Chronic heart failure — MSF Clinical guidelines

What this guideline says

GMJ summary

This MSF clinical guideline provides a practical approach to managing chronic heart failure in resource-limited settings. It distinguishes left-sided, right-sided, and global heart failure presentations, uses the New York Heart Association (NYHA) functional classification (Classes I–IV) to assess severity, and emphasises identification of causative or aggravating factors including coronary disease, hypertension, anaemia, rheumatic fever, and American trypanosomiasis.

The treatment strategy combines lifestyle modification (salt reduction, smoking cessation, weight loss if BMI ≥ 25) with stepwise pharmacotherapy. Diuretics (furosemide starting at 20 mg once daily, titrated to 80 mg 1–2 times daily if needed) address fluid retention. Long-term management centres on ACE inhibitors (enalapril titrated from 2.5 mg to a target of 20 mg once daily over 2 weeks), followed by beta-blockers (bisoprolol starting at 1.25 mg once daily, gradually increased to maximum 10 mg daily over 13 weeks) once the patient is stable for at least 2 weeks on ACE inhibitors. Spironolactone (25 mg once daily) may be added in severe cases (Classes III and IV) with appropriate monitoring.

The guideline stresses careful titration, monitoring for hypotension (systolic BP should remain above 90 mmHg), renal function, and electrolytes. It specifies when to use alternative agents (isosorbide dinitrate for ACE-intolerant patients, digoxin only in intensive care for atrial fibrillation with rapid ventricular response), and outlines surveillance requirements including monthly consultations for the first 6 months after stabilisation.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Classify heart failure severity using NYHA Classes I–IV based on functional limitation and symptoms during physical activity
2. Start furosemide at 20 mg once daily, increase to 80 mg 1–2 times daily as needed; oedema reabsorption may take 2–3 weeks
3. Enalapril titration: Week 1: 2.5 mg once daily for 3 days then 5 mg once daily; Week 2: 10 mg once daily for 3 days then target 20 mg once daily (maximum 40 mg daily)
4. Add bisoprolol only after patient stable for at least 2 weeks on ACE inhibitors, starting at 1.25 mg once daily and gradually increasing to maximum 10 mg once daily over 13 weeks
5. Maintain systolic blood pressure above 90 mmHg during ACE inhibitor titration; monitor serum potassium and creatinine levels
6. Consider spironolactone 25 mg once daily for severe heart failure (Classes III and IV) only if potassium levels and ECG can be monitored due to hyperkalaemia risk
7. Weight loss recommended if BMI ≥ 25; reduce salt intake to limit fluid retention
8. After stabilisation, schedule monthly consultations for first 6 months, then individualise follow-up frequency

NYHA Functional Classification of Heart Failure Severity

Table extracted from the guideline

Source: Médecins Sans Frontières, Chronic heart failure — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“ACE inhibitors are the first line treatment. Start with low doses, especially in patients with hypotension, renal impairment, hyponatraemia.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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