiac resynchronization therapy; ER Emergency room; ICD Implantable cardioverter defibrillator; LVEF Left ventricular ejection fraction; NYHA New York Heart Association; Rx Treatment

Figure 3)

Drug interactions with commonly used medications for congestive heart failure. Possible drug interactions with moderate to major impact are listed. Individual patient responses may vary. *Additive pharmacological effect (eg, additive hypotensive effects [↓blood pressure (BP)]). ↑ Increase; ↓ Decrease; ACEIs Angiotensin-converting enzyme inhibitors; ARBs Angiotensin receptor blockers; AV Atrioventricular; HR Heart rate. Adapted from reference

Figure 4)

Treatment algorithm for acute heart failure (AHF). BiPAP Bilevel positive airway pressure; BP Blood pressure; CPAP Continuous positive airway pressure; IV Intravenous; PA Pulmonary artery; PCWP Pulmonary capillary wedge pressure; SBP Systolic blood pressure