Introduction
Heart failure is a clinical syndrome characterized by signs and symptoms of intravascular and interstitial volume overload and manifestations of inadequate tissue perfusion, such as fatigue, poor exercise tolerance, orthopnea, paroxysmal nocturnal dyspnea, or dyspnea on exertion.

Initial Evaluation
1. To establish the diagnosis of CHF a physical examination should be performed including:

• Exam for jugular venous distention
• Cardiac auscultation
• Pulmonary exam
• Peripheral edema

2. Initial diagnostic tests to confirm the diagnosis include:

• CXR
• Patients with symptoms highly suggestive of CHF should have an echocardiogram performed due to the lack of sensitivity of physical findings in some patients with CHF.
• Patients with mild symptoms such as fatigue or peripheral edema should only undergo echocardiography if there are physical or radiologic findings suggestive of heart failure.

3. Patients with a confirmed diagnosis of congestive heart failure should have the following tests performed to screen for underlying causes of the heart failure.

• ECG
• CBC
• UA
• Serum Creatinine
• Serum Albumin
• If the patient is in atrial fibrillation/ flutter or is over 65 years old, a T4 or TSH should also be obtained.
• Echocardiogram

Treatment of CHF

1. The goal of treatment is to control symptoms and to identify and address all reversible causes of morbidity.

2. Patient should be considered candidates for hospitalization if:

• There is evidence of acute myocardial ischemia
• Heart failure is refractory to optimal outpatient therapy
• The patient has acute pulmonary edema or severe respiratory distress

3. If there are symptoms or findings of volume overload, the patient should be immediately started on diuretics. In general loop diuretics are preferred. For patients with severe symptoms or significant findings the diuretics should be administered intravenously. Avoid over-diuresing the patient prior to initiation of ACE inhibitor therapy as dehydration increases the potential for renal side effects.

4. ACE inhibitors should be prescribed to all patients with heart failure who do not have contraindications, due to evidence that these medications reduce mortality and improve functional status. ACE inhibitors frequently need to be used at higher than average doses to have the desired effect on a patient with CHF. Mild or transient side effects are not an indication to discontinue ACE inhibitors for these patients. Alternative agents for patients who cannot take ACE inhibitors include isorbide dinitrate and hydralazine.

5. Digoxin can be very effective in patients with CHF. Digoxin should be initiated along with ACE inhibitors in patients with severe CHF. For patients with milder CHF ACE inhibitors alone may be sufficient to control symptoms. Digoxin has not been demonstrated to reduce mortality.

6. Routine anticoagulation is not indicated for patients with CHF unless there is evidence of systemic or pulmonary emboli or recent atrial fibrillation.

7. A beta blocker should be prescribed to patients with stable NYHA Class II or Class III in the absence of a contraindication or known intolerance to beta blockers. This therapy is generally in addition to an ACE inhibitor and diuretic.

8. Measurement of left ventricular function should be performed on all patients with CHF. LVF measurement is important to establish if the heart failure is due to dilated cardiomyopathy, left-ventricular diastolic dysfunction, valvular heart disease, or a noncardiac etiology. This measurement can be by echocardiography or radionuclide ventriculography. Most patients with clinically significant CHF will have a ventricular ejection fraction of 40% or less.

• In patients with asymptomatic left ventricular ejection fractions of less than 35-40%, an ACE inhibitor should be started to reduce the possibility of developing clinical CHF.

9. The patient should be educated about CHF including diet, exercise, and the importance of compliance with recommendations. The patient should also be instructed in symptoms of recurring or worsening heart failure and what to do if that occurs.

• Dietary sodium should be restricted to 2 grams per day.
• Alcohol use should be discouraged, no more than one drink per day.
• Excessive fluid intake should be discouraged, but fluid restriction is rarely indicated.
• Moderate exercise such as walking or bicycling should be encouraged.

10. Consider referral to the Humana CHF Disease State Management program. This program emphasizes preventive care of patients with CHF on an outpatient basis via education, home nursing visits, and follow-up by telephone.

11. Patients and their families should be informed about the serious nature of CHF disease. Because of the high mortality rate, patients should be encouraged to consider a living will and advanced directives forms.

Follow-up

1. On follow-up visits the patient should be asked about the presence or absence of orthopnea, dyspnea, PND, and edema.

2. Patients should be encouraged to keep a record of their daily weights. An action plan should be developed so that if the patient experiences unexplained weight gain of greater than 3 pounds since their last clinical evaluation the patient can take action (call physician or take additional medication).

3. Patient compliance with the treatment regimen should be assessed and barriers to compliance addressed. Educational programs and support groups can be very helpful in improving patient compliance.

4. Providers should also inquire about health related quality of life issues including sleep, mental health, sexual function, and social activities.

5. Repeat echocardiograms or exercise testing is not indicated for patients with a history of CHF unless the patient suddenly deteriorates despite compliance with the treatment regimen.