Chronic heart failure in adults: summary of updated NICE guidanceBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3646 (Published 24 September 2018) Cite this as: BMJ 2018;362:k3646
All rapid responses
The definition given by the NICE guidelines of Heart Failure with Preserved Ejection Fraction (HFpEF) I think is quite appealing: “This is usually associated with impaired left ventricular relaxation, rather than left ventricular contraction, and is characterized by normal or preserved left ventricular ejection fraction with evidence of diastolic dysfunction.” The ESC guidelines in 2016 included in the definition of HFpEF the LVEF ≥50% and considered patients with an LVEF between 40 and 49% as a grey area, which could be indicated as HFmrEF. Although the ESC guidelines recognize that the cut-off of 50% for a diagnosis of HFpEF is arbitrary, they however continue to use it.
What does the evidence say? If one cannot be sure how to define preserved LVEF, let alone HFmrEF, how can one define a reference value of ‘normality’ for LVEF? The latest chamber quantification guidelines by the EACVI and the ASE recognize that LVEFs of <52% for men and <54% for women are suggestive of abnormal LV systolic function. More importantly for the European continent, the NORRE study was a large-scale prospective study with fully standardized equipment and methodology that was conducted in 22 collaborating European institutions. It included 734 (mean age: 45.8±13.3 years) healthy volunteers (320 men and 414 women) and concluded that the total population reference range for the biplane LVEF was 56.5–71.7 (2 standard deviations). The mean biplane LVEF was 63.9, well above the cut-off of 50% that we consider today a preserved LVEF in the heart failure field.
Regardless of what is going to happen to the ‘middle child’ of the heart failure family, the HFmrEF,  I think that maybe it is more important to reconsider how we define HFpEF; should we, of course, continue to rely on LVEF for the distinction of the different forms of heart failure. We need better ways to characterize heart failure in patients and to predict their response to treatment.
1. National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management (NICE guideline NG106) 2018.
2. Ponikowski P, Voors AA, Anker SD et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18:891–975.
3. R.M. Lang, L.P. Badano, V. Mor-Avi, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging
J Am Soc Echocardiogr, 28 (2015), pp. 1-39.e14
4. S. Kou, L. Caballero, R. Dulgheru, et al. Echocardiographic reference ranges for normal cardiac chamber size: results from the NORRE study
Eur Heart J Cardiovasc Imaging, 15 (2014), pp. 680-690
5. Lam CS, Solomon SD. The middle child in heart failure: heart failure with mid-range ejection fraction (40-50%). Eur J Heart Fail. 2014;16:1049–55.
Competing interests: No competing interests
Clinicians and commissioners should welcome the recent publication of a UK based multicentre trial on home-based cardiac rehabilitation  which responds to the updated NICE guidance on chronic heart failure reviewed in the BMJ. 
The BMJ first highlighted the importance of cardiac rehabilitation in heart failure in a letter from our group in 2010.  Subsequently, the BMJ published a clinical review where Kevin Paul, a patient who has been part of the Rehabilitation Enablement in CHronic Heart Failure (REACH-HF) investigator group, detailed his involvement in a podcast accompanying the online version of our paper (https://soundcloud.com/bmjpodcasts/cardiac-rehab-patient).
We believe REACH HF to be the largest trial of home based rehabilitation in heart failure with reduced ejection fraction. The trial provides important new evidence of clinical effectiveness for a novel home-based rehabilitation programme that was co-developed by clinicians, academics, caregivers and patients. The comprehensive intervention includes chair-based exercises, a patient manual with advice on lifestyle and medication together with an interactive progress tracker to record symptoms and activity. There is also a manual for use by caregivers aimed to increase their understanding of heart failure. 
Although the 2010 NICE guidelines (CG 108) recommended that adults with heart failure should receive rehabilitation, the 2015-16 national audit in England and Wales showed that less than 20% are referred for rehabilitation.  With this in mind, the updated 2018 NICE guidelines recommend that adults with heart failure are offered the option of a personalised home-based rehab programme that is easily accessible. 
The results of the REACH HF trial (n=216) show that it is possible to significantly improve patients’ health related quality of life and that the intervention has a cost of £418 per patient,  within the NHS tariff for cardiac rehabilitation.
The roll out of the REACH-HF intervention provides an opportunity for service providers and commissioners to offset the current inequity in access to rehabilitation by patients with heart failure both in the UK and abroad. We are already working with key stakeholders for future adoption of the REACH-HF programme in the NHS, starting with four enhanced dissemination beacon sites in 2019.
Hasnain M Dalal, Rod S Taylor, Kate Jolly, Patrick Doherty Colin Greaves and Jenny Wingham on behalf of the REACH-HF study investigators
Conflict of interest: HD and RT were topic specific advisors in cardiac rehabilitation to the 2018 NICE chronic heart failure guideline group and are co – chief investigators of the REACH HF Study
1.Dalal HM ,Taylor RS et al . The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: the REACH-HF multicentre randomized controlled trial. Eur J Prev Cardiol 2018 doi: 10.1177/2047487318806358
2. Chronic heart failure in adults: summary of updated NICE guidance. BMJ 2018;362:k3646; doi10.1136/bmj.k3646 ( 24 September 2018)
3. Dalal H. Don’t forget rehabilitation. BMJ 2010;341 doi: 10.1136/bmj.c4286
4. Dalal HM, Doherty P, Taylor RS. Cardiac rehabilitation. BMJ 2015;351:h5000. doi: 10.1136/bmj.h5000 [published Online First: 2015/10/01]
5. Greaves CJ, Wingham J, Deighan C, et al. Optimising self-care support for people with heart failure and their caregivers: Development of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) intervention using intervention mapping. Pilot Feasibility Stud 2016; 2: 37.
6. Donkor A et al. National heart failure audit. London: Healthcare Quality Improvement Partnership, 2017.
Competing interests: HMD and RST were topic specific advisors in cardiac rehabilitation to the 2018 NICE chronic heart failure guideline group and are the co – chief investigators of the REACH HF Study funded by the NIHR Programme Grants for Applied Research (grant number RP-PG-1210-12004)
Chronic heart failure in adults could also be related to dietary factors, including the type of table salt being consumed
Authors of this article do deserve best complements for summarizing the NICE guidelines on chronic heart failure in adults. NICE guidelines are quite helpful and are perhaps being read all around the world as well. Frankly, as of now, the question that emerges is whether we doing enough for the adults having chronic heart failure by just diagnosing them as per the guidelines, referring them to specialist, and using the recommended guidelines for using medicines to control the failure. Are we really doing enough with all the knowledge and experiences at our command? Shouldn't we rather attempt to cure chronic heart failures rather than just controlling it ?
In an adult patient with chronic heart failure, there are a few things that need special consideration:
(a) The first and foremost is a choked coronary system affecting not only the the main coronary arteries, but and also the microvascular coronary supply, which could also be compromised. It could result in poor left ventricular ejection fraction (LVEF), as well as a diastolic dysfunction with or without regurgitation from the heart valves.
(b) The underlying aetio-pathogenesis.
(c) The predisposing factors.
(d) Dietary factors & the possible inadvertent role of iodized table salt that probably the whole world is using, whether or not there is any identified iodine deficiency or not.
A lot has already been written out here in the BMJ's domain, as well as elsewhere [1-12]. Really wondering whether the idea should rather be of trying not to complicate the issues anymore and make it easy and straightforward. Our efforts should be directed to make the assessment and management simple, quick, efficient, affordable, accessible, etc. With all the knowledge gained, efforts should be to identify and remove all the complexities that have inadvertently come in. Within our own resources and means, without any help or assistance, we had accidentally come up with some simple and effective solutions. We had expected the world bodies and the global scientific community to take on from here on. We have seen a few results which had been quite remarkable, and had therefore pinned our hopes on the world researchers and medical community to make the assessment and the management very simple that could also possibly result in curing rather that just trying to control the chronic heart failure, as is being practiced now. We want that whatever little and unsubstantiated progress that we accidentally made, should be taken up with earnest by the world community. That was why we kept writing about all these issues and the newer ways that we had accidentally come across. Maybe there could be just a few successes at the very start, but with proper anticipation and backup the results can be improved with global support from researchers and scientists.
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Competing interests: These are our personal views and have nothing to do with any organization or institute.