Chronic heart failure - NICE guideline

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This guideline offers evidence-based advice on the care and treatment of people with chronic heart failure. New and updated recommendations are included on diagnosis, pharmacological treatment, monitoring and rehabilitation.

Key recommendations

Diagnosis

  • Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks.
  • Measure serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NTproBNP]) in patients with suspected heart failure without previous MI.
  • Because very high levels of serum natriuretic peptides carry a poor prognosis, refer patients with suspected heart failure and a BNP level above 400 pg/ml (116 pmol/litre) or an NTproBNP level above 2000 pg/ml (236 pmol/litre) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks. 

Treatment

  • Offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first. [new 2010]
  • Offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including:
    • older adults and

    • patients with:

      • peripheral vascular disease

      • erectile dysfunction

      • diabetes mellitus

      • interstitial pulmonary disease and

      • chronic obstructive pulmonary disease (COPD) without reversibility.

  • Seek specialist advice and consider adding one of the following if a patient remains symptomatic despite optimal therapy with an ACE inhibitor and a beta-blocker:

    • an aldosterone antagonist licensed for heart failure (especially if the patient has moderate to severe heart failure [NYHA class III–IV] or has had an MI within the past month) or
    • an angiotensin II receptor antagonist (ARB) licensed for heart failure (especially if the patient has mild to moderate heart failure [NYHA class II–III]) or
    • hydralazine in combination with nitrate (especially if the patient is of African or Caribbean origin and has moderate to severe heart failure [NYHA class III–IV]).

Rehabilitation

  • Offer a supervised group exercise-based rehabilitation programme designed for patients with heart failure.

    • Ensure the patient is stable and does not have a condition or device that would preclude an exercise-based rehabilitation programme.
    • Include a psychological and educational component in the programme.
    • The programme may be incorporated within an existing cardiac rehabilitation programme.

Monitoring

  • All patients with chronic heart failure require monitoring. This monitoring should include:

    • a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
    • a review of medication, including need for changes and possible side effects
    • serum urea, electrolytes, creatinine and eGFR.
  • When a patient is admitted to hospital because of heart failure, seek advice on their management plan from a specialist in heart failure.

Discharge planning

  • Patients with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised. Timing of discharge should take into account patient and carer wishes, and the level of care and support that can be provided in the community.

Introduction to chronic heart failure

Heart failure is a complex clinical syndrome of symptoms and signs that suggest the efficiency of the heart as a pump is impaired. It is caused by structural or functional abnormalities of the heart. Some patients have heart failure due to left ventricular systolic dysfunction (LVSD) which is associated with a reduced left ventricular ejection fraction. Others have heart failure with a preserved ejection fraction (HFPEF). Most of the evidence on treatment is for heart failure due to LVSD. The most common cause of heart failure in the UK is coronary artery disease, and many patients have had a myocardial infarction in the past.

Around 900,000 people in the UK have heart failure. Almost as many have damaged hearts but, as yet, no symptoms of heart failure. Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 76 years. The prevalence of heart failure is expected to rise in future as a result of an ageing population, improved survival of people with ischaemic heart disease and more effective treatments for heart failure.

Heart failure has a poor prognosis: 30–40% of patients diagnosed with heart failure die within a year – but thereafter the mortality is less than 10% per year.

Heart failure has a poor prognosis: 30–40% of patients diagnosed with heart failure die within a year – but thereafter the mortality is less than 10% per year. There is evidence of a trend of improved prognosis in the past 10 years. The 6-month mortality rate decreased from 26% in 1995 to 14% in 2005.

For both patients and their carers heart failure can be a financial burden and have adverse effects on their quality of life.

Notes on the scope of the guidance

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.

Topics covered include:

  • Diagnosing heart failure: symptoms and signs, use of serum natriuretic peptides (BNP and NTproBNP).
  • Pharmacological treatment of heart failure including: aldosterone antagonists, angiotensin II receptor antagonists, angiotensin-converting enzyme inhibitors, beta-blockers, and hydralazine in combination with nitrate.
  • Disease monitoring in chronic heart failure: serial measurement of circulating natriuretic peptide concentrations, monitoring at home.
  • Cardiac rehabilitation for heart failure.

You can read the guideline on NICE's website.