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Cardiovascular Alterations and Management 235
Severe symptoms (NYHA Class IV)
Identify/treat acute Non-pharmacological Pharmacological
precipitant treatment treatment
Acute ischaemia/ Multidisciplinary care*
infarction Salt/fl uid restriction
Arrhythmia Exercise/conditioning
Non-compliance program
Diuretic
+ ACEI**
No improvement Improved
Add spironolactone Add beta-blocker
+/- digoxin
+/- angiotensin II receptor
antagonists
No improvement Improved
Add hydralazine/nitrate Add beta-blocker
Consider heart (irrespective of NYHA
transplantation Class***)
Not tolerated Tolerated
Consider heart Continue medical
transplantation if age treatment
<65 years + no major
comorbidity
* Multidisciplinary care (pre-discharge and home review by a community care nurse, pharmacist and allied health personnel)
with education regarding prognosis, compliance, exercise and rehabilitation, lifestyle modifi cation, vaccinations and
self-monitoring.
** If ACEI intolerant, use angiotensin II receptor antagonists instead.
*** Patients with NYHA Class IV CHF should be challenged with beta-blockers provided they have been rendered euvolaemic
and do not have any contraindication to beta-blockers.
FIGURE 10.13 Pharmacological treatment of refractory systolic heart failure. Courtesy National Heart Foundation of Australia and the Cardiac Society
55
of Australia and New Zealand.
