Malaysia CPG for Heart Failure

Summary

• Heart Failure (HF) is a clinical diagnosis. To satisfy the definition of HF, symptoms, signs and/or objective evidence of cardiac dysfunction must be present. (Fig. 1)

• HF may be the result of any disorder of the endocardium, myocardium, pericardium or great vessels although commonly, it is due to myocardial dysfunction. It may occur in the presence of reduced left ventricular (LV) function, the left ventricular ejection fraction (LVEF) <40% (HFrEF) or with normal LV function, the LVEF > 50% (HF with with preserved LV function -HFpEF). If the LVEF is 41-49% it is called HFpEF, borderline.

• It may be classified as Acute HF or chronic HF depending on the acuteness of the clinical presentation.

• HF is not a complete diagnosis. It is important to identify the underlying disease and the precipitating cause(s), if present. Common causes are coronary artery disease and hypertension. Patients with Chronic HF may occasionally develop acute decompensation. Important causes that can lead to this Acute HF include acute myocardial infarction/ myocardial ischemia, arrhythmias (e.g. atrial fi brillation) and uncontrolled Blood Pressure. (Fig. 2)

• Prevention and early intervention wherever appropriate, should be the primary objective of management. (Fig. 3)

• Management of HFrEF (both Acute HF and Chronic HF) and grades of recommendations are as outlined in Flow Charts 1 & 2 and Tables 1 & 2.

• Management of HFpEF remains empiric since trial data are limited.

• Non pharmacological measures includes counseling the patient and family about the disease, diet and fl uid intake, regular exercise and appropriate lifestyle changes such as smoking cessation and abstinence from alcohol.

• HF in pregnancy and in children are best managed in tertiary centres.

• Performance measures should be instituted to assess quality of care.

Cardiovascular disease is an important cause of morbidity and mortality in Malaysia. Heart Failure (HF), the end stage of most diseases of the heart, is a common medical problem encountered in general practice and is an important cause of hospital admissions. With aging of the population the prevalence of HF is expected to increase.

The 1st Clinical Practice Guidelines (CPG) in HF was published in 2000 with the 2nd edition in 2007. This current document is an update of the last edition.

Objectives:

The objectives of this CPG are to assist the health care provider in:

• the prevention of HF

• the diagnosis and treatment of HF

• improving survival of patients with HF

• reducing the morbidity associated with the condition and improving the quality of life of these patients

Process:

Evidence was obtained by systematic review of current medical literature on HF using the usual search engines – PubMed and Ovid. International guidelines on HF were also studied. The draft was then submitted to the Technical Advisory Committee for Clinical Practice Guidelines, Ministry of Health Malaysia and key health personnel for review and feedback.

The level of recommendation and the grading of evidence used in this CPG was adapted from the American Heart Association and the European Society of Cardiology.

Clinical Questions Addressed:

• How do you make a diagnosis of HF.

• Who are individuals at high risk of developing HF and how do you prevent them from developing HF?

• How do you treat acute and chronic HF effectively using current knowledge and available resources?

• How do you prevent recurrent admissions for acute decompensated HF.

• How do you treat the following special groups?

  • the asymptomatic individual with reduced left ventricular (LV) function.

  • the individual with HF due to preserved LV function.

  • the pregnant patient with HF.

  • infants and children with HF.

  • the individual with refractory and terminal HF.

Target Group:

This CPG is directed at all healthcare providers treating patients with HF – general practitioners, general and family physicians, both adult and paediatric cardiologists and obstreticians.

Table 1 Levels of evidence and grades of recommendations

Figuur 1

Algorithm for the diagnosis of Heart Failure or LV dysfunction

Figuur 2

Factors Contributing to Decompensation in a Patient with Stable HF

Figuur 3

Prevention of Heart failure

Flowchart I

Management of Acute HF

Flowchart II

Optimizing Drug Therapy in Chronic HF

Table I Grading of Recommendations in the Management of Acute HF

Table II Grading of Recommendations in the Management of Chronic HF