{"id":8403,"date":"2025-08-20T13:39:17","date_gmt":"2025-08-20T10:39:17","guid":{"rendered":"https:\/\/jordan-cardiac.org\/?p=8403"},"modified":"2025-08-20T13:39:17","modified_gmt":"2025-08-20T10:39:17","slug":"general-national-heart-failure-consolidated-recommendations","status":"publish","type":"post","link":"https:\/\/jordan-cardiac.org\/en\/general-national-heart-failure-consolidated-recommendations\/","title":{"rendered":"General National Heart Failure \u2013 Consolidated Recommendations"},"content":{"rendered":"
General National Heart Failure \u2013 Consolidated Recommendations<\/div>\n
<\/div>\n
(Adapted from ESC Guidelines 2018\u20132024)<\/div>\n
<\/div>\n
Definition<\/div>\n
<\/div>\n
Heart failure is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling, fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, peripheral oedema), caused by a structural and\/or functional cardiac abnormality, leading to reduced cardiac output and\/or elevated intracardiac pressures at rest or during stress.<\/div>\n
<\/div>\n
1. Classification by LVEF<\/div>\n
<\/div>\n
1.1 HFrEF: LVEF \u226440%<\/div>\n
1.2 HFmrEF: LVEF 41\u201349%<\/div>\n
1.3 HFpEF: LVEF \u226550% + structural\/functional abnormality + elevated natriuretic peptides<\/div>\n
<\/div>\n
2. Diagnosis and Initial Assessment<\/div>\n
<\/div>\n
2.1 Measure BNP or NT-proBNP in suspected HF.<\/div>\n
2.2 Confirm diagnosis and classify by echocardiography.<\/div>\n
2.3 Support with ECG, chest X-ray, CBC, electrolytes, thyroid, glucose, HbA1c, lipids, iron studies.<\/div>\n
<\/div>\n
3. Core Pharmacological Therapy<\/div>\n
<\/div>\n
3.1 HFrEF (Foundational drugs):<\/div>\n
\u2003\u2022 ACE-I\/ARNI<\/div>\n
\u2003\u2022 Beta-blocker<\/div>\n
\u2003\u2022 MRA<\/div>\n
\u2003\u2022 SGLT2 inhibitor<\/div>\n
3.2 If symptoms persist: ivabradine, vericiguat, digoxin, hydralazine\/isosorbide dinitrate.<\/div>\n
3.3 HFmrEF: Same drugs may be considered; benefit less certain.<\/div>\n
3.4 HFpEF: Symptom relief (diuretics), comorbidity management; SGLT2 inhibitors reduce admissions.<\/div>\n
<\/div>\n
4. Device & Interventional Therapy<\/div>\n
<\/div>\n
4.1 ICD: For LVEF \u226435% with persistent symptoms despite optimal therapy and life expectancy >1 year.<\/div>\n
4.2 CRT: For sinus rhythm, LVEF \u226435%, QRS \u2265150 ms with LBBB pattern; avoid in QRS <130 ms.<\/div>\n
4.3 Valve disease: SAVR\/TAVI or percutaneous repair as indicated.<\/div>\n
<\/div>\n
5. Multidisciplinary & Lifestyle Management<\/div>\n
<\/div>\n
5.1 Enroll in multidisciplinary HF programs to reduce mortality and hospitalizations.<\/div>\n
5.2 Educate patients on symptoms, adherence, and self-management.<\/div>\n
5.3 Exercise training recommended in stable HF.<\/div>\n
5.4 Vaccinate against influenza and pneumococcus.<\/div>\n
5.5 Restrict sodium in symptomatic HF; complete smoking cessation and alcohol limitation.<\/div>\n
<\/div>\n
6. Monitoring and Follow-Up<\/div>\n
<\/div>\n
6.1 Post-discharge follow-up within 1\u20132 weeks.<\/div>\n
6.2 Annual ECG to detect CRT eligibility.<\/div>\n
6.3 Echocardiography if deterioration or 3\u20136 months after HFrEF therapy optimization.<\/div>\n
6.4 Telemonitoring may reduce hospitalizations and mortality (Class IIb).<\/div>\n
<\/div>\n
7. Acute Heart Failure<\/div>\n
<\/div>\n
7.1 Rapid assessment: airway, breathing, circulation, perfusion.<\/div>\n
7.2 Oxygen only if SpO\u2082 <90%.<\/div>\n
7.3 IV loop diuretics for congestion.<\/div>\n
7.4 Vasodilators if SBP >110 mmHg and congestion.<\/div>\n
7.5 Inotropes for hypoperfusion; vasopressors for shock.<\/div>\n
7.6 Address triggers (ACS, arrhythmia, infection).<\/div>\n
<\/div>\n
8. Advanced Heart Failure \u2013 Key Points (ESC 2021\u20132024)<\/div>\n
<\/div>\n
8.1 Inotropes & Diuretics<\/div>\n
\u2022 Used in haemodynamic instability or persistent low output.<\/span><\/div>\n
\u2022 Indication: \u201crescue therapy\u201d for shock or severe hypoperfusion.<\/span><\/div>\n
\u2022 Escalate diuretic therapy if resistant (double loop dose \u2192 add thiazide\/metolazone).<\/span><\/div>\n
\u2022 Renal Replacement Therapy (RRT): hemodialysis, peritoneal dialysis, or ultrafiltration may be considered for refractory congestion.<\/span><\/div>\n
\u2022 Class\/Level: IIb, C.<\/span><\/div>\n
<\/div>\n
8.2 Mechanical Circulatory Support (MCS)<\/div>\n
\u2022 Short-term MCS (ECMO, Impella, IABP): for INTERMACS profile 1\u20132 (critical shock or progressive decline).<\/span><\/div>\n
\u2003Purpose: Bridge to Decision (BTD), Bridge to Recovery (BTR), or Bridge to Bridge (BTB).<\/div>\n
\u2003Class\/Level: IIa, C.<\/div>\n
\u2022 Long-term LVAD: indicated in refractory HF despite OMT \u00b1 device therapy.<\/span><\/div>\n
\u2003Roles: Bridge to Transplant (BTT), Bridge to Candidacy (BTC), or Destination Therapy (DT).<\/div>\n
\u2003Class\/Level: IIa, B.<\/div>\n
<\/div>\n
8.3 LVAD Eligibility Criteria<\/div>\n
\u2022 Severe HF despite optimal therapy, no major contraindications.<\/span><\/div>\n
\u2022 At least one of:<\/span><\/div>\n
\u2003\u2022 LVEF <25% with poor exercise capacity (peak VO\u2082 <12 mL\/kg\/min)<\/div>\n
\u2003\u2022 \u22653 HF hospitalizations in past 12 months<\/div>\n
\u2003\u2022 Dependence on IV inotropes or temporary MCS<\/div>\n
\u2003\u2022 Progressive end-organ dysfunction with haemodynamic compromise (PCWP \u226520 mmHg, SBP \u226490 mmHg, cardiac index \u22642 L\/min\/m\u00b2)<\/div>\n
<\/div>\n
8.4 Heart Transplant<\/div>\n
\u2022 Indicated in advanced HF refractory to all medical\/device therapy.<\/span><\/div>\n
\u2022 Contraindications: active infection, severe comorbidity, advanced malignancy, uncontrolled substance abuse, poor psychosocial support.<\/span><\/div>\n
\u2022 Class\/Level: I, C.<\/span><\/div>\n
<\/div>\n
8.5 Palliative Care<\/div>\n
\u2022 For patients not eligible for advanced options.<\/span><\/div>\n
\u2022 Focus: symptom relief, quality of life (QOL), patient and family support, advance care planning.<\/span><\/div>\n
\u2022 Class\/Level: I, C.<\/span><\/div>\n
<\/div>\n
8.6 Digoxin<\/div>\n
\u2022 Without AF: may be considered to reduce HF hospitalization in HFrEF symptomatic patients. (Class IIb, Level\u00a0<\/span><\/div>\n
\u2022 With AF (rate control): if beta-blockers insufficient or not tolerated. (Class IIa, Level\u00a0<\/span><\/div>\n
\u2022 Benefit: reduces hospitalizations but no mortality benefit.<\/span><\/div>\n
\u2022 Caution: narrow therapeutic index, toxicity risk.<\/span><\/div>\n
<\/div>\n
8.7 Vericiguat<\/div>\n
\u2022 Soluble guanylate cyclase stimulator \u2192 enhances NO\u2013sGC\u2013cGMP pathway.<\/span><\/div>\n
\u2022 Indication: HFrEF with recent worsening (hospitalization or IV therapy) on GDMT.<\/span><\/div>\n
\u2022 Benefit: reduces CV death and HF hospitalizations.<\/span><\/div>\n
\u2022 Class IIb, Level B.<\/span><\/div>\n
<\/div>\n
8.8 BNP vs NT-proBNP<\/div>\n
\u2022 BNP: active hormone, short half-life (~20 min), less stable.<\/span><\/div>\n
\u2022 NT-proBNP: inactive fragment, longer half-life (~60\u2013120 min), more stable in lab.<\/span><\/div>\n
\u2022 Both accepted in ESC\/AHA guidelines; choice depends on lab availability.<\/span><\/div>\n
\u2022 Interpretation:<\/span><\/div>\n
\u2003\u2022 Acute HF: NT-proBNP <300 pg\/mL (rule-out), BNP <100 pg\/mL (rule-out).<\/div>\n
\u2003\u2022 Chronic HF: NT-proBNP <125 pg\/mL (rule-out).<\/div>\n
<\/div>\n
8.9 INTERMACS Profiles (1\u20137) (American \u201cInteragency Registry for Mechanically Assisted Circulatory Support\u201d)<\/div>\n
\u2022 Profile 1 \u2013 Critical shock: crashing, imminent death \u2192 immediate short-term MCS. Class IIa, C.<\/span><\/div>\n
\u2022 Profile 2 \u2013 Progressive decline: on inotropes but worsening \u2192 early LVAD\/transplant. Class IIa, C.<\/span><\/div>\n
\u2022 Profile 3 \u2013 Stable on inotropes: dependent but stable \u2192 consider durable LVAD\/transplant. Class IIa, B.<\/span><\/div>\n
\u2022 Profile 4 \u2013 Resting symptoms: severe symptoms at rest \u2192 evaluate for advanced therapies. Class IIa, B.<\/span><\/div>\n
\u2022 Profile 5 \u2013 Exertion intolerant: symptoms with minimal activity \u2192 outpatient advanced HF evaluation. Class IIb, C.<\/span><\/div>\n
\u2022 Profile 6 \u2013 Exertion limited: symptoms with moderate exertion \u2192 monitor, may progress. Class IIb, C.<\/span><\/div>\n
\u2022 Profile 7 \u2013 Advanced NYHA III: stable but frequent hospitalizations \u2192 early identification, structured follow-up. Class IIb, C.<\/span><\/div>\n
<\/div>\n
9. Cardiomyopathy Integration (for GPs and National Protocols)<\/div>\n
<\/div>\n
9.1 Cardiac Amyloidosis<\/div>\n
\u2022 When to suspect: LV wall thickness \u226512 mm plus red flags such as:<\/span><\/div>\n
* Peripheral neuropathy (numbness, weakness)<\/div>\n
* Bilateral carpal tunnel syndrome<\/div>\n
* Unexplained hypotension or orthostatic hypotension<\/div>\n
* Family history of amyloidosis or unexplained cardiomyopathy<\/div>\n
\u2022 Treatment: Tafamidis is indicated for transthyretin amyloidosis (ATTR, hereditary or wild-type) in patients with NYHA Class I\u2013II.<\/span><\/div>\n
<\/div>\n
9.2 Arrhythmogenic Cardiomyopathy (ACM)<\/div>\n
\u2022 Screen first-degree relatives of affected patients.<\/span><\/div>\n
\u2022 Recommend genetic counselling and clinical screening.<\/span><\/div>\n
\u2022 Avoid competitive sports; allow only moderate leisure activity.<\/span><\/div>\n
\u2022 Implant ICD in high-risk patients (e.g., survivors of cardiac arrest, sustained VT, or high-risk mutations).<\/span><\/div>\n
<\/div>\n
9.3 Hypertrophic Cardiomyopathy (HCM)<\/div>\n
\u2022 Management depends on LV outflow tract obstruction (LVOTO).<\/span><\/div>\n
\u2022 With LVOTO: use beta-blockers or verapamil; avoid hypovolaemia, digoxin, vasodilators.<\/span><\/div>\n
\u2022 Without LVOTO: treat HF symptoms cautiously (diuretics, verapamil\/diltiazem if tolerated).<\/span><\/div>\n
\u2022 Consider septal reduction (surgery or alcohol ablation) if LVOT gradient \u226550 mmHg with severe symptoms despite optimal therapy.<\/span><\/div>\n
<\/div>\n
9.4 Dilated Cardiomyopathy (DCM) & Hypokinetic Non-Dilated Cardiomyopathy (HNDC)<\/div>\n
\u2022 Offer genetic testing to all patients and first-degree relatives of mutation carriers.<\/span><\/div>\n
\u2022 Perform endomyocardial biopsy if inflammatory or autoimmune cardiomyopathy is suspected (e.g., giant cell myocarditis, sarcoidosis).<\/span><\/div>\n
\u2022 Treat according to HFrEF protocols.<\/span><\/div>\n
\u2022 Implant ICD in high-risk gene carriers (e.g., LMNA, FLNC, RBM20, PLN).<\/span><\/div>\n
<\/div>\n
<\/div>\n
10. National System Priorities<\/div>\n
<\/div>\n
10.1 Standardize early post-discharge review within 1\u20132 weeks.<\/div>\n
10.2 Establish referral pathways to advanced HF centers (LVAD, transplant).<\/div>\n
10.3 Create a national HF registry to benchmark against ESC standards.<\/div>\n
10.4 Develop unified patient education and structured follow-up programs.<\/div>\n
<\/div>\n
\u2e3b<\/div>\n
<\/div>\n
Reference:<\/div>\n
Ponikowski P, et al. 2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure. Eur Heart J. 2021;42:3599\u20133726.<\/div>\n
McDonagh TA, et al. 2023\u20132024 ESC Updates on Heart Failure and Cardiomyopathies. Eur Heart J. 2023\u20132024.<\/div>\n","protected":false},"excerpt":{"rendered":"

General National Heart Failure \u2013 Consolidated Recommendations (Adapted from ESC Guidelines 2018\u20132024) Definition Heart failure is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling, fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, peripheral oedema), caused by a structural and\/or functional cardiac abnormality, leading to reduced cardiac […]<\/p>\n","protected":false},"author":145,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-8403","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts\/8403","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/users\/145"}],"replies":[{"embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/comments?post=8403"}],"version-history":[{"count":1,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts\/8403\/revisions"}],"predecessor-version":[{"id":8404,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts\/8403\/revisions\/8404"}],"wp:attachment":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/media?parent=8403"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/categories?post=8403"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/tags?post=8403"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}