PUBLISHED BY:National Heart Association of MalaysiaD-13A-06, Menara SUEZCAP 1, KL GatewayNo.2 Jalan Kerinchi, Gerbang Kerinchi Lestari59200 Kuala LumpureISBN 978-967-11794-4-4COPYRIGHTThe owners of this publication are the National Heart Association of Malaysia(NHAM) and the Academy of Medicine Malaysia. The content in this document maybe produced in any number of copies and in any format or medium provided that acopyright acknowledgement to the owners is included and the content is notchanged in any form or method, not sold and not used to promote or endorse anyproduct or service. In addition, the content is not to be used in any inappropriate ormisleading context. 2019 National Heart Association of Malaysia. All right reserved.

STATEMENT OF INTENTThis clinical practice guidelines (CPG) is meant to be a guide for clinical practice,based on the best available evidence at the time of development. Adherence tothese guidelines may not necessarily guarantee the best outcome in every case.Every healthcare provider is responsible for the management of his/her patientbased on the clinical picture presented by the patient and the management optionsavailable locally.PERIOD OF VALIDITYThis CPG was issued in 2019 and will be reviewed in 5 years or sooner if newevidence becomes available.CPG Secretariatc/o Health Technology Assessment UnitMedical Development DivisionMinistry of Health Malaysia4th Floor,Block E1, Parcel E62590, Putrajaya.Electronic version available on the following rg.myThis is an update to the Clinical Practice Guidelines on Heart Failure (published2000, 2007 and 2014). It supersedes the previous CPGs on Heart Failure (2000,2007, 2014).1

MESSAGE FROM THE DIRECTOR GENERAL OF HEALTHIt gives me great pleasure to write a message for anotherClinical Practice Guideline (CPG) on the Management ofHeart Failure (HF), which is now in its fourth edition. The firstCPG in HF was published in 2000 with revisions in 2007 and2014.Cardiovascular disease is an important cause of morbidityand mortality in Malaysia. HF, the end stage of most diseasesof the heart, is a common medical problem encountered inclinical practice and is an important cause of hospitaladmissions and readmissions. It is also an important cause ofhospital expenditure.Since the last CPG in 2014 the treatment modalities for themanagement of HF has expanded extensively. There havebeen many significant developments in the use of drugs anddevices. These guideline-changing data have beenincorporated into this CPG, taking into account our localhealth resources.A CPG is only successful if it is accepted and implemented.I encourage all healthcare providers involved in themanagement of HF in children and adults to adopt theserecommendations in your practice.Finally, I would like to congratulate the Chairman andmembers of the Expert Committee for developing such acomprehensive CPG. Thanks to you, as well as the ExternalReviewers, for your time and effort.Datuk Dr Noor Hisham AbdullahDirector-General of Health Malaysia2

MEMBERS OF THE EXPERT PANELCHAIRPERSON:Dr. Jeyamalar RajaduraiConsultant Cardiologist,Subang Jaya Medical CentreMEMBERS (in alphabetical order)Dr. Azmee Mohd GhaziConsultant Cardiologist,Institut Jantung NegaraDr. Cham Yee LingConsultant Cardiologist,Sarawak Heart CentreDr. David Chew Soon PingConsultant Cardiologist,Cardiac Vascular Sentral, Kuala LumpurDr. Effarezan Abdul RahmanConsultant Cardiologist,KPJ Damansara Specialist HospitalDr. Haifa Abdul LatiffConsultant Paediatric Cardiologist,Institut Jantung NegaraDr. Izwan Effendy IsmailFamily Medicine Specialist,Klinik Kesihatan PuchongDr. Liew Houng BangConsultant Cardiologist,Hospital Queen Elizabeth IIDr. Ma Soot KengConsultant Cardiologist and Electrophysiologist,Loh Guan Lye Specialist CentreDr. Mohd Nizam Mat BahConsultant Paediatric Cardiologist,Hospital Sultanah AminahDr. Mohd Rahal YusoffConsultant Cardiologist & Specialist in Internal Medicine,Columbia Asia Hospital Klang3

Ms. Nirmala JaganClinical Pharmacist,Hospital Kuala LumpurDr. K. Sree RamanConsultant PhysicianChief Executive Officer,NSCMH Medical Centre, Negeri SembilanDr. Sunita BavanandanConsultant Nephrologist,Hospital Kuala LumpurDr. Vengketeswara Rao SeetharamanFamily Medicine Specialist,Klinik Kesihatan Kalumpang, SelangorDr. Wan Azman Wan AhmadConsultant Cardiologist,Pusat Perubatan Universiti Malaya4

EXTERNAL REVIEWERS(in alphabetical Order)Dr. Anwar Irawan RuhaniConsultant Cardiologist,Hospital Tengku Ampuan AfzanDr. Aizai Aizai Azan Abdul RahimConsultant Cardiologist,Institut Jantung NegaraDr. Gary Lee Chin KeongConsultant Cardiologist and Electrophysiologist,Hospital SerdangDr. Geeta KandavelloConsultant Paediatric Cardiologist,Institut Jantung NegaraDr. Hizlinda TohidFamily Medicine Specialist,University Kebangsaan MalaysiaDr. Letchumanan RamanathanConsultant Physician,Hospital IpohDr. Lee Chuey YanConsultant Cardiologist,Hospital Sultanah AminahDr. Martin Wong Ngie LeongConsultant Paediatric Cardiologist,Sarawak Heart CentreDr. Noel Thomas RossConsultant Physician,Hospital Kuala LumpurDr. Ong Loke MengConsultant Nephrologist,Hospital Pulau PinangDr. Ong Mei LinConsultant Cardiologist,Gleneagles PenangDr. Rozita ZakariaFamily Medicine Specialist,Klinik Kesihatan Putrajaya Presint 18Dr. Sahimi MohamedHead of Clinical Section,Pharmacy DepartmentHospital Tengku Ampuan AfzanDr. Saravanan KrishinanConsultant Cardiologist and Electrophysiologist,Hospital Sultanah BahiyahDr. Wong Kai FattGeneral Practitioner,Klinik Tan, 96, Jalan Ipoh, Kuala Lumpur5

RATIONALE AND PROCESS OF GUIDELINES DEVELOPMENTCardiovascular disease (CVD) is an important cause of morbidity and mortality inMalaysia. Heart Failure (HF), the end stage of most diseases of the heart, is acommon medical problem encountered in general practice and is an importantcause of hospital admissions and readmissions. It is also an important cause ofhospital expenditure. As the population ages, the prevalence of HF is expected toincrease.The 1st Clinical Practice Guidelines (CPG) in HF was published in 2000 withrevisions in 2007 and 2014. Since then, there have been many new developmentsin this field. Thus the publication of this 4th edition is timely. This CPG proposes astructured multidisciplinary strategy for the seamless care of patients with HFbetween hospital and community care.This CPG was drawn up by a committee appointed by the National Heart Associationof Malaysia and Ministry of Health. It consists of a multidisciplinary team of cardiologists,nephrologists, family medicine specialists, general physicians and pharmacists fromthe government, private sectors and the public Universities. The external reviewerswere also made up of a multidisciplinary team. Members of the public - patients andcarers - however, were not included.Objectives:The objectives of this CPG are to: Update the current management of HF based on recent evidence with respect to: Prevention Diagnosis Treatment – pharmacotherapy, device and surgical therapy Rehabilitation End of life and palliative care Recognise and manage HF in special populations: Adult congenital heart disease Geriatric population Pregnant women Develop a structured multidisciplinary strategy for the management of patientswith HF both in the primary and secondary care setting.6

ProcessThe last CPG published in 2014 was used as a base. In addition to the previousclinical questions that needed to be updated, the Expert Panel formulated newquestions that needed to be addressed. These clinical questions were then dividedinto sections and each member was assigned one or more topics.A review of current medical literature on HF from 1st October 2013 (the date of thelast CPG) till 31st August 2018 was performed. Literature search was carried outusing the following electronic databases - PubMed and Cochrane Database ofSystemic Reviews.The following MeSH terms or free text terms were used eithersingly or in combination:“Heart Failure”, “Congestive Cardiac Failure”, “Acute Heart Failure, “Chronic HeartFailure” “Right Heart Failure”, “Left Heart Failure” [MeSH], “Heart Failure ReducedLeft Ventricular Function”, Heart Failure Preserved Left Ventricular Function”[MeSH], Acute decompensated heart failure, tachycardia-induced cardiomyopathy,heart failure mid-range, refractory heart failure, terminal heart failure, end stageheart failure, cardio-oncology.The search was filtered to clinical trials and reviews, involving humans andpublished in the English language. The relevant articles were carefully selected fromthis huge list. In addition, the reference lists of all relevant articles retrieved weresearched to identify further studies. Experts in the field were also contacted to obtainfurther information. International guidelines on HF - the American Heart Association/ American College of Cardiology and European Society of Cardiology - were alsostudied. All literature retrieved were appraised by members of the Expert Panel andall statements and recommendations made were collectively agreed by the group.The grading of evidence and the level of recommendation used in this CPG wasadapted from the American College of Cardiology / American Heart Association andthe European Society of Cardiology (Table 1, Page 12).After much discussion, the draft was then drawn up and submitted to the TechnicalAdvisory Committee for Clinical Practice Guidelines, Ministry of Health Malaysia andkey health personnel in the major hospitals of the Ministry of Health and the privatesector for review and feedback.7

Clinical Questions Addressed:There were several topics and subtopics that were formulated addressing thediagnosis and management of HF.For diagnosis: In a person presenting with shortness of breath: What features in the history and clinical examination would make one suspectthis patient is having a HF? What diagnostic tests help confirm the clinical suspicion of HF with reasonablesensitivity and specificity? ECG Chest X-ray Natriuretic peptides EchocardiogramFor therapy, the topics and subtopics were formulated using the PICO method asfollows:P: Population - Persons with confirmed HF and: Reduced left ventricular (LV) function (LVEF 40%) - Heart failure with reducedejection fraction (HFrEF) and: Congested (Volume overload) Hypotensive (Cold) Combination of congestion and hypotension Coronary artery disease (CAD) Atrial fibrillation Older persons Persons with diabetes Women Chronic kidney disease- Not on renal replacement therapy- On renal replacement therapy Preserved LV function (LVEF 50%) Heart failure with preserved ejectionfraction (HFpEF) Mid range LV function (LVEF: 40-50%) Heart failure with mid-range LVEF(HFmrEF)8

I: Intervention: Non-pharmacological therapy Pharmacological therapy: Diuretics Angiotensin Converting Enzyme Inhibitors (ACE-I) Angiotensin Receptor Blockers (ARB) β-blockers Mineralocorticoid Antagonists (MRA) Statins Etc Surgery : Valve surgery Coronary artery bypass surgery Device therapy Cardiac resynchronisation therapy Catheter ablation Pacemaker therapyC: Comparison: Non-pharmacological therapy vs no non-pharmacological therapy Diuretics vs no diuretics ACE-I vs no ACE-I EtcO: Outcome: Improvement in symptoms Reduce hospital readmissions for HF Reduction in Major Cardiovascular Disease Event Rate (myocardial infarction(MI), stroke, cardiovascular (CV) death) Reduction in all-cause mortalityType of Question - Involves: Therapy drug therapy, surgery, device therapy Harm Worsening of symptoms and readmission rate Increase in cardiovascular event rate (MI, HF, CV death) Increase in bleeding risk and stroke rate Adverse effects due to pharmacotherapy Prognosis - reduction in MI, HF, CV death and improvement in all-cause mortality9

Type of Study Systematic review and meta-analysis Randomised controlled studies Cohort studiesThus, there were numerous clinical questions formulated.Example of some of these Clinical Questions: In a person with HFrEF and congested (volume overload) will the use of diureticslead to an improvement in symptoms, hospital readmission, cardiac event rateand/or all-cause mortality? In a person with HFrEF and not congested (volume overload) will the use ofdiuretics lead to an improvement in symptoms, hospital readmission, cardiacevent rate and/or all-cause mortality? In a person with HFrEF and congested (volume overload) will the use of ACE-Ilead to an improvement in symptoms, hospital readmission, cardiac event rateand/or all-cause mortality? In a person with HFrEF and CAD, will coronary artery bypass surgery lead toan improvement in symptoms, hospital readmission, cardiac event rate and/orall-cause mortality? In a person with HFpEF and congested (volume overload) will the use of ACE-Ilead to an improvement in symptoms, hospital readmission, cardiac event rateand/or all-cause mortality?Target Group:This guideline is directed at all healthcare providers involved in the management ofHF in children and adults.Target Population:It is developed to treat all individuals with and at risk of HF.Period of Validity of the Guidelines:These guidelines need to be revised at least every 5 years to keep abreast withrecent developments and knowledge that is being learnt.10

Applicability of the Guidelines and Resource Implications:This guideline was developed taking into account our local health resources. Bloodinvestigations, chest radiographs, ECGs and echocardiograms are common inalmost all public health facilities. The drugs used to treat HF - diuretics, ACE-I,β-blockers have been approved for use in Malaysia and available in public hospitalsas generics.This guideline aims to educate health care professionals on strategies to optimiseexisting resources in the timely management of patients with HF.Facilitators and Barriers:The main barrier for successful implementation of this CPG is the lack of knowledgeof healthcare providers in the: Diagnosis of HF. Management of HF - initial treatment and long term follow-up. Optimisation of therapy and when to refer to tertiary centres.Implementation of the Guidelines:The implementation of the recommendations of a CPG is part of good clinicalgovernance. To ensure successful implementation of this CPG we suggest: Increasing public awareness of CVD and HF in general and educating them onthe importance of seeking early medical attention. Continuous medical education and training of healthcare providers on theimportance of appropriate management of patients with HF. This can be doneby road shows, electronic media, and in-house training sessions.Clinical audit by individual hospitals and units to ensure compliance using thesuggested performance measures in Section 12, Page 115 and Appendix VI, pg 121.Dr. Jeyamalar RajaduraiChairperson11

Table 1: GRADES OF RECOMMENDATIONS AND LEVELS OF EVIDENCEGRADES OF RECOMMENDATIONIConditions for which there is evidence and/or general agreementthat a given procedure/therapy is beneficial, useful and/or effective.IIConditions for which there is conflicting evidence and/or divergence ofopinion about the usefulness/efficacy of a procedure/therapy.II-a : Weight of evidence/opinion is in favor of its usefulness/efficacy.II-b : Usefulness/efficacy is less well established by evidence/opinion.IIIConditions for which there is evidence and/or general agreement thata procedure/therapy is not useful/effective and in some cases may beharmful.LEVELS OF EVIDENCEAData derived from multiple randomised clinical trials or meta analyses.BData derived from a single randomised clinical trial or largenon-randomised studies.COnly consensus of opinions of experts, case studies or standard ofCare.Adapted from the American College of Cardiology Foundation / American Heart Associationand The European Society of Cardiology(Available at: Manual for ACC AHA Writing- Committees and at elines/about/Pages/rules-writing.aspx).12

TABLE OF CONTENTSPagesStatement of Intent1Message from the Director General of Health2Members of the Expert Panel3External Reviewers5Rationale and Process of Guideline Development6Grades of Recommendations and Levels of Evidence12Table of Contents13Glossary15What’s New in the Guidelines?18PART 1: Management of Heart Failure in AdultsSummary20Algorithm and Flow 97.PREVENTION448.MANAGEMENT488.1 Acute Heart Failure488.2 Chronic Heart Failure due to Reduced LVEF 40%628.2.1 Non-Pharmacological Measures628.2.2 Pharmacological Management668.2.3 Device Therapy in Heart Failure788.2.4 Surgery for Heart Failure818.3 Asymptomatic Left Ventricular Dysfunction828.4 Heart Failure with Preserved Left Ventricular Systolic Function8413

8.5 Special Groups878.5.1 Diabetes and Heart Failure878.5.2 Heart Failure in Pregnancy908.5.3 Heart Failure in Adult Congenital Heart Disease948.5.4 Arrhythmia-Induced Heart Failure988.5.5 Cardio-oncology and Heart Failure1008.5.6 Heart Failure and Kidney Dysfunction1038.6 Advanced Heart Failure/Refractory Heart Failure9.1078.6.1 Heart Transplant1078.6.2 Mechanical Circulatory Support1088.7 Palliative and End of Life Care109ORGANISATION OF CARE1109.1 Level of Care and Shared Management1109.2 Monitoring and Follow-Up1129.3 Cardiology Referral11210. OTHER THERAPIES FOR HEART FAILURE11311. FUTURE DEVELOPMENT11412. PERFORMANCE MEASURES115APPENDIX116REFERENCES122Part 2: Management of Heart Failure in Paediatrics13. HEART FAILURE IN THE PAEDIATRIC POPULATION145ACKNOWLEDGEMENTS158DISCLOSURE STATEMENT158SOURCES OF FUNDING15814

GLOSSARYAbbreviationDescriptionACE-IAngiotensin Converting Enzyme InhibitorsACHDAdult Congenital Heart DiseaseAFAtrial FibrillationAHFAcute Heart FailureARBAngiotensin Receptor BlockersARNIAngiotensin-Receptor Blocker- Neprilysin InhibitorASDAtrial Septal DefectsASLVSDAsymptomatic Lv Systolic DysfunctionAVAtrial VentricularBNPBrain Natriuretic PeptideCABGCoronary Artery Bypass SurgeryCADCoronary Artery DiseaseCKDChronic Kidney DiseaseCKMBCreatine Kinase-Muscle/Brain BandCMRICardiac Magnetic Resonance ImagingCVCardiovascularCVDCardiovascular DiseaseCPAPContinous Positive Airway PressureCPGClinical Practice GuidelineCRSCardiorenal SyndromeCRTCardiac Resynchronisation TherapyCSACentral Sleep ApnoeaDBPDiastolic Blood PressureDOACDirect Oral AnticoagulantsDPP-4iDipeptidyl Peptidase 4 Inhibitors15

AbbreviationDescriptionDVTDeep Vein ThrombosisECGElectrocardiogramEFEjection FractionseGFREstimated Glomerular Filtration RateGGTGamma-Glutamyl TransferaseGLP-1Glucagon Like Peptide-1HFHeart FailureHFCHeart Failure ClinicHFNCHigh Flow Nasal CannulaHfmrEFHeart Failure With Mid-Range LVEFHfrEFHeart Failure With Reduced Ejection FractionHfpEFHeart Failure With Preserved Ejection FractionHRQoLHealth Related Quality Of LifeIABPIntra-Aortic Balloon CounterpulsationICDImplantable Cardioverter DefibrillatorJVPJugular Venous PulseLBBBLeft Bundle Branch BlockLVLeft VentricularLVADLeft Ventricular Assist DeviceLVEFLeft Ventricular Ejection FractionLVHLeft Ventricular HypertrophyMIMyocardial InfarctionMRAMineralocortocoid Receptor AntagonistNPNatriuretic PeptideNSAIDsNon-Steroidal Anti-Inflammatory Drugs16

AbbreviationDescriptionNTproBNPN-Terminal Pro BNPNYHANew York Heart AssociationOMTOptimal Medical TreatmentOSAObstructive Sleep ApnoeaPCIPercutaneous Coronary InterventionPNDParoxysmal Nocturnal DyspnoeaPPPulse PressurePSPulmonary StenosisPSGPolysomnographyRASRenin Angiotensin SystemRCTRandomise Control TrialRVRight VentricularSBPSystolic Blood PressureSCDSudden Cardiac DeathSDBSleep Disordered BreathingSGLT2iSodium-Glucose Cotransport-2 InhibitorsVADVentricular Assist DeviceVFVentricular FibrillationVSDVentricular Septal DefectVTVentricular Tachycardia17

WHAT’S NEW IN THE GUIDELINES3rd Ed CPGHeart Failure (Old)Acute HeartFailureAcute CardiogenicPulmonary Oedema4th Ed CPGHeart Failure (New)Concept of classification according toclinical presentation: Warm and wet - adequate perfusion butcongested (lungs and/or periphery) Cold and dry - hypoperfusion anddehydrated/not congested Cold and wet - hypoperfusion andcongested (lungs and/or periphery) Warm and dry - adequate perfusionand dehydrated/not congested.These patients have either mild HFor are in the compensated stage of HF.Oxygen Therapy-High flow nasal cannula (HFNC) seemsmore effective than conventional oxygentherapy and non-inferior to non-invasivepositive pressure ventilation in moststudies. (IIa, B)Pharmacotherapyof HFrEF-ARNI should be considered as areplacement to ACE-I/ARB in patientswith HFrEF who remain symptomatic todecrease CV death, HF hospitalisations,and symptoms. (I,B)SurgicalManagement ofHFrEFNo mention ofmitraclipIn patients with moderate to severe MRand who are not surgical candidates, theuse of mitralclip has shown mixedresults. (IIb,B)8.5.1. Diabetes and Heart Failure8.5.3. Heart Failure in Adult CongenitalHeart Disease8.5.4. Arrhythymia induced Heart Failure8.5.5. Cardio-oncology and Heart Failure8.5.6. Heart Failure and KidneyDysfunction9.Organisation of Care14.Heart Failure in the Paediatricpopulation18

PART 1Management of Heart Failure in Adults19

SUMMARYKey Message 1: Heart Failure (HF) is an important cause of hospitalisation accounting for about6%-10% of all acute medical admissions and an important cause of hospitalreadmissions in Malaysia. HF costs was estimated to account for approximately 1.8% of total healthexpenditure.Key message 2: Definition and Classfication HF is a clinical syndrome due to any structural or physiological abnormality ofthe heart resulting in its inability to meet the metabolic demands of the body orits ability to do so only at higher than normal filling pressures.HF can also be classified according to the clinical presentation into: Acute heart failure (Acute HF) Chronic heart failure (Chronic HF).In the setting of Left Ventricular (LV) myocardial dysfunction, left ventricularejection fraction (LVEF) may be: Reduced (LVEF 40%) - Heart failure with reduced ejection function (HFrEF). Preserved (LVEF 50%) - Heart failure with preserved ejection fraction (HFpEF) Mid-range (LVEF 41%-49%) - Heart failure with the LVEF being in the midrange (HFmrEF).Key message 3: Diagnosis The clinical suspicion of HF should be supported by objective clinical evidenceof cardiac dysfunction. (Flow Chart I, Page 28)Exercise capacity in a patient with heart disease is assessed by the New YorkHeart Association (NYHA) functional classification.Relevant investigations help to confirm the diagnosis and determine the type ofHF and the aetiology.Key message 4: Prevention Prevention and early intervention wherever appropriate, should be the primaryobjective of management.20

Key message 5: Acute Heart Failure (AHF) AHF may present as: Pulmonary and/or peripheral oedema (“wet” - volume overload) Low output state - shock (“dry” - usually due to pump failure) Combination of pulmonary oedema and a low output stateThe principles of management are: Rapid recognition of the condition. Identification and stabilisation of life threatening haemodynamics. Maintaining oxygenation and perfusion of the vital organs. Relieving clinical symptoms and signs. Identification and treatment of the underlying cause and precipitating/aggravating factors.After initial clinical assessment, management should be instituted as in FlowChart II, Page 29.For grading of recommendations and levels of evidence, see Table 2, Page 30.Key message 6: Heart Failure with Reduced Left Ventricular Function (HFrEF) Non-pharmacological measures - These include: Education of the patient and family about the disease, treatment options andprognosis. Encouraging lifestyle measures such as: Regular exercise Avoid adding salt and flavouring sauces such as soya sauce, tomato ketchupand chilli sauce while cooking or at the table. Fluid intake should be individualised. - A general recommendation is 1-1.5litres per day in patients with normal renal function. Smoking cessation and avoiding alcohol. Advice regarding sexual activities and pregnancy.Pharmacological management: After initial clinical assessment, management should be instituted as in FlowChart III, Page 31. For grading of recommendations and levels of evidence, see Table 3, Page 33. Medications that have been shown to improve survival in HFrEF include: Angiotensin converting Enzyme Inhibitors (ACE-I)/ Angiotensin II ReceptorBlockers (ARB) if ACE-I intolerant Angiotensin receptor-neprilysin inhibitor (ARNI) β-blockers Mineralcorticoid receptor antagonist (MRA)21

Device therapy: Cardiac resynchronisation therapy (CRT) can be considered in patients withall of the following criteria: Sinus rhythm LVEF 35% Left Bundle Branch Block (LBBB) QRS duration 150ms An implantable cardioverter defibrillator (ICD) is indicated for secondaryprevention in: Patients resuscitated from sudden cardian death (SCD) due to ventricularfibrillation or haemodynamically unstable sustained ventricular tachycardia. Prior MI and LVEF 40% with non-sustained VT AND inducible sustained VTor VF during an an electrophysiology (EP) study. Patients with chronic HF and LVEF 35% who experience syncope ofunclear origin.Surgery For HF Coronary revascularisation (by either coronary artery bypass graft (CABG) orpercutaneous coronary intervention (PCI)) should be considered in patientswith HF and suitable coronary anatomy.Key message 7: Asymptomatic LV Dysfunction Identify patients who are at high risk of developing LV dysfunction and treat theunderlying disease appropriately.ACE-I and β-blockers (post MI) have been shown to slow down the onset ofsymptoms and reduce cardiac morbidity.Key message 8:Heart Failure with Preserved LV Function (HFpEF) HFpEF is a common cause of HF in the elderly.Hypertension is an important cause and should be treated according to guidelines.Management remains empiric since trial data are limited.Treat volume overload with diuretics and manage comorbidities.22

Key message 9: HFrEF in Special Groups Diabetes Persons with diabetes are managed in the same manner as persons withoutdiabetes. When managing diabetes in patients with HF: The sodium-glucose cotransport-2 inhibitors (SGLT2i) have been shownto reduce CV mortality and HF hospitalisations. Saxagliptin, a dipeptidyl peptidase 4 inhibitors (DPP-4i) and thiazolidinedionesare best avoided because of a trend towards harm. Sulphonylureas, biguanides like metformin and alpha-glucosidase inhibitorslike acarbose are generally safe. Pregnancy The management of HF in pregnancy is more difficult than in the non-pregnantstate and should be managed by a multidisciplinary team consisting of physicians,obstetricians and paediatricians. Patients with LVEF 30% and those in NYHA Class III and IV should bestrongly advised not to get pregnant. They should be refered to the pre-pregnancyclinic for advise on the modes of contraception. If pregnant, termination shouldbe considered. HF that develops during pregnancy can be managed with the judicious useof diuretics, digoxin, nitrates, β-blockers and/or hydralazine. Arrhythmias Arrhythmia-induced HF (also known as Tachycardia-induced cardiomyopathy)is a reversible cause of HF. Successful treatment of the arrhythmia by drug therapy or catheter ablationcan result in normalisation of LV function. Cardio-oncology Chemotherapy-induced cardiomyopathy is not common; clinical HF occurs in 1-5%. Close collaboration between the oncologist and the cardiologist is important. Patients undergoing chemotherapy should have a careful clinical evaluationand assessment and treatment of CV risk factors. Chronic Kidney Disease Cardiac and kidney disease frequently co-exist and this increases the complexityand costs of care, and may interact to worsen prognosis. Management includes the use of intravenous diuretics, careful use of ReninAngiotensin System (RAS) blockers, β-blockers and occasionally ultrafiltrationand haemodialysis.23

Key message 10: Advanced Heart FailurePatients with advanced HF should be referred to assess whether they may bepotential candidates for mechanical circulatory support (e.g. Left Ventricular AssistDevice - LVAD) and consideration for heart transplant.Patients with refractory symptoms despite guideline-directed medical therapy,should be considered for palliative and end of life care.Key message 11: Organisation of CareHeart Failure clinics will serve as an intermediary between in-patient hospital careand community primary care.24

Key RecommendationsKey Recommendation # 1:In making a diagnosis of Heart failure, a detailed history and a thoroughphysical examination are important. The clinical suspicion of HF should be supported by objective clinicalevidence of cardiac dysfunction. (Flow Chart I, Page 28) The exercise capacity in a patient with heart disease should be assessedby the New York Heart Association (NYHA) functional classification.(Table 6, Page 40) Key Recommendation # 2:To confirm the diagnosis and determine the type of HF and the aetiology,the following should be performed: Basic investigations such as ECG, Chest Radiography, blood and urinetests. An echocardiogram to help determine the type of HF (HFrEF, HFmrEFor HFpEF) and identify structural cardiac defects. Key Recommendation # 3: The underlying disease and the precipitating cause(s), if present, needto be identified so that disease-specific treatment can be initiated early.Key Recommendation # 4:The primary objective of management should be prevention of HF and earlyintervention, wherever appropriate. 25

Key Recommendation # 5: In Acute HF, it is important to: Rapidly recognise the condition. Identify an

Dr. Haifa Abdul Latiff Consultant Paediatric Cardiologist, Institut Jantung Negara Dr. Izwan Effendy Ismail Family Medicine Specialist, Klinik Kesihatan Puchong Dr. Liew Houng Bang Consultant Cardiologist, Hospital Queen Elizabeth II Dr. Ma Soot Keng Consultant Cardiologist and Electrophysiologist, Loh Guan Lye Specialist Centre Dr. Mohd Nizam .