Management protocols for chronic heart failure in India

Abstract

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient's quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.

Keywords: Algorithms; CHF; Chronic heart failure; Devices; Diagnosis; Drugs; HF; Heart failure; India; Management standards; Practice guidance; Protocols; Treatment.

Fig. 1

Different classification systems for HF. *It is referred to as a grey zone as the protocol and treatment for this group is not clear. $ New York Heart Association classification. HF = heart failure; LVEF = left ventricular ejection fraction; HFrEF = heart failure with reduced ejection fraction; HFmrEF = heart failure with mid-range ejection fraction; HFpEF = heart failure with preserved ejection fraction

Fig. 2

Algorithm for diagnosis of patients with chronic HF. *As suggested by this committee HF = heart failure; BNP = brain natriuretic peptide; NT-pro-BNP = N-terminal pro-BNP; HFrEF = heart failure with reduced ejection fraction; HFmrEF = heart failure with mid range ejection fraction; HFpEF = heart failure with preserved ejection fraction; LVEF = left ventricular ejection fraction

Fig. 3

Reduction in all-cause mortality, with; different classes of drugs vs. placebo. NS = Non-significant ARNI = angiotensin II receptor blocker neprilysin inhibitor; MRA = mineralocorticoid receptor antagonist; ACE = angiotensin converting enzyme; ARB = angiotensin II receptor blocker

Fig. 4

Core therapy plus other drugs for the management of HFrEF. Note: *If affordability is not an issue, then an ARNI can be used instead of an ACE inhibitor. In patients who cannot tolerate ACE inhibitors, ARBs can be considered. # Beta-blocker should be titrated to its maximum tolerated dose to obtain heart rate <70 bpm. Ivabradine is recommended in patients with sinus rhythm and heart rate >70 bpm despite being treated with a maximally tolerated dose of a beta-blocker. Ivabradine can also be used in patients who have contraindication/s for beta-blocker/s. € Spironolactone and eplerenone are equal in terms of efficacy, but spironolactone has lesser androgenic side-effects. ¢ First dose of pneumococcal vaccination should be given after confirmation of HF diagnosis and second dose after 5 years. Influenza vaccination should be given every year before the onset of winter (September/October). £ Loop diuretics (Torsemide or Frusemide) should be used in patients with volume overload. *Among antiarrhythmics, only amiodarone and dofetilide have a neutral effect on mortality in HF patients. HFrEF = heart failure with reduced ejection fraction; ARNI = angiotensin receptor neprilysin inhibitor; ACE = angiotensin converting enzyme; ARB = angiotensin II receptor blocker; MRA = mineralocorticoid receptor antagonist; IV = intravenous; AF = atrial fibrillation; CAD = coronary artery disease; HF = heart failure

Fig. 5

Management of patients with HF. *If affordability is not an issue, then ARNI can be used over RAAS inhibitors. # ARB should be used when ACE inhibitor is not tolerated ** Beta-blocker should be titrated to its maximum tolerated dose to obtain heart rate <70 bpm. If the beta-blocker is not tolerated or contraindicated, then add or replace it with ivabradine. ARNI = angiotensin II receptor blocker neprilysin inhibitor; MRA = mineralocorticoid receptor antagonist; ACE = angiotensin converting enzyme, ARB = angiotensin II receptor blocker

Fig. 6

Device therapy in HF. *RS = Residual Survival ≥1 year HF = heart failure; MI = myocardial infarction, LVEF = left ventricular ejection fraction, OMT = optimal medical therapy; ICD = implantable cardioverter defibrillators; CRT = cardiac resynchronization therapy; VAD = ventricular assist device