Heart failure clinical guideline. South African Medical Association Heart Failure Working Group

Abstract

Objective: This Guideline targets chronic heart failure (CHF) due to left ventricular systolic dysfunction. The approach to both diagnosis and management of the CHF syndrome is included in this document. Although the aetiology of the heart failure may differ among the different racial groups (hypertension, end-stage rheumatic heart disease and idiopathic cardiomyopathy in black patients, and ischaemic heart disease in white, coloured and Indian patients), the end result is a dysfunctional left ventricle. The therapy applied is therefore applicable to a wide spectrum of CHF patients. This allows for the compilation of a CHF Guideline that is relevant to a large group of patients. All health care workers are targeted in this Guideline, although the general practitioner and specialist physician would probably gain the most from it. The clinical recognition of heart failure as well as its management is a difficult clinical problem and a primary care guideline will have to be a separate document, although the summary of this Guideline can be appreciated at a primary level of care. The motivation for the development of this guideline includes: Congestive heart failure is probably the most important cardiovascular condition that is still increasing in incidence and prevalence. A major problem is the clinical recognition of the heart failure syndrome, and this Guideline concentrates on outlining a practical approach to obtaining a history and doing a relevant examination. Unless the condition is correctly diagnosed, any recommendations on therapy lose their relevance. Numerous large, randomised, international, double-blind randomised trials are a feature of this condition and a Guideline giving clear recommendations for therapy based on these trials is crucial. The ordinary busy practitioner cannot be expected to read all these published studies and assimilate them into a coherent protocol of management. South Africa has not published a guideline on CHF that sets the standard of care that is considered acceptable. With the emergence of essential drug lists, managed health care groups and a more litigious society in South Africa, this Guideline will serve as the standard for the optimal management of CHF.

Outcomes: Improvement in the quality of life, reduced CHF hospitalisations and mortality were the major considerations in the development of this Guideline. No economic analysis was made to assess cost-effective therapy, as this was not the brief of this document. The Directorate Medical Schemes, Supplies and Pharmaceutical Services (EDL) was a member of the working group.

Evidence: All the data were gathered from the published literature. Preference was given to the evidence provided by the numerous, large randomised CHF trials, the respective heart failure guidelines published by the European Society of Cardiology and the ACC/AHA Task Force and the clinical practice guidelines published by the US Department of Health and Human Services. An expert panel was then assembled and changes were made to the draft guideline both at a convened meeting and later on the basis of written comments following the distribution of a second draft. Where the evidence available was inconclusive or non-existent, a consensus of expert opinion was obtained. The most recent publications considered were published in 1997, but the literature was scanned on an ongoing basis for new data that may have changed the recommendations. METHODOLOGY/SPONSORSHIP: See Annexure B, p. 1155.

Recommendations: A clear history should be obtained identifying the symptoms of the heart failure syndrome together with an attempt at identifying an aetiology and precipitating factor(s) underlying the syndrome. Clinical examination is emphasised, including identifying the three tenets of the clinical diagnosis of CHF (syndrome, aetiology, precipitating factor(s)). The CXR, ECG (resting, effort), selected blood tests are recommended as a routine in the diagnosis of CHF. Echocardiograph