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Practice Guidelines

Diagnosis and management of adults with chronic heart failure: summary of updated NICE guidance

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4130 (Published 25 August 2010) Cite this as: BMJ 2010;341:c4130
  1. Abdallah Al-Mohammad, consultant cardiologist1,
  2. Jonathan Mant, professor of primary care research2,
  3. Philippe Laramee, health economist3,
  4. Sharon Swain, research fellow3
  5. on behalf of the Chronic Heart Failure Guideline Development Group
  1. 1South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S5 7AU
  2. 2General Practice & Primary Care Research Unit, University of Cambridge CB2 0SR
  3. 3National Clinical Guideline Centre, Royal College of Physicians of London, London NW1 4LE
  1. Correspondence to: A Al-Mohammad a.al.mohammad.87{at}googlemail.com

    Heart failure affects 900 000 people in the United Kingdom.1 Its prevalence is increasing owing to improved prognosis of ischaemic heart disease (the major cause of heart failure) and an ageing population.2 3 The two main types of heart failure are left ventricular systolic dysfunction and that associated with preserved left ventricular ejection fraction. Both types have a poor prognosis, although the introduction of effective treatments has led to a fall in mortality from heart failure caused by left ventricular systolic dysfunction (from 26% at six months in 1995 to 14% at six months in 2005).4 New evidence has emerged on diagnosis, treatment, rehabilitation, and monitoring of people with heart failure, and use of this evidence to guide diagnosis and management is likely to improve outcomes further and increase the cost effectiveness of services. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the diagnosis and management of chronic heart failure (which is a partial update of its 2003 guidelines5).6

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. The new recommendations are indicated in parentheses. Evidence levels for the recommendations are given in italic in square brackets.

    With the exception of the recommendations on drug treatment, all the recommendations apply to the diagnosis and management of heart failure with left ventricular systolic dysfunction and heart failure with preserved ejection fraction.

    Diagnosis

    • In patients with suspected heart failure and previous myocardial infarction, refer urgently for transthoracic Doppler two dimensional echocardiography and specialist assessment (both to take place within two weeks of referral). (New recommendation.) [Based on moderate to high quality observational studies and cost effectiveness evidence]

    • In patients with suspected heart failure and without previous myocardial infarction, measure serum natriuretic peptides (B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide) levels. (New recommendation.) [Based on moderate to high quality observational studies and cost effectiveness evidence]

      • -If the B-type natriuretic peptide level is >400 pg/ml (116 pmol/l) or an N-terminal pro-B-type natriuretic peptide level is >2000 pg/ml (236 pmol/l), refer urgently for transthoracic Doppler two dimensional echocardiography and specialist assessment (both to take place within two weeks of referral) as very high levels of serum natriuretic peptides carry a poor prognosis. (New recommendation.)

      • -If the B-type natriuretic peptide level is 100-400 pg/ml (29-116 pmol/l), or an N-terminal pro-B-type natriuretic peptide level is 400-2000 pg/ml (47-236 pmol/l), refer for transthoracic Doppler two dimensional echocardiography and specialist assessment (both to take place within six weeks of referral). (New recommendation.)

      • -If the serum B-type natriuretic peptide level is <100 pg/ml (29 pmol/litre) or an N-terminal pro-B-type natriuretic peptide level <400 pg/ml (47 pmol/litre), a diagnosis of heart failure is unlikely in an untreated patient. (New recommendation.)

    [The above three recommendations are based on moderate to high quality observational studies and cost effectiveness evidence]

    • Situations that may reduce serum natriuretic peptide levels include obesity or treatment with diuretics, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers, β blockers, or aldosterone antagonists. (New recommendation.) [Based on the experience and opinion of the Guideline DevelopmentGroup (GDG) and on epidemiological studies]

    • Conditions other than heart failure that may raise serum natriuretic peptide levels include diabetes, sepsis, age >70 years, and those affecting the heart (left ventricular hypertrophy, myocardial ischaemia, tachycardia, right ventricular overload); the lungs (hypoxaemia—from causes including pulmonary embolism and chronic obstructive pulmonary disease); the kidneys (glomerular filtration rate <60 ml/min); and the liver (cirrhosis). (New recommendation.) [Based on the experience and opinion of the Guideline DevelopmentGroup (GDG) and on epidemiological studies]

    • Do electrocardiography and consider tests to evaluate possible aggravating factors and/or alternative diagnoses. The tests include chest radiography, pulmonary function tests, urine analysis, and blood tests for full blood count and film plus biochemical assessment of the liver, kidneys, thyroid, glucose, and lipids. [Based on the experience and opinion of the GDG]

    • Once heart failure has been diagnosed, assess severity, aetiology, precipitating factors, type of cardiac dysfunction (whether it is associated with left ventricular systolic dysfunction or preserved left ventricular ejection fraction), and correctable causes. (New recommendation.) [Based on the experience and opinion of the GDG]

    Referral and approach to care

    • Care should be delivered by a multidisciplinary team with an integrated approach across the healthcare community. [Based on evidence from randomised controlled trials and from cost analysis]

    • Refer patients to a specialist multidisciplinary heart failure team for initial diagnosis of heart failure and management of the following: severe heart failure (New York Heart Association (NYHA) class IV (see box defining the four classes)); heart failure that does not respond to treatment; heart failure resulting from valvular disease; and heart failure that can no longer be managed effectively in the home setting. (New recommendation.) [Based on the experience and opinion of the GDG]

    New York Heart Association (NYHA) classification of heart failure symptoms

    • Class I—No limitations

    • Class II—Slight limitation of physical activity (symptomatically “mild” heart failure)

    • Class III—Marked limitation of physical activity (symptomatically “moderate” heart failure)

    • Class IV— Symptoms of heart failure are present even at rest (symptomatically “severe” heart failure)

    Treatment of heart failure with left ventricular systolic dysfunction

    • Offer both ACE inhibitors and β blockers licensed for heart failure to all patients with heart failure that is caused by left ventricular systolic dysfunction. (New recommendation.) [Based on moderate to high quality randomised controlled trials and cost effectiveness evidence] With regard to β blockers, this includes older adults as well as patients with peripheral vascular disease, erectile dysfunction, diabetes mellitus, interstitial pulmonary disease, or chronic obstructive pulmonary disease without reversibility. (New recommendation.) [Based on low to moderate quality randomised controlled trials, cost effectiveness evidence and the experience and opinion of the GDG]

      • -For patients who have intolerable side effects with ACE inhibitors, consider an angiotensin receptor blocker licensed for heart failure as an alternative. (New recommendation.) [Based on moderate to high quality randomised controlled trials]

      • -For patients who are intolerant of both ACE inhibitors and angiotensin receptor blockers, seek specialist advice and consider hydralazine in combination with nitrate. (New recommendation.) [Based on a low quality single randomised controlled trial]

    • If a patient remains symptomatic despite optimal treatment with an ACE inhibitor and a β blocker, consider adding second line treatment:

      • -An aldosterone antagonist licensed for heart failure, especially if the patient has moderate to severe heart failure (NYHA class III or IV) or has had a myocardial infarction within the past month. (New recommendation.) [Based on moderate to high quality randomised controlled trials and cost effectiveness evidence] or

      • -An angiotensin receptor blocker licensed for heart failure, especially if the patient has mild to moderate heart failure (NYHA class II or III). (New recommendation.) [Based on low to high quality randomised controlled trials and cost effectiveness evidence] or

      • -Hydralazine in combination with nitrate (especially if the patient is of African or Caribbean descent with moderate to severe heart failure (NYHA class III or IV)). (New recommendation.) [Based on moderate to high quality randomised controlled trials and cost effectiveness evidence]

    • Consider digoxin for worsening or severe heart failure caused by left ventricular systolic dysfunction despite first line and second line treatment for heart failure. [Based on evidence from randomised controlled trials and cost effectiveness evidence]

    Practical prescribing recommendations

    • ACE inhibitors: Start at a low dose and titrate upwards at short intervals (for example, every two weeks) until the optimal tolerated or target dose is achieved. Measure serum urea, creatinine, electrolytes, and estimated glomerular filtration rate when starting an ACE inhibitor and after each dose increment. [Based on the experience and opinion of the GDG]

    • β blockers: Start in a “start low, go slow” manner, and assess heart rate, blood pressure, and clinical status after each titration. If patients who are stable and already taking a β blocker for a comorbidity (for example, angina or hypertension) develop heart failure caused by left ventricular systolic dysfunction, switch them to a β blocker licensed for heart failure. (New recommendation.) [Based on moderate to high quality randomised controlled trials]

    • Angiotensin receptor blockers: In patients taking these, monitor serum urea, electrolytes, creatinine, and estimated glomerular filtration rate for signs of renal impairment or hyperkalaemia. (New recommendation.) [Based on low to moderate quality randomised controlled trials]

    • Aldosterone antagonists: In patients taking these, closely monitor potassium, creatinine, and estimated glomerular filtration rate. Seek specialist advice if the patient develops hyperkalaemia or if renal function deteriorates. (New recommendation.) [Based on low to high quality randomised controlled trials]

    Treatment of heart failure with preserved ejection fraction

    Treat congestive symptoms with diuretics, and aim for optimal management of comorbidities such as hypertension, ischaemic heart disease, and diabetes. Insufficient evidence exists to make a recommendation on the role of ACE inhibitors, angiotensin receptor blockers, and β blockers in heart failure with preserved ejection fraction. [Based on moderate to high quality randomised controlled trials and the experience and opinion of the GDG]

    Rehabilitation

    • Offer a supervised, exercise based, group rehabilitation programme designed for patients with heart failure in patients who are stable and do not have a condition or device that would preclude an exercise based rehabilitation programme (such as uncontrolled ventricular response to atrial fibrillation; uncontrolled hypertension; high energy pacing devices set for activation at rates likely to be achieved during exercise). Include a psychological and educational component in the programme. The programme may be incorporated within an existing cardiac rehabilitation programme. (New recommendation.) [Based on very low to high quality randomised controlled trials and cost effectiveness evidence]

    Monitoring

    • Seek the opinion of a specialist in heart failure to guide the care of patients admitted to hospital. (New recommendation.) [Based on low to moderate quality randomised controlled trials and the experience and opinion of the GDG]

    • Monitor all patients with chronic heart failure, including clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status, and nutritional status; medication review; and measurement of serum urea, creatinine, and electrolyte levels, and estimated glomerular filtration rate. [Based on the experience and opinion of the GDG]

    • Consider specialist monitoring of serum natriuretic peptides in some patients (such as those in whom uptitration of treatment is difficult, and those with previous admissions to hospital). (New recommendation.) [Based on low to moderate quality randomised controlled trials and cost effectiveness evidence]

    • The frequency of monitoring depends on the clinical status (including the presence of comorbidity) and stability of the patient. The monitoring interval should be short (from a few days to two weeks) if the clinical condition or medication has changed. Monitor stable patients at least every six months. [Based on the experience and opinion of the GDG]

    • Provide patients who wish to be involved in the monitoring of their condition with sufficient education and support from their healthcare professional to do this. [Based on the experience and opinion of the GDG]

    Discharge planning

    • Patients 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 patients’ and carers’ wishes and the level of care and support that can be provided in the community. The primary care team, patient, and carer must be aware of the management plan. Give clear instructions on how the patient or carer can access advice, particularly in the high risk period immediately after discharge. [Based on the experience and opinion of the GDG]

    Overcoming barriers

    Local access to natriuretic peptide testing, two dimensional transthoracic echocardiography, and specialist opinion will need to be improved for optimal implementation of the diagnostic pathway. Reduced emergency admissions as a result of earlier diagnosis will offset the implementation costs. Better uptake of proved interventions will depend on the training of staff who provide heart failure care in both primary and secondary care and better communication between generalists and specialists. Greater availability of rehabilitation programmes with a focus on heart failure will be necessary to ensure that more people have access to such programmes.

    Further information on the guidance

    Evidence of inconsistent practice

    Although the use of natriuretic peptides was proposed for the diagnosis of heart failure in the original NICE guidelines for chronic heart failure in 2003,5 the availability and use of the test for this purpose in the United Kingdom have remained patchy. In hindsight, this has been because natriuretic peptides were recommended only as an optional alternative (to electrocardiography). However, evidence has continued to mount that the use of natriuretic peptides in the diagnosis of heart failure is both cost effective and of particular diagnostic value in the large group of patients with preserved left ventricular ejection fraction heart failure.

    What’s new?

    The diagnostic pathway now for assessing patients with suspected heart failure is substantively different from 2003, in the light of new evidence on natriuretic peptides and recent systematic reviews on the value of clinical features.

    Important new evidence has emerged about several pharmacological agents used to treat heart failure, particularly aldosterone antagonists, angiotensin receptor blockers and combined hydralazine and nitrate. The treatment algorithm (figure) has been modified to incorporate this.

    The evidence base for rehabilitation in heart failure (as opposed to general cardiac rehabilitation) is much larger than was available in 2003. This is reflected in the revised rehabilitation recommendations.

    Although much promising evidence has emerged about the potential role of telemonitoring and monitoring of natriuretic peptides (the evidence for which is discussed in detail in the full guideline), the Guideline Development Group believed that further evidence was needed before including a recommendation (with the exception of limited use of natriuretic peptide monitoring).

    Methods

    The partial update to the chronic heart failure guidelines of 2003 was developed according to NICE guideline methodology (www.nice.org.uk/page.aspx?o=114219), particularly the GRADE (grading of recommendations assessment, development and evaluation) system for assessing the identified studies.7 This process involved systematic searching, critically appraising, and summarising the clinical and cost effectiveness evidence. New cost effectiveness analysis was also conducted on the use of natriuretic peptides in the monitoring of patients with chronic heart failure. This analysis compared three strategies to optimise heart failure medication: serial monitoring of natriuretic peptide in secondary care; clinical assessment in secondary care; and usual care in the community.

    The multidisciplinary GDG discussed the evidence and formulated clinical recommendations. The guideline went through an external consultation with stakeholders and received direct assessments from referees. The GDG assessed the comments and where necessary reanalysed the data and modified the guideline.

    NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website.5 NICE has also produced tailored, web based, implementation tools to help put the guideline into practice, including a slide set, an audit support tool, and a costing report. Future updates of the guideline will be published according to the NICE guideline development programme.

    Future research/remaining uncertainties
    • What is the effectiveness of ACE inhibitors and β blockers compared with placebo in patients with heart failure with preserved ejection fraction?

    • What is the comparative effectiveness of vasodilator treatment with nitrates and hydralazine in patients with heart failure with preserved ejection fraction?

    • What is the effectiveness and cost effectiveness of home telemonitoring, monitoring of serum natriuretic peptides, and formal follow-up by a heart failure team for patients with heart failure caused by left ventricular systolic dysfunction?

    • What is the optimal use of natriuretic peptides in the management and prognostic stratification of patients with heart failure?

    • What is the comparative effectiveness of aldosterone antagonists and angiotensin receptor blocker in symptomatic patients with heart failure caused by left ventricular systolic dysfunction who either are receiving optimal treatment with a β blocker and an ACE inhibitor or are taking a β blocker but are intolerant of ACE inhibitors?

    Notes

    Cite this as: BMJ 2010;341:c4130

    Footnotes

    • doi:10.1136/bmj.c4202
    • This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

    • Contributors: AAl-M and JM drafted the article. All authors revised it critically for important intellectual content and approved the final version to be published. All authors are guarantors.

    • Funding: The National Clinical Guideline Centre was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

    • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) All of the authors have no financial support for the submitted work from anyone other than their employers; (2) In the previous three years AAl-M has been an investigator in the recently stopped Emphasis trial. AAl-M is a clinical adviser to the Health Technology Assessment programme of the National Institute for Health Research on the clinical and cost effectiveness of home telemonitoring or structured telephone support programmes for patients with severe chronic heart failure. AAl-M accepted in March 2008 hospitality from Novartis to attend the American College of Cardiology scientific meeting in Chicago, USA; the other authors declare no relationships (3) All authors have no spouses, partners, or children with financial relationships that may be relevant to the submitted work; and (4) all authors were members of the Guideline Development Group for the NICE guideline (AAl-M the clinical adviser, JM the chair, SS the systematic reviewer, and PL the health economist). The authors have no other non-financial interests that may be relevant to the submitted work.

    • The members of the guideline development group were Abdallah Al- Mohammad (clinical adviser), Mark Davis, Paresh Dawda, Paul Foley (deputy for a GDG member in two meetings), Ahmet Fuat (deputy for a GDG member in two meetings), Jane Gilmour, Suzanna Hardman, Georgina Kirwin (to July 2009), Philippe Laramee, Francisco Leyva, Jonathan Mant (chair), Hugh McIntyre, Richard Mindham, Nan Newberry (from December 2008), Adrian Price, Alison Richards, Gill Ritchie (from May 2009), Sharon Swain, and Claire Turner (to Decemebr 2008). Invited experts were Ainsley Cowie and Paul Collinson.

    • Provenance and peer review: Commissioned; not externally peer reviewed.

    References

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