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National Collaborating Centre for Chronic Conditions (UK). Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care. London: Royal College of Physicians (UK); 2003. (NICE Clinical Guidelines, No. 5.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

8Monitoring

Heart failure is a chronic condition with a high mortality and a considerable impact on the patient’s (and often carer’s) quality of life. The clinical condition may fluctuate and repeated admission to hospital is common, particularly for patients with more severe heart failure and other co-morbidities.166,204 Treatment usually involves the prescription of several drugs, as outlined in the earlier parts of this guideline. Monitoring of the clinical status is necessary and will involve healthcare professionals in both primary and secondary care. Assessment of cognitive state, such as detecting acute confusion; and monitoring for development of anxiety or depression, is also important. Work with focus groups suggests that many patients and their carers do not know how to access medical advice should the clinical condition deteriorate, thus limiting the possibility of early intervention to reduce the need for readmission to hospital. Patients and their carers are playing an increasing role in monitoring, but this requires appropriate education and support. This section of the guideline gives guidance on the monitoring of patients with heart failure.

8.1. Clinical review

There have been few direct comparisons of the impact of different intensities and frequencies of monitoring of patients with chronic heart failure – although almost all published studies comparing closer, more frequent contact with a healthcare professional who has experience in managing heart failure with ‘routine’ care report an improvement in quality of life for patients, and a reduction in the need for urgent hospitalisation.205–208 (I)

It is not clear which components of these programmes are responsible for the benefit. Authors of trials have commented that more frequent contact with health professionals in itself may have a beneficial clinical effect. Monitoring of patients with chronic heart failure is necessary for a variety of reasons, and the guideline development group agreed a pragmatic approach as suggested below. (IV)

At clinical review the following assessments should be made:

  1. Assessment of functional capacity Chiefly from history, but more objectively by use of NYHA Class, specific Quality-of-life questionnaires, 6 minute walk test, or maximal exercise test. NB Not all of these tests are likely to be necessary, or appropriate, at each assessment.
  2. Assessment of fluid status Chiefly by physical examination – changes in body weight, extent of jugular venous distension, lung crackles and hepatomegaly, extent of peripheral oedema, and lying and standing blood pressure (postural drop in blood pressure may indicate hypovolaemia).
  3. Assessment of cardiac rhythm Chiefly by clinical examination, but may require 12 lead electrocardiogram (ECG) or 24 hour electrocardiographic monitoring (‘Holter’) if suspicion of arrhythmia.
  4. Laboratory assessment Checking of serum biochemistry (urea, electrolytes, creatinine) is essential, but other tests (such as thyroid function, haematology, liver function, level of anticoagulation) may also be required depending on the medication prescribed and co-morbidity.

8.2. Review of management plan – including medication

The guideline development group recommended that the assessment of nutritional and cognitive status may also be helpful in determining the overall management plan for the patient with heart failure. Nutritional assessment is not always clear-cut, especially where fluid retention masks malnutrition, so that use of a screening tool209 and referral to a dietitian for assessment (and management) may sometimes be appropriate. (IV)

8.3. Serial cardiac imaging

There is no evidence that serial chest radiographs, Doppler echocardiograms or invasive haemodynamic monitoring improve clinical management over and above the items mentioned above. (IV)

8.4. Therapeutic drug monitoring of serum digoxin concentrations

There is no evidence from RCTs that routine monitoring of serum digoxin concentrations improves survival or quality of life for patients with heart failure who are prescribed this therapy. A systematic review of therapeutic drug monitoring suggested that such monitoring may reduce the risk of toxicity.210 Several studies have reported a very high proportion of requests for serum digoxin measurement were not acted upon or were inappropriate in terms of timing (which should be 8–12 hours after the last digoxin dose and several days after a change in dosage).211–213 The most recent guidelines from the American College of Cardiology and American Heart Association do not advocate the measurement of serum digoxin concentration to assess efficacy of therapy, but rather as an aid to the detection of toxicity.68 (IV)

Electrolyte abnormalities (particularly hypokalaemia or hypomagnesaemia) may increase the risk of toxicity, even with serum concentrations of digoxin within the so-called ‘therapeutic range’ of 0.7–2 ng/ml. Deteriorating renal function increases the risk of high serum concentrations of digoxin, as do certain drugs (eg amiodarone, spironolactone). Please see British National Formulary for further details (http://bnf.org)

8.5. Serial measurement of circulating natriuretic peptide concentration

Updated in August 2010

Serial measurement of plasma NTproBNP concentrations has been shown in one small RCT to reduce the risk of decompensation,214 but further trials are ongoing. Currently it is not possible to give advice on the added value of serial measurement of plasma BNP or NTproBNP in the monitoring of patients with heart failure, but further evidence should be available within the next two years. (Ib)

8.6. Patient self-monitoring and remote monitoring

Updated in August 2010

After appropriate education, some patients may be able to monitor their volume status, usually by regular weighing, with adjustment of their therapies (most typically diuretic dose) in response to changes in weight. To be successful the patient needs to know how to adjust their therapy, and when to access help when their symptoms deteriorate or fail to respond to these first-line measures. More complex remote monitoring (such as telemonitoring) of patients with heart failure is in its infancy, but shows promise for the future. (IV)

RECOMMENDATIONS

Updated in August 2010

R60.

All patients with chronic heart failure require monitoring. This monitoring should include: [GPP]

  • a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse) fluid status, cognitive status and nutritional status
  • a review of medication, including need for changes and possible side-effects
  • serum urea, electrolytes and creatinine.*
R61.

More detailed monitoring will be required if the patient has significant co-morbidity or if their condition has deteriorated since the previous review. [GPP]

R62.

The frequency of monitoring should depend on the clinical status and stability of the patient. Monitoring interval should be short (days to two weeks) if the clinical condition or medication has changed, but is required at least six-monthly for stable patients with proven heart failure. [GPP]

R63.

Patients who wish to be involved in monitoring of their condition should be provided with sufficient education and support from their healthcare professional to do this, with clear guidelines as to what to do in the event of deterioration. [GPP]

R64.

Routine monitoring of serum digoxin concentrations is not recommended.

A digoxin concentration measured within 8–12 hours of the last dose may be useful to confirm a clinical impression of toxicity or non-compliance. [GPP]

R65.

The serum digoxin concentration should be interpreted in the clinical context as toxicity may occur even when the concentration is within the ‘therapeutic range’. [GPP]

Footnotes

*

This is a minimum. Patients with co-morbidities or co-prescribed medications will require further monitoring – please see relevant section above. Monitoring serum potassium is particularly important if a patient is taking digoxin or spironolactone.

Copyright © 2003, Royal College of Physicians of London.
Cover of Chronic Heart Failure
Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care.
NICE Clinical Guidelines, No. 5.
National Collaborating Centre for Chronic Conditions (UK).

NICE (National Institute for Health and Care Excellence)

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