Intended for healthcare professionals

Practice Guidelines

Chronic heart failure in adults: summary of updated NICE guidance

BMJ 2018; 362 doi: (Published 24 September 2018) Cite this as: BMJ 2018;362:k3646
  1. Jacqui Real, senior research fellow1,
  2. Emma Cowles, senior health economist1,
  3. Anthony S Wierzbicki, guideline committee chair and consultant in metabolic medicine and chemical pathology2
  4. on behalf of the Guideline Committee
  1. 1National Guideline Centre, Royal College of Physicians, London, UK
  2. 2Department of Metabolic Medicine/Chemical Pathology, Guy’s & St Thomas’ Hospitals, London, UK
  1. Correspondence to jacqui.e.real{at}

What you need to know

  • Refer people with suspected heart failure and N-terminal pro B-type natriuretic peptide (NT-proBNP) greater than 400 ng/L for specialist assessment and transthoracic echocardiography within 6 weeks.

  • Offer angiotensin converting enzyme (ACE) inhibitors and beta blockers as first line treatment for heart failure with reduced ejection fraction, and add mineralocorticoid receptor antagonist (MRA) if symptoms continue.

  • Offer exercise based cardiac rehabilitation therapy to people with stable heart failure in a format and setting that is easily accessible.

  • Provide management in primary care once the person’s condition is stable, with advice from specialist heart failure teams (MDTs).

  • People with heart failure do not routinely need to restrict their sodium or fluid consumption.

What’s new in this guidance

  • Clearer advice on managing the care of people with heart failure, including a greater emphasis on multidisciplinary working, shared decision making, care planning, lifestyle advice and interventions, co-morbidities, and end-of-life care.

  • N-terminal pro-B-type natriuretic peptide (NT-proBNP) specified as the biomarker to be used in the diagnosis (and, if relevant, the monitoring) of people with heart failure.

  • Mineralocorticoid receptor antagonist (MRA) to be offered (in addition to an ACE inhibitor (or angiotensin receptor blocker, ARB) and beta blocker) in people with heart failure with reduced ejection fraction who remain symptomatic.

The prevalence of heart failure is increasing because of an ageing population and improved survival of chronic diseases that contribute to heart failure. Heart failure includes reduced ejection fraction (<40%) and preserved ejection fraction (>50%) disease. The National Institute for Health and Care Excellence (NICE) guideline on chronic heart failure was last updated in 2010. Since then, further evidence on novel and existing therapies, for example mineralocorticoid receptor antagonists (MRAs), has emerged. New research has also been published on diagnosing heart failure and approaches to heart failure care, including monitoring, rehabilitation, and the composition of the multidisciplinary team.

This article summarises …

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