Symptoms and management options

The iPOS questionnaire may be a useful tool to assist with holistic assessment:

Optimally treat heart failure and co-morbidities

Assess and manage anxiety / depression

Consider referral for cardiac rehabilitation

Suggest use of hand fan on exertion

FAB (fatigue, anxiety, breathlessness) or similar symptom management programme

Consider slow-release Morphine 5mg-10mg BD & titrate to response (in normal renal function)

For further non-pharmacological and pharmacological management please

See chapter: breathlessness management section

  • Assess and manage reversible factors
  • Consider assessment and treatment of anaemia
  • Consider correction of low iron levels with intravenous therapy (50% of patients are not anaemic)
  • Encourage appropriate gentle exercise as tolerated.
  • Breathlessness management programme or FAB programme.
  • Specific causes of pain in heart failure include:
  • Angina (consider transdermal nitrate if patient cannot take oral nitrate medication)
  • Claudication
  • Diabetic neuropathy
  • Abdominal bloating (due to e.g. liver capsule distension, gut wall oedema, constipation)

If renal impairment is present, take into account when prescribing analgesia.

For further information see: Chapter: Pain  and Chapter: Renal Failure

Consider reversible causes – constipation, blood glucose control, dry mouth, digoxin toxicity.
Consider if gut oedema is affecting absorption of oral agents and if non-oral route may be more effective.
In heart failure, cyclizine is generally avoided due to its antimuscarinic effect.

For further information see chapter: Nausea and vomiting.

Constipation is a common and troublesome symptom in advanced heart failure. It can exacerbate other symptoms such as fatigue and breathlessness.

Suggested laxatives:
1st line: Stimulant (e.g. senna, sodium picosulphate); provide routinely to patients on opioids.
2nd line: Softener ( e.g. sodium docusate, polyethylene glycol).

  • Review and rationalise medications that might be contributing
  • Exclude oral thrush
  • Use of saliva substitutes eg Oral balance gel, Oralieve, Biotene
  • Other practical measures – ice, regular sips of fluid, chewing gum
  • Pressure area care
  • Soap substitute
  • Emollient
  • 2% menthol cream for itch

There is a high incidence of depression in patients with chronic illness. Specific tools are available to assess for this eg Hospital Anxiety and Depression Scale (HADS)

Consider referral to appropriate psychological services
If antidepressants are indicated:

  • Avoid Tricyclic antidepressants and drugs with many potential drug interactions (e.g. Fluoxetine)
  • Consider Sertraline 50mg OD, Citalopram 10-20mg OD, Mirtazapine 15mg OD
  • Look for reversible problems e.g. dry mouth, oral candida, untreated nausea or constipation, ill-fitting dentures
  • Have small meals
  • Help preparing food – if patient too fatigued to cook
  • Dietician advice


This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.