The Permanente Medical Group Clinical Practice Guidelines 
have been developed to assist clinicians by providing an analytical 
framework for the evaluation  and treatment of selected common 
problems encountered in patients.  These guidelines are not 
intended to establish a protocol for all patients with a particular 
condition. 

HEART FAILURE TEAM
Rik Smith, MD, Chair, Internal Medicine, Harvard
Robert Blumberg, MD, Cardiology, Redwood City
James Chan. Pham D. PhD, Pharmacy, Operations, Regional Offices
Robert Heller, MD., Cardiology. Harvard
David Levy, MD, Internal Medicine, Walnut Creek. Park Shadelands
Pam Kotler, PhD, TPMG Department of Quality and Utilization, Regional Offices
Valerie McClymont, NE Cardiovascular Surgery,  San Francisco
John Takahashi, MD, Emergency, Santa Clara
Susan Woodier MD, Cardiology, Santa Teresa

PROJECT MANAGEMENT
Pam Kotler, PhD, TPMG Department of Quality and Utilization, Regional Offices
Purvi Mody Kunwar. MPH, TPMG Department of Quality and Utilization

DESIGN AND PRODUCTION
Wendy Jung, MA, TPMG Department of Quality and Utilization

ACKNOWLEDGEMENT
Jodi Cupp. MBA, Lanna Butler-McCoy, Kalev Golubijatnikov, and Anita Klein of KP Consulting, 
Kaiser Foundation Health Plan/Hospitals 
provided additional support
for the development and implementation of these guidelines.

CLINICAL REVIEW GROUP
The following individuals reviewed this guideline and contributed to its final form.
Henry M. Brodkin. MD, Redwood City
Paul A. Feigenbaum. MD, San Francisco
David Gee. MD, Walnut Creek
Arthur Klatsky, MD, Oakland
Pansy Kwong. MD, Oakland
David Langkammer. MD, Antioch
Eleanor Levin. MD, Santa Clara
Roy Meyer, MD, Santa Rosa
Jonathan R. Rompf, MD, Santa Teresa
Laurie J. Weisberg, MD, South San Francisco
David Williams, MD, Vallejo

Copyright 1997
The Permanente Medical Group, Inc. All rights reserved. Please contact TPMG Department 
of Quality and Utilization at 510-987-2309 or tie-line 8-427-2309 for permission to reprint any 
portion of this publication. For additional copies of the guidelines, please call 510-987-2950 
or tie-line 8-427-2950.

Contents - Clinical Practice Guidelines for Heart Failure

Topic
INTRODUCTION
INITIAL EVALUATION
CLINICAL VOLUME OVERLOAD
SCREENING FOR ARRHYTHMIAS
ASSESSMENT OF LEFT-VENTRICULAR SYSTOLIC DYSFUNCTION
DIASTOLIC DYSFUNCTION

PHARMACOLOGICAL MANAGEMENT/SYSTOLIC DYSFUNCTION
DIURETICS
DIGOXIN
ACE INHIBITORS
ANTICOAGLimON
ATRIAL FIBRILLATION
ADDITIONAL PHARMACOLOGICAL MANAGEMENT

GENERAL COUNSELING
ACTIVITY
DIET
MEDICATIONS
COMPLIANCE
PROGNOSIS

PREVENTION IN ASYMPTOMATIC PATIENTS WITH LEFI-VENTRICULAR SYSTOLIC DYSFUNCTION
HOSPITAL MANAGEMENT
REVASCULARIZATION
No ANGINA AND No MI
NO ANGINA AND HISTORY OF MI 
ANGINA
COUNSELING AND DECISION
CONTINUE MEDICAL MANAGEMENT
REVASCULARIZATION
FOLLOW-UP
HEART TRANSPLANTATION
SELECTED REFERENCES
GUIDELINE HIGHLIGHTS
FIGURES AND TABLES
Figure 1: Overview of
Evaluation and Care ofPatients With Heart Failure
Figure 2: Initial Evaluation of Patients uith Heart Failure
Figure 3: Recommended Tests for Patients with Signs or Symptoms of Heart Failure
Table 1: Initial Diagnostic Testing in Heart Failure
Table 2: Other Laboratory Testing to Consider in the Initial Evaluation of Selected Patients Who Have Been 
Diagnosed with Heart Failure
Table 3: Potentially Reversible Causes of Heart Failure
Table 4: Medications Used in Heart Failure
Figure 4: Pharmacological Managenment of Patients with Heart Failure
Table 5: Suggested Topics for Patient, Family and Caregiver Education and Counseling
Figure 5: Evaluation and Treatment of Coronary Heart Disease in Patients with Heart Failure

Heart failure is characterized by: signs and symptoms of intravascular and interstitial volume overload, 
including shortness of breath, rales, and edema 
or manifestations of inadequate tissue perfusion, such as fatigue or poor exercise tolerance. 
These are the results of the inability of the heart to meet bodily demands.

There is a trend towards omitting the word "congestive" with heart failure since not all patients are congested; 
however, for purposes of this documents, 
the terms heart failure, congestive heart failure, and left-ventricular systolic dysfunction may be considered 
interchangeable.

CLINICAL PRACTICE GUIDELINES for HEART FAILURE

INTRODUCTION

1.  signs and symptoms of intravascular and interstitial volume overload, including shortness of breath, rales, and 
edema or
2.  manifestations of inadequate tissue perfusion, such as fatigue or poor exercise tolerance.

These are the results of the inability of the heart to meet bodily demands.

The National Heart, Lung, and Blood Institute estimates that over 2 million Americans have heart failure with 
about 200,000 deaths per year.
Approximately 400,000 new cases are diagnosed each year and about 1 million hospitalizations are due to heart 
failure for an estimated cost of over $7 billion. At Kaiser Permanente Northern California we had 3,952 hospitalizations 
in 1995 for which the  principle condition was heart failure and another 2,755 hospitalizations for which heart failure 
was an associated condition for an estimated cost of $59,476,854 for inpatient care. Since the American population 
is aging, conditions such as heart failure will become more prevalent. 
However, there is evidence that changes in both inpatient and outpatient management can have substantial impacts 
on moibiditv and mortality.

The Agency for Health Care Policy and Research issued a clinical practice guideline on "Heart Failure: Management 
of Patients with Left-Ventricular Systolic Dysfunction" in 1994. This guideline was developed through a rigorous 
evidence-based process in which 16 clinical experts reviewed over 1.000 studies and developed a guideline which 
primarily addresses outpatient management. Each recommendalion made by the panel was graded by the level of 
evidence upon which it was based:

A. Good evidence: Evidence from well-conducted randomized controlled trials or cohort studies
B. Fair evidence: Evidence from other types of studies (case-controlled, uncontrolled)
C.  Expert Opinion

Because heart failure is such a prevalent condition for which changes in management can be expected to substantially 
increase positive out-comes, the TPMG Department of Quality and Utilization was asked by the Continuum of Care 
Group of Kaiser Foundation Health Plan/ Hospitals to sponsor the development of a guideline for heart failure 
management. A team of clinicians from around Northern California was convened as a Heart Failure Guideline Team 
and met eight times to review the AHCPR guidelines. The team examined each of the 
recommendations made by AHCPR and categorized them into three categories:
agree; agree with discussion: and need to see further evidence. When further evidence was needed, a literature 
search was undertaken for new research bearing on the issue and the team then discussed the new evidence, 
the team did not go back and review all the studies summarized by AHCPR. The following work represents the 
KPNCR Heart Failure Guideline Team's adaptation of the AHCPR guideline.

...there is evidence that changes in both inpatient and outpatient management can have substantial impacts on 
mormidity and mortality due to heart failure.

All patients who complain of dyspnea on exertion, paroxysmal nocturnal dyspnea (awakening from sleep with 
shortness of breath) or orthopnea (shortness of breath while lying down) should have heart failure considered 
in the initial evaluation unless other causes for the symptoms are clearly present.

INITIAL EVALUATION
All patients who complain of dyspnea on exertion, paroxysmal nocturnal dyspnea (awakening from sleep with shortness 
of breath) or orthopnea (shortness of breath while lying down) should have heart failure considered in the initial 
differential diagnosis unless other causes for the symptoms are clearly present. Even the presence of other explanations 
for the symptom of dyspnea does not exclude multiple etiologies, including heart failure.

The physical examination can provide important information about the etiology of patients' symptoms and about 
appropriate initial treatment. However, physical signs are not highly sensitive for detecting heart failure. Therefore, 
patients with symptoms that are highly suggestive of heart failure (dyspnea on exertion, paroxysmal nocturnal 
dyspnea, orthopnea) should be evaluated in accordance with the algorithm below. 

In addition to low sensitivity, many physical findings of heart failure are not highly specific. Elevated jugular 
venous pressure, a third heart sound and a laterally displaced apical impulse are the most specific Findings 
and are virtually diagnostic in patients with compatible symptoms* Pulmonary rales or peripheral edema are 
relatively nonspecific finding for heart failure.** The presence of these signs does not require 
measurement of left-ventricular ejection fraction if other symptoms, signs, and radiographic findings of heart 
failure are absent or if they can be attributed to other causes.

Elevated jugular venous pressure, a third heart sound and a laterally displaced apical impulse are the most 
specific findings and are virtually diagnostic in patients with compatible symptoms.

Pulmonary rules or peripheral edema are relatively nonspecific findings for heart disease.

Symptoms and signs of volume overload include orthopnea, paroxysmal nocturnal dyspnea, dyspnea 
on exertion, pulomonary rales, a third heart sound, jugular venous distension, ascites, peripheral edema, 
and pulmonary vascular congestion or pulmonary edema on chest x-ray.

Screening evaluation for asymptomatic arrhythmias is not routinely warranted as part of the evaluation 
of patients with heart failure.

Measurement of left-ventricular performance is a critical step in the evaluation and management of 
almost all patients with suspected or clinically apparent heart failure.

Practitioners should perform a chest x-ray, EKG, complete blood count, serum sodium, serum potassium, serum 
BUN, serum creatinine, and serum glucose on all patients with suspected or clinically evident heart failure. 
A thyroid-stimulating hormone (TSH) level should also be checked in all patients with heart failure and no 
obvious etiology and in patients who have atrial fibrillation or other signs or symptoms of thyroid disease.
See Table I for the rationale for these tests. 
In addition, several other tests may be considered part of the initial evaluation in selected circumstances 
(see Table 2).

CLINICAL VOLUME OVERLOAD
During the initial evaluation, the clinician should determine if the patient manifests symptoms or signs of volume 
overload. Symptoms and signs of volume overload include orthopnea, paroxysmal nocturnal dyspnea dyspnea 
on exertion, pulmonary rales, a third heart sound, jugular venous distension, hepatic engorgement, ascites, 
peripheral edema, and pulmonary vascular congestion or pulmonary edema on chest x-ray.

SCREENING FOR ARRHYTHMIAS
Screening evaluation for asymptomatic arrhythmias, such as ambulatory electrocardiognphic (Holier) 
recording, is not routinely warranted as part of the evaluation of patients with heart failure. Patients 
with known heart failure and a history of unexplained syncope should be discussed with a cardiologist.

ASSESSMENT OF LEFT-VENTRICULAR FUNCTION
Patients with suspected heart failure should undergo echocardiography and, if needed, radionuclide 
ventritulography to measure left-ventricular ejection fraction (if information is not available from 
previous tests).

INITIAL EVALUATION
All patients who complain of dyspnea on exertion, paroxysmal nocturnal dvspnea (awakening from sleep with 
shortness of breath) ororthopnea (shortness of breath while lying (town) should have heart failure considered 
in the initial differential diagnosis unless other causes for the symptoms are clearly present. 
Even the presence of other explanations for the symptom of dyspnea does not exclude multiple etiolegies, 
including heart failure.

The physical examination can provide important information about the etiology of patients' symptoms and 
about appropriate initial treatment. However, physical signs are not highly sensitive for detecting heart failure. 
Therefore, patients with symptoms that are highly suggestive of heart failure (dyspnea on exertion, paroxysmal 
nocturnal dyspnea, orthopnea) should be evaluated in accordance with the algorithm below. In addition to low 
sensitivity, many physical findings of heart failure are not highly specific. 

Elevated jugular venous pressure, a third heart sound and a laterally displaced apical impulse are the most 
specific findings and are virtually diagnostic in patients with compatible symptoms.* Pulmonary rales or 
peripheral edema are relatively nonspecific findings for heart failure,** The presence of these signs does 
not require measurement of left-ventricular ejection fraction if other symptoms, signs, and radiographic 
findings of heart failure are absent or if they can he attributed to other causes.

A variety of conditions can mimic or provoke heart failure, including pulmonary disease, myocardial infarction, 
arrhythmias, pulmonary emboli, cardiac tamponade, anemia, renal failure, nephrotic syndrome, and thyroid 
disease. These conditions should be considered in every patient with suspected new-onset heart failure. 
This guideline does not address the management of patients with -
This section just ends here without explanation.  No pages are missing in this book.

Patients with suspected heart failure should undergo echocardiography and if needed radionuclide 
ventriculography to measure left-ventricular ejection fraction (if information about ventricular function 
is not available from previous tests).

Once left-ventricular systolic dysfunction is confirmed, the results of the history and physical examination 
should be reviewed to search for clues to potentially treatable causes of heart failure.

Routine use of myocardial biopsy is not warranted.

Echocardiography or radionuclide ventriculography can substantially imporove diagnotic accuracy in 
distinguishing between systolic and diastolic dysfunction.

The optimal treatment of diastolic dysfunction is not well defined but agents used to treat systolic dysfunction 
can be deleterious in patients with diastolic dysfunction.

DIASTOLIC DYSFUNCTION
As many as 40% of patients with a clinical diagnosis of heart failure have preserved left-ventricular systolic 
function and no evidence of valvular heart disease. Most have left-ventricular diastolic dysflunction. 
In these cases, the left ventricle has increased diastolic stiffness and cannot fill adequately abnormal 
diastolic pressures. The elevated pressures required for filling result in symptoms of pulmonary 
congestion. In addition, the reduced left-ventricular filling volume leads to lowered stroke volumes 
and symptoms of poor cardiac output.

Most diastolic dysfunction resulls from coronary artery disease or hypertension. Because ischemia can 
produce diastolic dysfunction before systolic dysfunction develops, physiologic testing for ischemia 
should be considered in patients with diastolic dysfunction, particulariy when dyspnea on exertion is a 
prominent symptom. Hypertension is also a common cause of diastolic dysfunction which can develop 
even in the absence of left-ventricular hypertrophy.

The optimal treatment of diastolic dysfunction is not well defined but agents used to treat systolic 
dysfunction can be deleterious in patients witb diastolic dysfunction. Excessive diuresis can reduce 
stroke volume and cardiac output. Digitalis may further decrease left-ventricular compliance. 
The role of ACE inhibitors is not clear. Vasodilators may be detrimental in diastolic function although ACE
inhibitors may have beneficial effects by directly improving ventricular relaxation and causing regression of 
hypertrophy.

This guideline does not provide management strategies for diastolic dysfunction and the remainder of 
the guideline discusses heart failure due to left-ventricular systolic dysfunction. Patients who are 
symptomatic from diastolic dysfunction may benefit from referral to a cardiologist.

PHARMACOLOGICAL MANAGEMENT: SYSTOLIC DYSFUNCTION
DIURETICS
Diurelics are extremely useful for reducing symptoms of volume overload, including orthopnea and 
paroxysmal nocturnal dyspnea. Patients suspected of heart failure with signs of significant volume overload 
should be started immediately on a diuretic. Those with severe volume overload should be started on a 
loop diuretic. Patients with mild volume overload may be managed adequately on thiazide diuretics. 
Patients with minimal symptoms and minimal volume overload should receive dietary counseling 
and may not require diuretic therapy.

Although initiation of diuretics is important in these patients, it is also important to avoid over-diuresis 
before starting ACE inhibitors. Volume depletion may lead to hypotension or renal insufficiency when 
ACE inhibitors are started or when the doses of these agents are increased to full therapeutic levels. 
After the ACE inhibitor is increased to full therapeutic levels, additional diuretic therapy may
be necessary to optimize the patient's status.

The recommendations contained in this guideline are designed for patients with heart failure due of 
left-ventricular systolic dysfunction, i.e., EFs of less than 35-49 percent.

Patients suspected of heart failure with signs of significant volume overload should be started 
immediately on a diuretic.

...it is important to avoid over-diuresis before starting ACE inhibitors.

All patients should have their serum potassium levels checked frequently (e.g., every 3 days until stable) 
during initiation, titration, or modification of diuretic or ACE inhibitor therapy and every few months
thereafter.

ACE inhibitors may be considered as first-line therapy in the subset of heart failure patients who 
present with fatigue or mild dyspnea on exertion and who do not have any other signs or minimal 
symptoms of volume overload.  Diuretics may be added if symptoms persist.

...relatively low blood pressure, moderate renal insufficiency, and mild hyperkalemia are not 
contraindictions to ACE inhibitors.
 

Potassium depletion commonly occurs when patients are treated chronically with diuretics. However, 
ACE inhibitors decrease renal potassium losses and raise serum potassium levels, so many patients 
with heart failure who are treated with both agents may not develop potassium depletion. All patients 
should have their serum potassium levels checked frequently (e.g., every 3 days until stable) during 
initiation, titration, or modification of diuretic or ACE inhibitor therapy and every few months thereafter. 
Potassium-sparing diuretics should be used with great caution, if at all, in patients taking ACE inhibitors.

ACE INHIBITORS
Because of their beneficial effect on mortality and functional status, angiotensin-converting enzyme
(ACE) inhibitors should be prescribed for all patients with left-ventricular systolic dysfunction 
unless specific contraindications exist: (1) history of intolerance or adverse reactions to these 
agents, (2) serum potassium >5.5 mEq/L that cannot be reduced or (3) symptomatic hypotension.

If diuretic therapy is initiated in patients with clinical volume overload and left-ventricular systolic 
dysfunction is confirmed as the cause of symptoms, an ACE inhibitor should be added, even if the 
patient has become asymptomatic on diuretics. Patients should be assessed closely for volume 
depletion before therapy is initiated (ortho-static hypotension, prerenal anotemia, melabolic
alkalosis), and if volume depletion is evident, diuretics should be withheld for a brief period 
(24 to 48 hours) until volume depletion resolves. ACE inhibitors may be considered as first-line 
therapy in the subset of heart failure patients who present with fatigue or mild dyspnea on
exertion and who do not have any other signs or minimal symptoms of volume overload. 
Diuretics may be added if symptoms persist.

If serum creatinine is 3.0 mg/dL or greater, ACE inhibitors should be used with caution and titrated 
upward slowly, as tolerated, to a maximum of half the usual maintenance dose. Patients with lesser 
degrees of renal insufficiency also require close follow-up and a reduced dose if the glomeerular filtration 
rate is less than 30 mL/min.

Hyperkalemia is considered a contraindication to ACE inhibitor therapy unless the serum potassium 
can be reduced. Potassium-sparing diuretics should be stopped in all patients who are being started 
on ACE inhibitors, regardless of the serum potassium.
These agents may be restarted if the patient remains hypokalemic on full therapeutic doses of ACE 
inhibitors. 

Potassium supplements should also be withheld unless the serum potassium is low(<4.0 mEq/L).

Patients with low blood pressure must also be carefully monitoied but therapy should be continued.
In the absence of orthostatic hypotension, a systolic blood pressure of 90 mm Hg is perfectly acceptable.
Some patients with heart failure will feel best with a blood pressure below 90 mm Hg. If a physician is 
uncomfortable treating with ACE inhibitors in the setting of a low blood pressure, he or she should 
refer the patient to someone with expertise in treating heart failure, rather than abandon attempts to use 
ACE inhibitors or other vasodilators.

Cough is common in patients taking ACE inhibitors, but it is also common in patients with heart failure. 
Patients who report cough while taking ACE inhibitois should be evaluated to see whether this results 
from pulmonary congestion before considering discontinuing ACE inhibitors. For most patients, the 
cough is a nuisance that they are willing lo tolerate in exchange for the benefits of the medication, 
however, angioedema of the oropharyngeal region is an absolute contraindication to further use of an 
ACE inhibitor.
Recently angiotensin II receptor blockers, such as Losartan, which avoids the side effect of cough, 
have recently become available. 
The outcome of long-term use of these agents in patients with heart failure is cunently under evaluation. 
Hydralazine Isosorbide (HYD/ISDN) is an appropriate  alternative in patients with contraindications or 
intolerance to ACE inhibitors.

Patients who are at high risk for first-dose hypotension should be given a small dose of a
short-acting agent (e.g., Caplopril 6.35 mg) and monitored closely for 2 hours. Patients over the age of 75 
may also be at increased risk for hypotension and may be started on once-daily dosing. If the test dose 
is tolerated, or if a test dose is unnecessary,
Caplopril 12.5mg TIDorLisinopril 2.5mg QD can be started. Patients with hypertension can be started 
on Captopril 25 mg TID or Lisinopril 5 mg QD.

Patients should have blood pressure, renal function, and serum potassium monitored within 1 week of  /httpdocs/cajud/heart
initiation of an ACE inhibitor. 
It is appropriate to contact the patient by telephone 48 hours after an ACE inhibitor is initiated to ask 
about symptoms of hypotension, Treatment should be modified if the patient develops (1) an increase 
in serum creatinine of 0.5 mg/dL or more, (2) a serum potassium of 5.5 mEq/L or higher, or 
(3) symptomatic hypotension.

Doses of ACE inhibitors should be titrated upward over 2 to 3 weeks with the goal of reaching the 
doses comparable to those used in large-scale clinical trials: Captopril 50 mg TID or Lisinopril 20mg QD. 
Volume status should be reassessed if hypotension or a rise in the serum creatine of 0.5 mg/dL occurs 
as the dose is increased. If volume depletion occurs, the dose of the ACE inhibitor should be reduced 
to the highest dose that was previously tolerated and the diuretic dose reduced. 
The dose of the ACE inhibitor should then be increased again. If higher doses are not toleraled despite 
euvolemia, then the lower dose should becontinued or a trial of HYD/ISDN instituted.

Patients with low blood pressure must also be carefully monitored but therapy should be continued.
 

Patients should have blood pressure, renal function, and serum potassium monitored within 1 week 
of initiation of an ACE inhibitor. 
It is appropriate to contact the patient by telephone 48 hours after an ACE inhibitor is initiated to 
ask about symptoms of hypotension.

Doses of ACE inhibitors should be titrated upward over 2 to 3 weeks with the goal of reaching the 
doses comparable to those used in large-scale clinical trials:  Captopril 50 mg TID or Lisinopril 20 mg QD.

With judicious dosing and close follow-up, almost all patients can tolerate these agents.  The full effect of  /httpdocs/cajud/heart
ACE inhibitors on functional status may not be seen for several months.  Patients who tolerate the 
preceding doses but who remain symptomatic may benefit from higher doses.

If patients remain symptomatic on a combination of a diuretic, an ACE inhibitor, and digoxin, a 
consultation should be obtained with a cardiologist if this has not been done previously.
 

With judicious dosing and close follow-up, almost all patients can tolerate these agents. 
The full effect of ACE inhibitor on functional status may not be seen for several months. 
Patients who tolerate the preceding doses but who remain symptomatic may benefit from 
higher doses.

ANTICOAGULATION
Routine anticoagulation is controversial. Patients with a history of systemic or pulmonary 
embolism, atrial fibrillation or mobile left-ventricular thrombi should be anticoagulated to an 
International
Normalizalion Ratio of 2.0 to 3.0.

There has never been a controlled trial of anticoagulalion for patients with heart failure. The risks  /httpdocs/cajud/heart
of routine treatment, including intracranial or gastrointestinal hemorrhage, must be balanced 
against the relatively low reported incidence of significant thromboembolic events in this population.

ATRIAL FIBRILLATION
Atrial fibrillation is present in 10 to 15% of patients with heart failure and it may occur in up to 50% 
of patients with more severe heart failure. If atrial fibrillalion causes sudden, severe worsening of 
heart failure, immediate cardioversion may be necessary.However, most palienis can be stabilized 
by using digoxin to control the heart rate. Once stable, all patients should be considered 
for cardioversion.

Patients with less than one year history of atrial fibrillation should be considered for cardioversion. 
Patients should be anticoagulated to therapeutic levels for 3 to 5 weeks before cardioveision and for 
1 to 2 months after cardioversion.

ADDITIONAL PHARMACOLOGICAL MANAGEMENT
If patients remain symptomatic on a combination of a diuretic, an ACE inhibitor, and digoxin, a
consultation should be obtained wilh a cardiologist if this has not been done previously,

Patients with persistent volume overload despite initial medical management may require more
aggressive administration of the current diuretic (e.g., intravenous administration), more potent
diuretics, or a combination of diuretics. Salt restriction should be re-emphasized and compliance
assessed and encouraged since dietary noncompliance is often the cause of persistent volume overload.

Patients with heart failure and angina who will not or cannot undergo revascularization should be 
treated with nitrates and aspirin. /httpdocs/cajud/heart
Patients with persistent dyspnea after optimal doses of diuretics, ACE inhibitors and digoxin 
should have a Trial of hydralazine and/or nitrates added to the medical regimen. 
The addition of a vasodilator to an ACE inhibitor may also relieve symptoms. Direct vasodilalors 
may be particularly helpful in patients with hypertension or evidence of severe mitral regurgitation. 
Even patients with blood pressure in the usual normal range may benefit by reducing their blood 
pressure with direct vasodilator. Alternatively, if a patient primarily has symptoms of pulmonary 
congestion or has a low syslolic blood pressure, nitrates are preferred over arterial vasodilators.

Patients who remain symptomatic or hypertensive may benefit from more aggressive treatment.
After maximization of conventional therapy, beta blockers, calcium channel blockers, or alpha 
blockers may be employed. However, none of these drugs has been approved specifically for 
use in heartfailure, although carvedilol (Coreg), a new drug with combined alpha and beta blocking 
activity, has been recommended for approval by the Cardiovasular and Renal Drugs Advisory 
Committee. Beta-adrenergic receptor and calcium channel blocking drugs have potential negative 
inotropic effects and should be considered investigational and only given after consultation with 
a practitioner who is experienced in their use in heart failure./httpdocs/cajud/heart

Several studies have demonstrated that the careful titration of beta blockers in selected heart 
failure patients results in improved symptomatology, ventricular function, and exercise tolerance. 
Benefits appear to be more pronounced in patients with idiopathic dilated cardiomyopathy than 
those with coronary disease when compared to placebo-controlled trials. 
Three studies have demonstrated a significant decrease in cardiovascular events, and two 
studies to date have shown improved survival.
Further studies are underway.

Only a few randomized trials of calcium channel blochers in heart failure patienis have been published 
and most trials have shown either no difference or an increase in mortality. The results appear due to 
negative inotropic effects in patients on nondihydropyridine drugs such as verapamil and diltiazem. 
Even some of the dihydropyridine drugs such as nifedipine, nicardipine and isradipine have resulted in 
activation of the renin-angiotensin system and a poor prognosis.
However, recent randomized studies with felodipine and amiodipine have demonstrated improved 
symptoms and no increase in mortality; in fact, there appears to be improved survival in the smaller 
subgroup of patients without coronary disease. 
Therefore, given the informatton currently available, the use of calcium channel blockers in  /httpdocs/cajud/heart
heart failure should be restricted to amlodipine or felodipine; patients on other calcium channel 
blockers should have their therapy changed to one of these agents or an alternative medication.

Use of alpha blockers has not demonstrated benefit in heart failure patients but should be considered 
in patients who remain hypertensive after treatment This is especially important given that hypertension 
often predates worsening heart failure and a poor prognosis.

Several studies have demonstrated that the careful titration of beta blockers in selected heart failure 
patients results in improved symptomatology, ventricular function, and execise tolerance.

...given the information currently available, the use of calcium channel blockers in heart failure should 
be restiricted to amlodipine or felodipine;patients on other calcium channel blockers should have their 
therapy changed to one of these agents or an alternative medication.

The impact of heart faiilure on a patient's life may be related as much to psychological adaptation 
condition as to impairment in physical functioning.

Patients should be encouraged to keep a daily record of their weight and to bring that record with 
them when visiting their practitioner. 
Patients should be carefully instructed in how to change their medical regimen on an as-needed 
basis or call for specific instructions if they experience a weight gain greater than 3 to 5 pounds 
since their last clinical evaluation.
 

GENERAL COUNSELING
After a diagnosis of heart failure is established, all patients should be counseled regarding the 
nature of heart failure, drug regimens, dietary restrictions, symptoms of worsening heart failure, 
what to do if these symptoms occur, and prognosis. The impact of heart failure on a patient's 
life may be related as much to psychological adaptation to the disease as to impairment in 
physical functioning. Nursing interventions, family involvement, and support groups may all 
help patients cope with heart failure. Practitioners should emphasize the importance of not 
smoking or chewing tobacco and should recommend that patients receive vaccination against
influenza and pneumococcal disease.

It is vital that patients understand their disease and be involved in developing the plan for 
their care. In addition, family members and other responsible caregivers should be included 
in counseling and decision-making sessions. Durable power of attorney or other advance 
directives should be discussed with all patients.

ACTIVTTY
Regular exercise such as walking or cycling at a comfortable pace should be encouraged for 
all patients with stable heart failure. Even short periods of bed rest result in reduced exercise  /httpdocs/cajud/heart
tolerance and aerobic capacity, muscular atrophy, and weakness. Recent studies show that 
patients with heart failure can exercise safely, and regular exercise may improve functional 
status and decrease symptoms. An explanation of the importance of exercise can help prevent 
patients from becoming afraid to perform daily activities that might provoke some shortness 
of breath. Patients should be advised to stay as active as possible.

There is insufficient evidence at this time to recommend the routine use of formal rehabilitation
programs for patients with heart failure.

DIET
Dietary sodium should be restricted to as close to 2 grams per day as possible, especially 
in patients with evidence of fluid retention and/or volume overload.

Acute ingestion of alcohol depresses myocardial contractility in patients with known 
cardiac disease. This may be clinically significant in patients with heart failure, although 
there are no studies that address this issue. Complete abstention from alcohol is crucial for 
patients with alcohol-induced cardiomyopathy. For patients without a history of alco-
holism, it is unclear whether abstinence makes a difference in functional status or mortality 
In general alcohol use should be discouraged. If patients want to continue to drink, they should 
be strongly advised to have no more than one drink per day.
0ne drink equals 4oz.of wine, 12oz of beer, or a mixed drink or cocktail containing no more than 
1 ounce of alcohol.

Practitioners should empasize the importance of not smoking or chewing tobacco...

Patients should be advised to stay as active as possible.

Because noncompliance is a major cause of morbidity and unnecessary hospital admissions 
in heart failure, education programs or support gruops should be a routine part of the care of
patients with heart failure.

In general, alcohol use should be discouraged. 

Asymptomatic patients who are found to have moderately or severely reduced left-ventricular 
systolic function (ejection fraction <35 to 40 percent) should be treated with an ACE inhibitor to 
reduce the chance of developing clinical heart failure.

...the ER should be determined in most patients following a myocardial infarction unless they 
are at low risk for significant systolic dysfunction, i.e., unless they meet all of the following criteria:
1.  No previous myocardial infarction.
2.  Ingerior infarction.
3.  Relatively small increase in cardiac enzymes (i.e., <2 to 4 times normal).
4.  No Q waves develop on electrocardiogram.
5.  Uncomplicated clinical course (e.g., no arrhythmia or hypotension).

MEDICATIONS
Medications are prescribed for patients with heart failure for two basic reasons: 
(1) to reduce mortality (angiotensin-converting enzyme [ACE] inhibitors, isosorbide
dinitrate/ hydralazine) and (2) to reduce symptoms and improve ftinctional status (ACE
inhibitors, diuretics, digoxin). Patients should be provided with complete and accurate 
information concerning the medications they are being asked to take, including the reasons 
the medications are being prescribed, dosing requirements and possible side effects.

COMPLIANCE
Because noncompliance is a major cause of morbidity and unnecessary hospital admissions 
in heart failure, education programs or support groups should be a routine part of the care 
of patients with heart failure. Noncompliance may reduce life expectancy and is also a major 
cause of hospitaliations. Practitioners should be attuned to the problem of noncompliance 
and its causes and should discuss the importance of compliance at Follow-up visits and 
assist patients in removing barriers to compliance.

PROGNOSIS
Heart failure is a serious disease and it is important that patients receive information concerning 
their prognosis in order to make decisions and plans for the future. Prognosis can vary 
considerably depending upon etiology, functional class, and response to therapy. 
Studies quote mortality rates from 5 to 5O% per year depending upon these factors and there
are indications that newer forms of therapy have improved prognosis.

Practitioners should discuss patients' decisions regarding resuscitation and all patients should
be encouraged to complete a durable power of attorney for health care or another form of advance 
directive.

If a patient desires resuscitation, family members should consider learning cardio-pulmonary 
resuscitation. Such a course should be combined with psychosocial support for patients and 
family members because it may otherwise have negative psychological consequences.

Patients, families, and caregivers must be provided with the accurate information necessary to make
decisions and plans for the future, while maintaining hope and emphasizing that good quality of life
is still possible.

Patients who have been hospitalized for heart failure should be contacted within 2 to 4 days of discharge...

Appropriate laboratory tests should also be checked within 7 days following discharge, and medication 
adjusted as necessary.

HOSPITAL MANAGEMENT
The presence or suspicion of clinically evident heart failure and any of the following findings usually
indicate a need for observation or hospitalization:
* clinical or electrocaidiographic evidence of acute myocardial ischemia,
* moderate or severe pulmonary edema or severe respiratory distress not responsive to treatment,
   oxygpn saturation below 90 percent (not due to pulmonary disease),
* severe complicating medical illness (e.g., pneumonia),
* symptomatic hypotension or syncope, heart failure refractory to outpatient therapy,
* inability to arrange adequate social support for safe outpatient management, or
* new onset and poorty tolerated supraventricular tachyarrhythmias.

Occasionally, patients with one of the above findings may be managed at home or in an assisted 
living or nursing home setting if the clinician believes it is safe to do so and adequate follow-up 
can be arranged. Heart failure is one of the most common causes for recurrent admission to hospitals, 
and many of these admissions may be avoidable. Readmission rates as high as 57 percent within 90
days have been reported in patients over the age of 70 years. Proper discharge planning is essential
to prevent unnecessary readmissions.

Patients with heart failure should be discharged from the hospital only when:
*symptoms of heart failure have been adequately controlled,
* all reasons for admission haw been treated or stabilized,
* patients and their caregivers have been educated about medications, diet, activity, and 
exercise recommendations, and symptoms of worsening heart failure, and
* adequate outpatient support and follow-up care have been arranged.

This guideline does not address management strategies specific to the hospital setting 
(e.g.,invasive hemodynamic monitoring, intravenous dobutamine). Refer to Inpatient Care Path.
 

REVASCULARIZATION
Coronary artery disease is currently the most common cause of heart failure in the US. 
Some patients may benefit from revascularization.
In particular, patients with viable myocardium subserved by substantially stenotic vessels 
may reasonably be expected to obtain longevity benefits and, perhaps, improved quality of
life if the stenosis is successfully relieved. On the other hand, revascularization entails significant 
morbidity and mortality. Before studies are initiated to determine if patients are candidates for 
revascularization (i.e., have viable myocardium supplied by stenotic arteries), it is important 
to determine first if any conditions exist that may preclude intervention or that could raise the 
risk of revascularization above any potential benefit These may include:
* patient would not consider surgery or is unable to give informed consent,
*severe comorbid diseases, especially renal failure, pulmonary disease, or 
cerebrovascular disease (e.g., severe stroke),
* very low ejection fraction (i.e., <20%),
* illnesses with a projected life expectancy less than or equal to 1 year. 
These include advanced cancer, severe lung or liver disease, chronic renal disease, 
advanced diabetes mellitus, and advanced collagen vascular disease, or 
*technical factors, including previous myocardial revascularization or other cardiac 
procedure, history of chest irradiation, and diffuse distal coronary artery atherosclerosis.

Patients without contraindication to revascularization should be advised of the possibility 
of revascularization, including its potential benefits and known risks.

Three parameters are important:
(1) likelihood of surgically correctable lesions,
(2) Bipedal benefits of revascularization, and
(3) expected risks and potential harms of
revascularization.

These parameters vary depending on several factors, including whether clinical evidence 
of myocardial ischemia is present and the patient's general state of health.

The three major randomiad clinical trials involving revascularization excluded patients with 
marked left ventricular dysfunction (EF< 35% in CASS). In addition, patients were required 
to have clinical evidence of ischemia and demonstrated benefits have largely been proportionate
to the degree of myocardium at risk. In general, the presence of heart failure increases perioperative 
risk but appropriately selected patients with heart failure may experience substantial benefit.

Counseling should be based on patients' particular characteristics, particularly on an assessment 
of patients' risk factors for coronary artery disease.

Patients can be classified into three major subgroups:
(1) patients who have neither angina nor a history of infarction, (2) patients without 
significant angina(angina that limits exercise or occurs frequently at rest), but who 
have a history of MI, and (3) patients
with significant angina pectoris.

Coronary artery disease is currently the most common cause of heart failure in the US. 
Some patients may benefit from revascularization.

In general, the presence of heart failure increases perioperative risk but appropriately  /httpdocs/cajud/heart
selected patients with heart failure may experience substantial benefit.

Patients without contraindication to revascularization should be advised of the possibility 
of revascularization, including its potential benefits and known risks.

The likelihood of coronary disease in heart failure patients without angina or history of 
myocardial infarction varies depending on patient risk factors.

...there is no evidence from controlled trials to show that revascularization benefits heart 
failure patients in the absence of evidence of reversible ischemia.

The decision about whether to perform physiological tests for ischemia or coronary 
angiography should be based on a consideration of patients' risk factors for coronary 
artery disease and the likelihood of alternative etiologies (e.g., alcoholic cardiomyopathy).

Patients without angina but with a history of MI should be advised to undergo an adequate 
physiologic test  for ischemia.
 

NO ANGINA AND NO MI
The likelihood of coronary disease in heart failure patients without angina or history of 
myocardial infarction varies depending on patient risk factors (e.g., age, sex, smoking history,  /httpdocs/cajud/heart
hyperlipidemia, hypertension, family history of premature coronary artery disease, and diabetes).

Patients should he counseled concerning the expected benefits and risks of evaluation for 
ischemia, including the fact that there is no evidence from controlled trials to show that 
revascularization benefits heart failure patients in the absence of evidence of reversible 
ischemia.

It is unclear whether patients who are unlikely to have coronary disease should be 
routinely evaluated for ischemia. 
The decision about whether to perform physiological tests for ischemia or coronary 
angiography should be based on a consideration of patients' risk factors for coronary 
artery disease and the likelihood of alternative etiologies 
(e.g., alcoholic cardiomyopathy). If the decision is made to proceed with an evaluation,
noninvasive testing for ischemia (e.g., thallium scanning) should be performed as the 
initial test; coronary angiography may be performed if noninvasive testing 
demonstrates ischemia or is inconclusive.

Given that non-invasive listing is sometimes more difficult to interpret in patients with 
cardiomyopathy, there should be a low threshold for contacting a cardiologist or considering 
angiography in patients with significant risk factors for coronary disease.

NO ANGINA AND HISTORY OF MI
Available evidence supports that as many as half of patients who suffer a myocardial 
infarction have clinically important myocardial ischemia in areas supplied by other coronary 
arteries. There are no data, however, to show that revascularization of these areas is 
beneficial, in terms of increased life expectancy or enhanced quality of life, in the absence 
of angina. Nevertheless, patients with large areas of ischemia may possibly benefit from 
revascularization.

There are a number of acceptable physiologic tests for ischemia. Clinicians must be familiar 
with the availability, quality, and cost of the different physiologic tests for ischemia and 
should use this information in deciding what test to order. The most widely available and 
accepted procedure for determining the presence of ischemic myocardium is myocardial  /httpdocs/cajud/heart
perfusion scintigraphy, such as thallium scanning, with post-stress, redistribution, and 
rest reinjection imaging.
 

ANGINA
The potential benefit of revascularization is clearest and probably greatest in individuals 
with severe or limiting angina or angina-equivalent (e.g., recurrent acute episodes of pulmonary 
edema despite appropriate medical management). Available evidence suggests that about 
75 percent of heart failure patients with significant concomitant angina have operable disease.
Although the three randomized trials of coronary artery bipass graft (CABG) surgery excluded 
patients with heart failure or severe left-ventricular dysfunction, several cohort 
studies and registries suggest that patients with angina and impaired left-ventricular function 
have improved functional status and survival if they undergo bypass surgery.

Heart failure patients without contraindications to revascularization and who have 
exercise-limiting angina, angina that occurs frequently at rest, or episodes of acute pulmonary 
edema that may be secondary to ischemia should be advised to undergo coronary artery 
angiography as the initial test for significant coronary lesions. Some patients may need 
physiological testing for ischemia to interpret the significance of the findings from coronary 
artery angiography.

COUNSELING AND DECISION
Based on the results of physiological testing and/or cardiac catheterization, a cardiologist 
should give the patient a refined estimate of the risks and benefits of revascularization. 
The patient can then decide if he or she desires revascularization.

No data are available that address the question of how much ischemia should be present
to justify the risk of revascularization for the chance of an improvement in survival. 
In general, patients with severely depressed ejection fractions (EF <20 percent) should 
undergo revascularization only if large areas of ischemia are detected. Patients with less 
severely depressed ejection fractions may be willing to risk surgery for more modest-sized 
ischemic areas. The lack of data in this area makes it difficult to justify revascularization 
for small ischemic areas, except when severe angina is present.

Coronary angiography should be considered if: (1) ichemic regions are detected, or 
(2) physiologic test is inconclusive, or 
(3) physiologic test shows a fixed defect outside the infarct zone.

The potential benefit of revascularization is clearest and probably greatest in individuals with 
severe or limiting angina or angina-equivalent.

Available evidence suggests that about 75 percent of heart failure patients with significant 
concomitant angina have operable disease.

On follow-up visits, patients should be asked about the presence of orthopnea, paroxysmal 
nocturnal dyspnea, edema, and dyspnea on exertion.   It is important to remember that patients 
are likely to experience changes in symptoms before there is evidence of deterioration by 
physical examination.

Revascularization

Coronary artery bypass grafting is the only revascularization procedure that has been shown 
to prolong life in patients with angina and left-ventricular dysfunction. 
The effect of coronary artery angioplasty on survival of heart failure patients has not been studied,
nor are the risks of angioplasty in heart failure patients known at this time.  The choice between
CABG and angioplasty will depend on numerous considerations, including multiple technical 
factors (e.g., coronary anatomy), relative risk of the two procedures in individual patients, and 
patient preferences.  A discussion of these factors lies beyond the scope of this guideline.

Follow-up

Careful history and physical examination should be major guides to determining outcomes
and directing therapy.  A thorough history would evaluate satisfaction with current lifestyle
and include questions regarding physical and mental functioning and the presence or absence 
of heart failure symptoms.

On follow-up visits, patients should be asked about the presence of orthopnea, paroxysmal 
nocturnal dyspnea, edema, and dyspnea on exertion.  It is important to remember that patients 
are likely to experience changes in symptoms before there is evidence of deterioration by physical 
examination.

Patients should be encouraged to keep a daily record of their weight and to bring that record with 
them when visiting their practitioner.  Patients should be carefully instructed in how to change 
their medical regimen on an as-needed basis or call for specific instructions if they experience a 
weight change greater than 3 to 5 pounds.

Family members or other caregivers can often contribute important additional information about 
the patient's status and compliance when asked similar questions.  In some cases, it may be desirable
to interview family members or other caregivers apart from the patient in order to validate the patient's 
report.  If discrepancies do occur, additional measures need to be instituted for clarification.  In addition 
to questions about symptoms and activities, providers should ask about other aspects of patients' 
health-related quality of life, including sleep, sexual function, mental health (or outlook on life), appetite,  /httpdocs/cajud/heart
and social activities.  A worsening in any of these parameters may indicate the need to adjust therapy. 
To ensure optimal care for heart failure, the provider must view the disease in the broad context of the 
patient's life and see how the patient is coping with the disease.  Consultation with psychologists,
dietitians, health educators, and clinical nurse specialists may be necessary to deal with specific problems 
such as depression, difficulties adhering to complicated dietary or medical regimens, or poor 
functional status.

The team recommends against the routine use of invasive or noninvasive tests, such as 
echocardiography 
or maximal exercise testing, for monitoring the response of heart failure patients to treatment. 
No data exist to suggest that the monitoring of these endpoints contributes information beyond 
that obtained by a careful history and physical examination.  However, repeat testing may be useful 
in patients with a new heart murmur, a new myocardial infarction, or sudden deterioration despite 
compliance with medications.  Repeat testing as part of the evaluation for transplantation may also be 
necessary.

Heart Transplantation

Patients with severe functional limitations or repeated hospitalizations despite aggressive  /httpdocs/cajud/heart
medical therapy in whom revascularization is not likely to convey benefit should be considered 
for cardiac transplantation.  Kaiser Permanente has a regional heart transplant program at 
Santa Teresa Kaiser where pre-transplant and post-transplant care are performed. 
The transplant surgery is performed at Stanford or another designated center of excellence.

The program at Santa Teresa is part of a Kaiser Permanente national transplant network 
which has standarized criteria for transplant candidacy.  These are available upon request
and similar to those used throughout the country.  These criteria require that the patient 
be unlikely to benefit from other therapy, that heart transplantation be likely to confer 
benefit and that any cormorbid states be unlikely to significantly offset the expected benefit.

Patients thought to be candidates for cardiac transplant should be referred for cardiac 
consultation at the local facility.  Subsequently, the cardiologist can refer the patient 
for formal evaluation.  A history and phsycial, including details of recent attempts at improving 
medical therapy, and pertinent study results can be sent to the heart transplant service. 
Patients who are candidates for heart transplantation will generally have a number of 
poor prognostic indicators, such as reduced LVEF (<20%), markedly increased left-ventricular 
size (LVEDD>7.0 cm), severe symptoms (advanced NYHA Class III or Class IV), low exercise 
tolerance (measured objectively as maximum oxygen consumption), evidence of activation 
of the renin-angiotensin system (low serum Na++), and a low cardiac index (<2.0) despite 
aggresive medical therapy.  In addition to the history and physicial, the avaluation includes a 
panel of laboratory tests available as STR Panel 1, a chest x-ray, and EKG, an echocardiogram, 
dietary and psychosocial evaluations, pulmonary function tests, exercise ergometry, and 
right heart catheterization.  Selected patients undergo carotid and peripheral arterial dopplers, 
measurement of creatinine clearance, and abdominal ultrasound.  Emergency consults should /httpdocs/cajud/heart
be directed to Dr. Susan Woodley or the cardiologist on call through the Santa Teresa page 
operator at 8-440-7188 or (408) 972-7188.

Patients whose symptoms are controlled need not be referred for transplantation but may benefit 
from contact with the transplant service.  Patients ineligible for transplantation on the basis of 
comorbid conditions should be informed of the availiability of experimental protocols, although 
such programs may not be an insured benefit available through Kaiser Permanente. 
In summary, heart failure is a treatable condition which many patients can live with comfortably. 
Most patients will sustain substantial benefit from education as well as dietary and medical 
management.  Such therapies should be maximized prior to consideration for heart transplantation
and experimental surgical procedures.

This guideline is one component of a multi-disciplinary approach to the treatment of heart 
failure which is designed to maximize patient outcomes and potentially minimize the need 
for heroic procedures.
 

To ensure optimal care for heart failure, the provider must view the disease in the broad 
context of the patient's life and see how the patient is coping with the disease. 
Consultation with psychologists, dietitians, health educators, and clinical nurse 
specialists may be necessary to deal with specific problems...

The team recommends against the routine use of invasive or noninvasive tests, such as 
echocardiolography or maximal exercise testing, for monitoring the response of heart 
failure patients to treatment.

Kaiser Permanente has a regional heart transplant program at Santa Teresa Kaiser 
where pre-transplant and post-transplant care are performed.

In summary, heart failure is a treable condition which many patients can live with comfortably. 
Most patients will sustain substantial benefit from education as well as dietary and medical 
management.  Such therapies should be maximized prior to consideration for heart transplantation 
and experimental surgical procedures.