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 Table of Contents  
STATE OF THE ART
Year : 2015  |  Volume : 1  |  Issue : 2  |  Page : 105-112

Consensus statement on management of chronic heart failure in India


1 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
3 Department of Cardiology, King's College Hospital, London, United Kingdom
4 Department of CTVS, All India Institute of Medical Sciences, New Delhi, India
5 Department of Cardiology, CARE Hospitals, Hyderabad, India
6 Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
7 Department of Cardiology, GB Pant Hospital, New Delhi, India
8 Department of Cardiology, Dr. Ram Manohar Lohia Hospital, New Delhi, India
9 Department of Cardiology, SJH, New Delhi, India

Date of Web Publication30-Sep-2015

Correspondence Address:
Dr. Sandeep Seth
Department of Cardiology, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-5414.166340

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  Abstract 

Summary of the Consensus Statement: This statement has been prepared keeping Indian heart failure patients in mind. Optimal management of CHF improves quality of life, reduces hospitalization rates and prolongs survival for people with this condition. Echocardiography is the single most useful test in the evaluation of heart failure, and is necessary to confirm the diagnosis. Plasma B-natriuretic peptide (BNP) measurements may be useful in excluding CHF but not mandatory in India. Educate people with CHF about lifestyle changes (e.g., increase physical activity levels, reduce salt intake and manage weight). Educate people with CHF about CHF symptoms and how to manage fluid load. Avoid prescribing drugs that exacerbate CHF. Prescribe angiotensin-converting enzyme inhibitors (ACEI) at effective doses for people with all grades of systolic heart failure, and titrate to the highest recommended dose tolerated. Angiotensin II receptor antagonists (ARA) may be used as alternatives in people who cannot tolerate ACEIs. Mineralocorticoid receptor antagonists (MRAs) should also be used. For people with stabilised systolic heart failure, prescribe beta-blockers that have been shown to improve outcome in heart failure (e.g., bisoprolol, carvedilol, extended release metoprolol or nebivolol). Titrate to the highest recommended dose tolerated. Prescribe diuretics, digoxin and nitrates for people already using ACEIs and beta-blockers to manage symptoms as indicated. For people who have systolic heart failure (New York Heart Association (NYHA) Class II-IV) despite appropriate doses of ACEIs and diuretics, consider prescribing spironolactone. Eplerenone can be considered in certain setting especially post myocardial infarction though it is more expensive. Consider direct sinus node inhibition with ivabradine for people with CHF who have impaired systolic function, have had a recent heart failure hospitalisation and are in sinus rhythm with a heart rate >70 bpm despite beta blockers or where beta blockers are contraindicated Check for, and treat, iron deficiency in people with CHF to improve their symptoms, exercise tolerance and quality of life Consider assessing people with CHF for biventricular pacemakers and implantable defibrillators. Patients with end stage heart failure have an option for heart transplant and ventricular assist devices which is now available in select centers.

Keywords: Consensus statement, heart failure, India


How to cite this article:
Seth S, Bhargava B, Maulik S K, McDonagh T, Saxena A, Airan B, Calambur N, Hote M, Parakh N, Bahl A, Ramakrishnan S, Chaturvedi V, Nath R, Chakroborthy P. Consensus statement on management of chronic heart failure in India. J Pract Cardiovasc Sci 2015;1:105-12

How to cite this URL:
Seth S, Bhargava B, Maulik S K, McDonagh T, Saxena A, Airan B, Calambur N, Hote M, Parakh N, Bahl A, Ramakrishnan S, Chaturvedi V, Nath R, Chakroborthy P. Consensus statement on management of chronic heart failure in India. J Pract Cardiovasc Sci [serial online] 2015 [cited 2018 Dec 13];1:105-12. Available from: http://www.j-pcs.org/text.asp?2015/1/2/105/166340


  Introduction Top


This statement has been prepared keeping Indian patients in mind and is presented for discussion and debate as version 1 and has been prepared by circulation amongst the authors who represent some of the major hospitals in India and are handling large numbers of HF patients. The authors hope that these guidelines would offer a base from which treatment can be started. They provide just a frame work around which treatment can be started. Based on further circulation and discussion, version 2 will be prepared after 1 year.


  Management of Chronic Heart Failure Top


Chronic heart failure

The clinical syndrome of heart failure (HF) may result from disorders of the pericardium, myocardium, endocardium, heart valves, or great vessels, or from certain metabolic abnormalities, but most patients with HF have symptoms due to impaired left ventricular (LV) myocardial function. The cardinal manifestations of HF are dyspnea, edema and fatigue. There is no single diagnostic test for HF because it is largely a clinical diagnosis based on a careful history and physical examination. Echocardiography is useful to assess systolic and diastolic function and cardiac anatomy. Radionuclide angiography is useful to assess cardiac function where echocardiographic images are suboptimal. Coronary angiography should also be considered in patients who have angina or positive noninvasive tests. Cardiac magnetic resonance might be useful in identifying inflammatory and infiltrative disorders and if possible should be done for all patients with cardiomyopathy. Functional capacity should be assessed using the New York Heart Association (NYHA) functional classification.

HF is a major public health problem. It is associated with high mortality and morbidity, frequent, hospitalization and extremely poor quality of life. HF is highly prevalent with hospitalizations for HF being the number one diagnosis related group in patients over the age of 65 years in most Western countries. In India, using calculations based on the morbidity and mortality profiles and prevalence of coronary artery disease (CAD), Hypertension and rheumatic heart disease (RHD), there would be at least 1 million patients with HF at any time.

Epidemiology

Approximately, 5.1 million persons in the United States have clinically manifest HF. HF incidence increases with age, rising from approximately 20/1000 individuals 65–69 years of age to >80/1000 individuals among those ≥85 years of age.

Burden of heart failure in India

In a recent acute HF registry of 90 patients from India,[1] the patients were middle aged (50.8 years) with a mean ejection fraction (EF) of 27.8%. They had a high mortality (in-hospital mortality rate of 30.8%) with a postdischarge 6-month rehospitalization and mortality rates of 39.5% and 26.3%. The mean age was lower than Western cohorts (6, 7, 8) (ranging from 65 to 73 years) such as Euro HF Study, the Acute Decompensated HF National Registry, the Organized Program to Initiate Life-saving Treatment in Hospitalized Patients with HF and the Effects of Oral Tolvaptan in Patients Hospitalized for Worsening HF (EVEREST). This supports the concept that cardiovascular (CV) disease affects patients in India at a younger age than their Western counterparts. The burden of CV disease is increasing in India.

Estimates based both on data of established risk factors for HF as well as small studies suggest that the burden of HF in India is not <2–5 million patients with an estimated prevalence of 2–3/1000 population. Results from clinical trials show that in-hospital mortality associated with CV disease is higher in India than in Western nations. Mortality rates due to myocardial infarction (MI) have been reported as high as 16.7% in Indian hospitals, compared with rates of 4–7% in Western hospitals.[2]

The causes

Causes of congestive heart failure in India

  • RHD (major cause for India)
  • CAD (major cause for India)
  • Conditions that cause pressure overload (e.g., hypertension, aortic stenosis) (major cause for India)
  • Idiopathic dilated cardiomyopathy less common
    • Volume overload (e.g., mitral valve regurgitation)
    • Uncontrolled arrhythmias (e.g., atrial fibrillation [AF])
    • Thyroid dysfunction (e.g., hyperthyroidism, hypothyroidism)
    • Other illness (e.g., amyloidosis, sarcoidosis, scleroderma, haemochromatosis, constrictive pericarditis)
  • Idiopathic.



  Diagnosis Top


The diagnosis of HF is made when symptoms and physical signs of congestion and reduced tissue perfusion are present along with abnormal systolic and/or diastolic cardiac function. The history examination and investigations recommended are outlined below [Figure 1].
Figure 1: Diagnostic Algorithm.

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History and physical examination

  • A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders
  • In patients with idiopathic dilated cardiomyopathy, a three-generational family history should be obtained to aid in establishing the diagnosis of familial dilated cardiomyopathy
  • Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea.


Initial laboratory tests

  • Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea, serum creatinine, glucose, fasting lipid profile, liver function tests, and thyroid-stimulating hormone
  • Serial monitoring, when indicated, should include serum electrolytes and renal function. A 12-lead electrocardiogram (ECG) should be performed initially on all patients presenting with HF.


Biomarkers

  • Not mandatory, only useful if there is diagnostic doubt, not available in many places
  • In ambulatory patients with dyspnea, measurement of B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) is useful to support clinical decision making regarding the diagnosis of HF, especially in the setting of clinical uncertainty
  • The usefulness of BNP or NT-proBNP − guided therapy for acutely decompensated HF is not well-established.


Noninvasive cardiac imaging

  • Patients with suspected or new-onset HF, or those presenting with acute decompensated HF, should undergo a chest X-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient's symptoms
  • A two-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function
  • Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with de novo HF, who have known CAD and no angina, unless the patient is not eligible for revascularization of any kind
  • Viability assessment is reasonable in select situations when planning revascularization in HF patients with CAD
  • Radionuclide ventriculography or magnetic resonance imaging (MRI) can be useful to assess LVEF and volume when echocardiography is inadequate
  • MRI is reasonable when assessing myocardial infiltrative processes or scar burden. MRI is also useful when suspecting myocarditis especially in the 1st month of presentation when it can alter the therapeutic decisions.


Invasive evaluation

  • Invasive hemodynamic monitoring with a pulmonary artery catheter can be performed to guide therapy in patients who have respiratory distress or clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. Routine use of invasive hemodynamic monitoring is not recommended in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators
  • When ischemia (as indicated by stress test and to assess for myocardial revascularization) may be contributing to HF, coronary arteriography is reasonable for patients eligible for revascularization
  • An endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy especially in a setting of dilated cardiomyopathy within a month of presentation of symptoms.


Management of chronic heart failure

The key aims of therapy for HF are to relieve symptoms and prolong survival. Lifestyle measures include exercise (usually a graded exercise program, initially under the supervision of a physiotherapist), dietary salt restriction, alcohol restriction and weight loss in overweight patients. Patients in systemic or pulmonary congestion should be encouraged to consume low amounts of salt and fluid. Treatment of commonly associated conditions, such as hypertension, arrhythmia, depression, anemia, and iron deficiency is essential.


  Routinely Instigate Nonpharmacological Treatment in People With Congestive Heart Failure Top


Strong evidence supports the routine instigation of nonpharmacological measures as a central component of congestive HF (CHF) management.

Educate people with CHF about self-management.

Teach people with CHF to monitor and control their fluid balance.

  • Limit dietary sodium to <2 g/day, and fluid intake to <2 L/day (1.5 L for severe CHF), although this will depend on individual circumstances
  • Limit caffeine to 1–2 drinks per day
  • Use the person's weight after correction of fluid overload as a benchmark. Explain that steady weight gain over days may indicate fluid retention. Instruct people to weigh themselves each morning (after urinating and before dressing and breakfast), and to contact a doctor or specialist HF nurse immediately if there is a 1 kg gain or loss over 48 h
  • Explain symptoms of dyspnea, edema and bloating, and advise people to report these symptoms if detected
  • Some people can learn to self-adjust diuretics (e.g., double the dose if there is evidence of retention)
  • Advise people with CHF about healthy lifestyle and prevention strategies
  • Minimize alcohol intake: Should not exceed one to two standard drinks per day. Patients who have alcohol-related cardiomyopathy should not consume alcohol to help slow their disease's progression
  • Quit smoking
  • Vaccinate against influenza and pneumococcal disease
  • Bed rest when clinically unstable or during an acute exacerbation.


Pharmacological therapies

Drug therapy for HF aims to improve prognosis by inhibiting the renin–angiotensin–aldosterone system and sympathetic nervous system and achieving and maintaining euvolemia.[3]

Angiotensin-converting enzyme (ACE) inhibitors (or angiotensin receptor blockers [ARBs] in those unable to tolerate ACE inhibitors) and β-blockers are the cornerstone of drug therapy for systolic (i.e., low EF) HF. These agents should be initiated at low doses and up-titrated to the target or maximal tolerated dose, as per guidelines. Mineralocorticoid receptor antagonists, in addition to background ACE inhibitor and β-blocker therapy, have been found to be beneficial. Diuretics are primarily used to relieve symptoms through achievement of euvolemia. They have not been shown to provide prognostic benefit. Digoxin is the mainstay therapy to control ventricular response in patients with HF and AF. Its use in sinus rhythm is less though many patients maintained on digoxin worsen on withdrawal of the drug. Therefore it continues to play a role in symptomatic patients with repeated hospitalizations. The use of antiplatelet and anticoagulant therapy in HF is somewhat controversial. For patients with known ischemic heart disease, aspirin, and other antiplatelet agents should be continued. Warfarin should be reserved for patients with chronic HF and AF or where there is a history of embolism.

Specific details are tabulated below:




  Recommendation for Specific Drugs Top


Angiotensin-converting enzyme inhibitor

  • We recommend an ACE inhibitor be used in all patients as soon as safely possible after an MI and be continued indefinitely if EF <40% or if HF complicates an MI
  • We recommend ACE inhibitors be used in all symptomatic or asymptomatic patients with systolic dysfunction and with an EF <40%.


Angiotensin receptor blockers

  • We recommend an ARB be used in patients who cannot tolerate an ACE inhibitor
  • ARB should not be added to ACE inhibitors since the chances of complications are likely to be more in Indian patients.


Spironolactone

Recommended for patients with systolic CHF with severe symptoms (NYHA Class III–IV), despite appropriate doses of ACEIs and diuretics. Not recommended if glomerular filtration rate <30 mL/min. Monitor potassium and renal function regularly, especially in the elderly.

Eplerenone

Recommended early post-MI in patients with LV systolic dysfunction and symptoms of HF. Recommended in patients with systolic HF, who still have mild (NYHA Class II) symptoms despite receiving standard therapies with ACEIs and beta-blockers. This is as per the evidence of published literature and guidelines but eplerenone is costly and in this subset of patients, if patients cannot afford eplerenone they may be prescribed spironolactone though trial evidence for this is lacking.

Beta-blocker

All HF patients with an EF <40% should receive a beta-blocker proven to be beneficial in clinical trial.

We recommend NYHA Class IV patients be stabilized before initiation of a beta-blocker. Though studies have shown that decompensated patients can be initiated on beta-blockers before discharge, this practice in India should be carried out very carefully in view of the very high mortality of the patients seen after discharge. Dose titration of beta-blockers should take place after the first OPD visit after the discharge. If the patient is euvolemic, stable and mobilized at the time of discharge, then a very low dose of beta-blockers can be initiated in the hospital.

Therapy is started at a low dose and titrated to the target dose used in large trials or the maximum tolerated dose if less than the target dose.

We recommend a beta-blocker not be generally introduced to patients with symptomatic hypotension despite adjustment of other therapies, patients with severe reactive airways disease, symptomatic bradycardia, or with significant atrioventricular block without a permanent pacemaker; stable chronic obstructive pulmonary disease is not a contraindication for use of blockade.

Diuretics

  • We recommend a loop diuretic, such as furosemide or torsemide, for most patients with HF and congestive symptoms. When acute congestion is cleared, the lowest dose should be used that is, compatible with stable signs and symptoms
  • We recommend that for patients with persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function, and serum potassium.


Digoxin

  • We recommend digoxin in patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy to relieve symptoms and reduce hospitalizations
  • We recommend digoxin in patients with chronic AF and poor control of ventricular rate despite optimal-beta blockers therapy, or when-beta blockers cannot be used.


Isosorbide dinitrate and hydralazine

We recommend the combination of isosorbide dinitrate and hydralazine be considered in addition to standard therapy for patients unable to tolerate an ACE inhibitor or ARB because of intolerance, hyperkalemia, or renal dysfunction.


  Ivabradine Top


  • NYHA Class II to IV stable chronic HF with systolic dysfunction (EF <35%)
    • In sinus rhythm with a heart rate of 75 beats/min bpm or more
    • Given ivabradine in combination with standard therapy including beta-blocker therapy, ACE inhibitors, and aldosterone antagonists, or when beta-blocker therapy is contraindicated or not tolerated.


Other promising drugs

The angiotensin receptor–neprilysin inhibitor LCZ696 with enalapril in patients who had HF with a reduced EF has recently been approved by Food and Drug Administration (FDA).

Trimetazidine is a cytoprotective drug that normalizes metabolic disturbances in low-flow ischemia via several mechanisms of action. The best-known trimetazidine mechanism of action is its capacity to inhibit β-oxidation of free fatty acid. Fragasso et al. published the results of a large, multicentre, retrospective study, including 669 CHF patients (including 362 patients receiving trimetazide). A follow-up of 38.76 ± 15.66 months in the trimetazidine group and 40.17 ± 15.53 months in the group receiving conventional therapy alone demonstrated that the addition of trimetazidine versus conventional therapy alone is associated with reduced CV hospitalization rate (adjusted hazard ratio [HR] 0.524, 95% confidence interval [CI] 0.352–0.781, P = 0.001), CV mortality (HR 0.072, 95% CI 0.019–0.268, P = 0.0001), as well as overall mortality (HR 0.102, 95% CI 0.046–0.227, P = 0.0001).

The data on trimetazidine is promising, and trimetazidine is often used in patients with HF though as yet it is not recommended in the guidelines due to lack of very big randomized placebo-controlled trials.

Platelet inhibition and anticoagulation

  • We recommend aspirin at a dose 75 mg be considered only in HF patients with clear indications for secondary prevention of CV events
  • We recommend anticoagulation not be used routinely for HF patients who are in sinus rhythm
  • We recommend anticoagulation be considered for patients with demonstrated intracardiac thrombus, previous systemic embolism, or after a large anterior MI or AF (using the CHADS VAS2 score).


Device-based therapies

The two main device-based therapies used in patients with HF are the implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) or a combination of two (CRT-D). ICDs are indicated to reduce sudden death in high-risk patients – about half of patients with systolic HF die a sudden, presumed arrhythmic, death. Implantation of these devices is currently recommended for patients with a low EF (i.e. 30% after MI, irrespective of the severity of symptoms, or 35% in other patients). In resource-poor countries, blindly following guidelines should be debated.

Translating the trial evidence to clinical practice

Clinical trials are instructive to clinicians in determining the best treatments for individual patients. However, there are some important caveats that are particularly relevant to this population. First, we are treating a younger population that is, not well represented in clinical trials. Second, devices are expensive and implementing MADIT-II criteria in particular, is associated with a significant cost burden to healthcare budgets that are coming under increasing pressure. Finally, the potential benefits of ICD therapy could have been overestimated in clinical trials by the use of potentially toxic antiarrhythmic medications in the control groups and by increased use of beneficial beta-blocker therapy in the ICD arms. These are all valid concerns, and we must also balance prognostic benefit against the potential risk of harm as well as financial implications of ICD insertion.

Proposed recommendations for treatment options with ICD or CRT for people with HF who have LV dysfunction with an LVEF of 35% or less (according to NYHA class, QRS duration, and presence of left bundle-branch block [LBBB], and on optimal medical therapy).



These guidelines are written after considering the economic constraints so that it is suggested that ICDs and CRT are implanted in a population likely to benefit the most from these devices. Patients in Class I and ambulatory Class IV and with QRS 120–130 also feature in other Western guidelines. Clinical benefit in this subset is likely to be less. Emphasis should be optimize medical therapy, ensure lifestyle changes and address the comorbid conditions.


  Recommendation for Implantable Cardioverter Defibrillator Top


We recommend an ICD be implanted in patients with a history of hemodynamically significant sustained ventricular arrhythmia (VA) in the absence of a reversible medical cause (secondary prevention). It is important the devices are implanted in patients who have a life expectancy of more than 2 years. Hence careful clinical evaluation is necessary to exclude implants in pts with terminal CHF, and multiple comorbidities.

ICD therapy is suggested for primary prevention of sudden cardiac death to reduce total mortality in selected patients with:

Nonischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-MI.

With LVEF of 35% or less and NYHA Class II or III symptoms, or <30% with NYHA Class I.

With one additional risk factor such as:

  • Frequent ventricular premature complexes or nonsustained ventricular tachycardia on holter, wide QRS on surface ECG, or history of syncope
  • These are recommendations for primary prevention in Western guidelines but for a country like India, these should be individualized and financial resources of the patient and the government also needs to be factored in, therefore, these cannot be kept as mandatory guidelines but just accepted as a subset for which there is evidence of clinical benefit. In clinical practice, not all patients in this subset are getting ICD implants
  • We recommend an ICD not be implanted in NYHA Class IV HF patients who are not expected to improve with any further therapy and who are not candidates for cardiac transplant or mechanical circulatory support
  • Unless there is a definite current or future need of ventricular pacing therapies, a single chamber ICD (as opposed to a dual chamber ICD) should be preferred for prevention of sudden cardiac death. This is relevant for Indian populations as the cost of dual chamber ICD is twice that of single chamber ICD.



  Indications for Cardiac Resynchronization Therapy Top


  • CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, LBBB with a QRS duration of 150 ms or greater, and NYHA Class III, or select ambulatory IV patients
  • CRT can be considered for patients who have LVEF of 35% or less, sinus rhythm, LBBB with a QRS duration of 130–149 ms, and NYHA Class II, III, or select ambulatory IV patients
  • CRT can be considered in patients with AF and LVEF of 35% or less if the patient requires ventricular pacing or otherwise meets CRT criteria and atrioventricular nodal ablation or pharmacological rate control will allow near 100% ventricular pacing with CRT
  • CRT can be considered for patients who have LVEF of 35% or less and are undergoing placement of a new or replacement device implantation with anticipated requirement for significant (>40%) ventricular pacing
  • CRT is not indicated for patients whose comorbidities limit survival to <1 year.


When CRT is implanted in younger patients, without comorbid illnesses, the risk of VAs should be carefully assessed. If patients are at high-risk of VA, CRT-D should be considered.


  Other Medications and Interventions Top


Recommendation heart failure and atrial fibrillation

  • We recommend in patients with HF and AF that the ventricular rate be controlled at rest and during exercise
  • We recommend that restoration and maintenance of sinus rhythm not be performed routinely
  • We recommend beta-blockers for rate control particularly in those with HF with reduced EF
  • We recommend beta-blockers combined with digoxin for uncontrolled ventricular rates on-blocker therapy at optimal dose alone
  • We recommend the use of antiarrhythmic therapy to achieve and maintain sinus rhythm, if rhythm control is indicated, be restricted to amiodarone
  • We recommend oral anticoagulation for AF in HF patients deemed high risk for stroke unless contraindicated per current AF guidelines, and not to coadminister with antiplatelet agents unless the latter are needed for other indications
  • Patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor for cardioembolic stroke (history of hypertension, diabetes mellitus, and previous stroke or transient ischemic attack, or ≥75 years of age) should receive chronic anticoagulant therapy. The selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal AF should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin.



  Recommendations for Iron Therapy Top


  • We suggest that for patients with documented iron deficiency, oral or intravenous iron supplement be initiated to improve functional capacity
  • Testing for ferritin levels and transferrin saturation will better quantify iron deficiency and can be done when clinically indicated
  • We recommend erythropoiesis-stimulating agents (ESAs) not be routinely used to treat anemia in HF. The iron supplement recommendation was derived mostly from the experience of clinicians, small clinical trials, and two large randomized controlled trials (RCTs). The recommendations against the use of ESAs were derived from robust data from RCTs.



  Nonpharmacological Interventions Top


  • Patients with HF should receive specific education to facilitate HF self-care
  • Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF, who are able to participate to improve functional status.



  Recommendations for Inotropic Support Top


Until definitive therapy (e.g., coronary revascularization, mechanical cardiac support [MCS], heart transplantation) or resolution of the acute precipitating problem, patients with cardiogenic shock should receive temporary intravenous inotropic support to maintain systemic perfusion and preserve end-organ performance.

Continuous intravenous inotropic support is reasonable as “bridge therapy” in patients with Stage D HF refractory to guideline-directed medical therapy (GDMT) and device therapy who are eligible for and awaiting MCS or cardiac transplantation.

Short-term, continuous intravenous inotropic support may be reasonable in those hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly depressed cardiac output to maintain systemic perfusion and preserve end-organ performance.

Long-term, continuous intravenous inotropic support may be considered as a palliative therapy for symptom control in select patients with Stage D HF despite optimal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation.

Long-term use of either continuous or intermittent, intravenous parenteral positive inotropic agents, in the absence of specific indications, or for reasons other than palliative care is potentially harmful in the patient with HF.

Use of parenteral inotropic agents in hospitalized patients without documented severe systolic dysfunction, low blood pressure, or impaired perfusion and evidence of significantly depressed cardiac output, with or without congestion, is potentially harmful.


  Cardiac Transplantation Top


Indications

Cardiogenic shock requiring either continuous intravenous inotropic support or MCS with an intra-aortic balloon pump counterpulsation device or MCS.

Persistent NYHA Class IV CHF symptoms refractory to maximal medical therapy (LVEF <20%) and other alternative therapy including CRT. These are often patients with ischemic or dilated cardiomyopathy India.

Congenital heart disease - either primary uncorrectable or failed palliated congenial.

The following two indications are there in Western recommendations but not commonly followed in India, but these indications may be considered for patients with symptoms in spite of maximum medical care.

Intractable or severe anginal symptoms in patients with CAD not amenable to percutaneous or surgical revascularization (this is usually not considered an indication for heart transplant in India).

Intractable life-threatening arrhythmias unresponsive to medical therapy, catheter ablation, and/or implantation of an intracardiac defibrillator.


  Ventricular Assist Device Top


For ventricular assist devices, the decision process is shown below:



Bridge to transplantation: Patient listed for transplant with a severe hemodynamic compromise that is, unlikely to survive without mechanically assisted circulation.

Destination therapy: Patient with HF refractory to medical management but who is ineligible for transplant (most commonly older age, renal dysfunction, pulmonary hypertension, and high body mass index).

Bridge to recovery/decision: Patient with a potentially reversible cardiomyopathy requiring imminent mechanical support or candidacy for transplant cannot be determined at the time that a decision about ventricular assist device implant must be made.




  Conclusion Top


Heart failure is a complex clinical syndrome, with diagnosis based on typical symptoms, signs and supportive investigations. Mainstay therapy for heart failure comprises lifestyle modification, and pharmacotherapy . Medical management, devices and end stage management with assist devices and transplant can provide care for all patients. This statement is meant to provide a simple summary of the current state of art management of heart failure as applicable to India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Seth S, Khanal S, Ramakrishnan S, Gupta N, Bahl VK. Epidemiology of acute decompensated heart failure in India: The AFAR study (Acute failure registry study). J Pract Cardiovasc Sci 2015;1:35-8.  Back to cited text no. 1
  Medknow Journal  
2.
HUFFMAN MD, PRABHAKARAN D. Heart failure: Epidemiology and prevention in India. The National medical journal of India. 2010;23:283-8.  Back to cited text no. 2
    
3.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013 15;128:1810-52.  Back to cited text no. 3
    


    Figures

  [Figure 1]


This article has been cited by
1 Cardiac resynchronization therapy is associated with improvement in clinical outcomes in Indian heart failure patients-results of a large, long-term observational study
Ajay Naik,Balbir Singh,Rakesh Yadav,Ulhas Pandurangi,T.S. Kler,Bhim Shankar,Rajesh Radhakrishnan,Vinayakrishnan Rajan,Vinit Bhatia,Upendra Kaul,Jagmohan Varma,Santosh Dora,C. Narasimhan
Indian Heart Journal. 2018;
[Pubmed] | [DOI]



 

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