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Practice Guidelines

Diagnosing and managing acute heart failure in adults: summary of NICE guidance

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5695 (Published 08 October 2014) Cite this as: BMJ 2014;349:g5695
  1. Katharina Dworzynski, senior research fellow1,
  2. Emmert Roberts, research fellow2,
  3. Andrew Ludman, specialist trainee adviser3,
  4. Jonathan Mant, guideline chair, professor of primary care research4
  5. on behalf of the Guideline Development Group
  1. 1National Clinical Guideline Centre, Royal College of Physicians of London, London NW1 4LE, UK
  2. 2Academic Clinical Fellow in Psychiatry, Maudsley Hospital, South London and the Maudsley Mental Health Trust, London, UK
  3. 3Consultant Cardiologist, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
  4. 4Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  1. Correspondence to: K Dworzynski Katharina.Dworzynski{at}rcplondon.ac.uk

Acute heart failure may present de novo in people without known cardiac dysfunction, or as an acute decompensation of known chronic heart failure. Acute heart failure is a common cause of admission to hospital (more than 67 000 admissions in England and Wales each year) and is the leading cause of hospital admission in people aged 65 years or more in the United Kingdom.1 European registry data show that nearly 50% of people admitted to hospital with acute heart failure are re-admitted within 12 months,2 and a third of people with acute heart failure die within a year of their first hospital admission.1 The diagnosis of heart failure can be challenging because of non-specific symptoms and clinical signs, and there is evidence of wide variation in the way people with acute heart failure are managed.1 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on acute heart failure.3

Recommendations

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

Organisation of care

  • All hospitals that admit people with suspected acute heart failure should have a specialist heart failure team that is based on a cardiology ward and provides outreach services.

  • All people being admitted to hospital with suspected acute heart failure should have early and continuing input from a dedicated specialist heart failure team.

  • [Based on very low quality evidence from observational studies and a new cost effectiveness analysis]

  • In line with guidelines for chronic heart failure (NICE Clinical Guideline 1084), plan the following with people with acute heart failure:

    • -Discharge from hospital after the acute phase, and

    • -Subsequent management in primary care, including ongoing monitoring and care provided by the multidisciplinary team, and

    • -Information and communication about their condition, its treatment, and the prognosis.

  • [Based on previously published NICE guidance[4]

  • A follow-up clinical assessment should be undertaken by a member of the specialist heart failure team within two weeks of the person being discharged from hospital.

  • [Based on the experience and opinion of the Guideline Development Group (GDG)]

Diagnosis and assessment

  • In people presenting with new suspected acute heart failure, use a single measurement of serum natriuretic peptides (B type natriuretic peptide or N-terminal pro-B-type natriuretic peptide) to rule out the diagnosis of heart failure. Use the following thresholds to rule out heart failure:

    • -B type natriuretic peptide less than 100 ng/L

    • -N-terminal pro-B-type natriuretic peptide less than 300 ng/L.

  • [Based on high quality evidence from observational studies and a new cost effectiveness analysis]

  • In people presenting with new suspected acute heart failure and raised natriuretic peptide levels, perform transthoracic Doppler two dimensional echocardiography to establish the presence or absence of cardiac abnormalities. Consider performing this within 48 hours of admission to guide early specialist management.

  • [Based on the experience and opinion of the GDG]

The figure outlines the diagnosis and treatment algorithm for patients with clinically suspected acute heart failure.

Figure1

Diagnostic and treatment algorithm for clinical suspicion of acute heart failure. ACE=angiotensin converting enzyme; BNP=B type natriuretic peptide; NT-proBNP=N-terminal pro-B-type natriuretic peptide

Drug treatment

  • Do not routinely offer opiates to people with acute heart failure.

  • [Based on very low quality evidence from observational studies]

  • Do not routinely offer nitrates to people with acute heart failure.

  • If intravenous nitrates are used in specific circumstances—for example, in people with concomitant myocardial ischaemia, severe hypertension, or regurgitant aortic or mitral valve disease—monitor blood pressure closely in a setting where at least level 2 care can be provided. (Level 2 care is for people who need more detailed observation or intervention, including support for a single failing organ system or postoperative care, and for those stepping down from higher levels of care.5)

  • [Based on low or very low quality evidence from randomised controlled trials]

  • Do not routinely offer inotropes or vasopressors to people with acute heart failure.

  • Consider inotropes or vasopressors in people with acute heart failure with potentially reversible cardiogenic shock. Administer these treatments in a cardiac care unit, high dependency unit, or an alternative setting where at least level 2 care can be provided.

  • [Based on moderate or very low quality evidence from randomised controlled trials]

Diuretics

  • Offer intravenous diuretics to people with acute heart failure. Start treatment using either a bolus or infusion strategy.

  • For people already taking a diuretic, consider increasing the dose unless there are serious concerns with patient adherence to diuretic treatment before admission.

  • [Based on moderate to very low quality evidence from randomised controlled trials]

  • Closely monitor the person’s renal function, weight, and urine output during treatment with diuretics.

  • [Based on the experience and opinion of the GDG]

β blockers

  • In people presenting with acute heart failure who are already taking β blockers, continue the treatment unless they have a heart rate less than 50 beats/min, second or third degree atrioventricular block, or shock.

  • [Based on low or very low quality evidence from a randomised controlled trial]

  • Start or restart β blockers during hospital admission in people with acute heart failure as a result of left ventricular systolic dysfunction once their condition has been stabilized—for example, when intravenous diuretics are no longer needed.

  • [Based on very low quality evidence from observational studies]

  • Ensure that the person’s condition is stable for typically 48 hours after starting or restarting β blockers and before discharging from hospital.

  • [Based on very low quality evidence from observational studies]

Angiotensin converting enzyme inhibitors and aldosterone antagonists

  • Offer an angiotensin converting enzyme inhibitor (or angiotensin receptor blocker if there are intolerable side effects) and an aldosterone antagonist during hospital admission to people with acute heart failure and reduced left ventricular ejection fraction. If the angiotensin converting enzyme inhibitor (or angiotensin receptor blocker) is not tolerated an aldosterone antagonist should still be offered.

  • [Based on very low quality evidence from observational studies]

Non-drug based treatment

  • Do not routinely use non-invasive ventilation (continuous positive airways pressure or non-invasive positive pressure ventilation) in people with acute heart failure and cardiogenic pulmonary oedema.

  • If a person has cardiogenic pulmonary oedema with severe dyspnoea and acidaemia consider starting non-invasive ventilation without delay:

    • -At acute presentation or

    • -As an adjunct to medical treatment if the person has not responded to initial treatment.

  • [Based on high to very low quality evidence from randomised controlled studies]

  • Consider invasive ventilation in people with acute heart failure that, despite treatment, is leading to or is complicated by:

    • -Respiratory failure or

    • -Reduced consciousness or physical exhaustion.

  • [Based on very low quality evidence from observational studies]

  • Consider ultrafiltration for people with confirmed diuretic resistance. (Diuretic resistance is defined as dose escalation beyond a person’s previously recognised dose ceiling or a dose approaching the maximum recommended daily dose without incremental improvement in diuresis.6)

  • [Based on moderate to very low quality evidence from randomised controlled trials]

Mechanical assist devices

In some patients with severe acute heart failure associated with severe haemodynamic compromise, drugs alone are inadequate to support life and mechanical circulatory assistance may be considered. Different mechanical assist devices are available and can be grouped by their intended duration of use (short, intermediate, or long term) and their means of insertion (percutaneous or surgical). At present in the UK, these devices are not funded for long term use in people who are not thought suitable for heart transplantation, but owing to the rapidly expanding technology in this area the decision making process is complex.

  • At an early stage, the specialist should have a discussion with a centre that provides mechanical circulatory support about:

    • -People with potentially reversible severe acute heart failure or

    • -People who are potential candidates for transplantation.

  • [Based on moderate to very low quality evidence from randomised controlled trials]

Overcoming barriers

Some of these recommendations will be challenging to implement. Hospital trusts will need to ensure that they have a specialist heart failure team, provide urgent serum natriuretic peptide testing, and can offer echocardiography within 48 hours. This will entail upstream costs, but some downstream savings, so commissioners will need to work imaginatively with trusts to ensure implementation in a cost constrained environment. Clinicians may need to review their practice so that they do not routinely use opioids, nitrates, or non-invasive ventilation for respiratory distress and to ensure that treatment with an angiotensin converting enzyme inhibitor, β blocker, and aldosterone antagonist is started during the hospital stay. Cardiology and heart failure multi-disciplinary teams will have a key role in supporting local implementation of this guideline. The development of NICE Quality Standards (prioritised statements designed to drive measurable quality improvements within a particular area of health or care) for acute heart failure will facilitate such organisational changes. In addition, professional societies (such as the British Society for Heart Failure, British Cardiovascular Society, and British Society of Echocardiography) and patient organisations could facilitate guideline implementation by disseminating information and educating their members. The National Heart Failure Audit can provide key data to monitor implementation.

Further information on the guidance

Methods

The Guideline Development Group (GDG) consisted of four consultant cardiologists, a consultant in emergency medicine, a consultant in acute medicine, a consultant intensivist and anaesthetist, a lead heart failure specialist nurse, a heart failure specialist consultant nurse, and two patient members. The GDG also co-opted a consultant cardiac surgeon, a lead pharmacist in cardiology, a group general manager, a professor of primary care, a consultant nephrologist, and a consultant chemical pathologist.

The GDG followed standard National Institute for Health and Care Excellence (NICE) methods in the development of this guideline.7 The group developed clinical questions, collected and appraised clinical evidence, and evaluated the cost effectiveness of proposed interventions through literature review and original economic modelling. A new cost effectiveness analysis was undertaken for organisation of care (specialist management units and the role of natriuretic peptides).

Quality ratings of the evidence were based on GRADE methodology (www.gradeworkinggroup.org/). These relate to the quality of the available evidence for assessed outcomes rather than the quality of the clinical study.

The scope and the draft of the guideline went through a rigorous reviewing process, in which stakeholder organisations were invited to comment; the group took all comments into consideration when producing the final version of the guideline.

A formal review of the need to update a guideline is usually undertaken by NICE after its publication. NICE will conduct a review to determine whether the evidence base has progressed significantly to alter the guideline recommendations and warrants an update.

NICE has produced four different versions of the guideline: a full version; a pathway; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients (https://www.nice.org.uk/guidance/CG187/InformationForPublic ) and the public. All these versions are available from the NICE website.

Future research and remaining uncertainties

The GDG identified the following areas for further research:

  • In people with acute heart failure, congestion, and worsening renal function, does the addition of low dose dopamine to standard treatment increase diuresis and improve renal protection compared with the addition of placebo?

  • In people with acute heart failure and persistent congestion, does the addition of a thiazide diuretic to standard treatment increase diuresis compared with the addition of placebo?

  • In people with acute heart failure and hypoperfusion syndrome, is the use of an intra-aortic balloon counter pulsation pump more effective and safer than intravenous inotropes?

  • In people with decompensated heart failure, fluid congestion, and diuretic resistance, does ultrafiltration lead to more rapid and effective decongestion compared with continuing diuretic treatment?

Notes

Cite this as: BMJ 2014;349:g5695

Footnotes

  • 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.

  • The members of the Guideline Development Group were: Abdallah Al-Mohammad, Liz Avital, Peter Bolton, Jane Butler, Saskia Cheyne, Amelia Ch’ng, Jill Cobb, Martin Cowie, Katharina Dworzynski, Elisabetta Fenu, Ed Griffin, Lina Gulhane, Suzanna Hardman, Nicholas Ioannou, Christopher Jones, Jason Kendall, Andrew Ludman, Jonathan Mant (guideline chair), Jayne Masters, John McMurray, Su Park, Ben Pordes, Tanzeem Raza, Juan Carlos Rejon, Gill Ritchie (guideline lead), Emmert Roberts, Giulia Zuodar.

  • Contributors: KD, ER, AL, 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 of this article and accept full responsibility for the work and/or conduct of the study, had access to the data, and controlled the decision to publish.

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

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none. The authors’ full statements can be viewed at www.bmj.com/content/bmj/349/bmj.g5695/related#datasupp.

  • All authors were members of the Guideline Development Group for the NICE guideline. (KD a systematic reviewer, ED health economist, ER research fellow, AL specialist trainee adviser, and JM guideline chair).

References

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