Dr Andrew Ludman (pictured) and Professor Jonathan Mant describe significant changes to the structure of care and standard treatment of patients with acute heart failure

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    Read this article to learn more about:

    • the impact of the updated recommendations on treatment of acute heart failure, particularly provision of a specialist heart failure team
    • individual and organisational level change needed in order to improve quality of life and reduce re-hospitalisation and mortality rates for people with heart failure
    • changes in treatment recommendations for opiates and intravenous nitrates.

    Key points

    GP commissioning messages

 The burden of heart failure remains considerable. Approximately 800,000 people in the UK have a diagnosis of heart failure, which accounts for 5% of all emergency hospital admissions and 2% of total bed days.1 It is even more striking that, for those patients admitted to hospital with heart failure and who survive to discharge, the 1-year mortality is approximately 25%.1 Treating people who become acutely unwell with heart failure may be difficult; the diagnosis is often challenging, the best way to structure care is not known, and within the UK there is significant variation in clinical practice.

The recently published NICE Clinical Guideline (CG) 187 on Acute heart failure: diagnosing and managing acute heart failure in adults2, which has been awarded the NICE Accreditation Mark (see Box 1, below), aims to address these difficulties. Much of the guideline reviews the evidence for the treatment of patients with heart failure within acute care settings; however, if we are to successfully lower morbidity and mortality from heart failure, then a co-ordinated approach across the healthcare spectrum is essential. This new guideline complements NICE CG108 on Management of chronic heart failure,3 and the new recommendations on acute heart failure are important reading for GPs.

Box 1: NICE Accreditation Mark
NICE Accreditation Mark

NICE Clinical Guideline 187 on Acute heart failure: diagnosing and managing acute heart failure in adults has been awarded the NICE Accreditation Mark.

This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.

Definition

The NICE guideline does not explicitly define acute heart failure, but examined evidence pertaining to adults hospitalised with an acute onset of heart failure.2 The management of heart failure in people younger than 18 years old, during pregnancy, and following cardiac surgery were not examined. Heart failure may be defined as a syndrome with characteristic symptoms (dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, etc) and signs (peripheral oedema, pulmonary oedema, etc) caused by a structural abnormality of the heart meaning it is unable to provide adequate cardiac output for systemic requirements. Acute heart failure may present in a number of different ways; therefore, where available, evidence was considered for acute heart failure with:

  • pulmonary oedema
  • acutely decompensated chronic heart failure
  • cardiogenic shock
  • acute right heart failure.

Organisation of care

Because of the nature of heart failure as a chronic disease with periodic decompensations, patients are likely to seek treatment both in primary and secondary care at some point. It is important that care is organised to allow continuity across these settings. Observational data in the UK have consistently shown improved outcomes when patients with acute heart failure receive input to their care from a specialist, usually a cardiologist.1 Therefore NICE recommends that all hospitals admitting people with suspected acute heart failure should provide a specialist heart failure team, based on a cardiology ward and providing outreach services (see Box 2, below, for NICE priorities for implementation).2 The specialist team should provide:2

  • rapid identification of people admitted to hospital with suspected acute heart failure to allow early and ongoing specialist input
  • information to the patient about their condition, treatment, and prognosis
  • discharge planning from hospital, guidance on subsequent management in primary care, and co-ordination of follow up
  • a follow-up clinical assessment within 2 weeks of discharge.

Box 2: NICE key priorities for implementation2

Organisation of care

  • All hospitals admitting people with suspected acute heart failure should provide a specialist heart failure team that is based on a cardiology ward and provides outreach services
  • Ensure that all people being admitted to hospital with suspected acute heart failure have early and continuing input from a dedicated specialist heart failure team.
Diagnosis, assessment, and monitoring
  • In people presenting with new suspected acute heart failure, use a single measurement of serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NT proBNP]) and the following thresholds to rule out the diagnosis of heart failure:
    • BNP less than 100 ng/litre
    • NT proBNP less than 300 ng/litre
  • In people presenting with new suspected acute heart failure with raised natriuretic peptide levels, perform transthoracic Doppler 2D echocardiography to establish the presence or absence of cardiac abnormalities
  • In people presenting with new suspected acute heart failure, consider performing transthoracic Doppler 2D echocardiography within 48 hours of admission to guide early specialist management.
Treatment after stabilisation
  • In a person presenting with acute heart failure who is already taking beta blockers, continue the beta blocker treatment unless they have a heart rate less than 50 beats per minute, second- or third-degree atrioventricular block, or shock
  • Start or restart beta blocker treatment during hospital admission in people with acute heart failure due to left ventricular systolic dysfunction, once their condition has been stabilised—for example, when intravenous diuretics are no longer needed
  • Ensure that the person's condition is stable for typically 48 hours after starting or restarting beta blockers and before discharging from hospital
  • 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.

NICE (2015). Acute heart failure: diagnosing and managing acute heart failure in adults. Clinical Guideline 187. Available at: www.nice.org.uk/guidance/CG187 Reproduced with permission.

Diagnosis, assessment, and monitoring

The diagnosis of acute heart failure is often challenging as non-specific symptoms may originate from a number of pathologies. To assist in an earlier diagnosis of heart failure, and in addition to standard investigations, a single measure of a serum natriuretic peptide (NP) level is now recommended2 (see Figure 1, below). In the UK, NPs have previously been adopted fairly widely within primary care, but this recommendation means that acute care settings should also now plan for routine NP use in patients suspected of heart failure. Either B‑type natriuretic peptide (BNP) or N‑terminal pro‑B‑type natriuretic peptide (NT‑proBNP) may be used, with thresholds for ruling out a diagnosis of heart failure of less than 100 ng/l (BNP) and less than 300 ng/l (NT-proBNP). If results are positive, echocardiography should be performed as soon as possible, but ideally within 48 hours of admission, in order to confirm the diagnosis and guide therapy.2 If heart failure is confirmed, the differentiation between heart failure with preserved ejection fraction (HFPEF) and heart failure with left ventricular systolic dysfunction is very important, as this determines subsequent medical therapy.2

Figure 1: Diagnostic and treatment algorithm for clinical suspicion of acute heart failure.4
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.

Reproduced from BMJ 2014; 349: g5695 doi: 10.1136/bmj.g5695 with permission.

[Click here to download the full size algorithm in a new tab] 

Initial pharmacological therapy

Opiates and intravenous nitrates have commonly been given to people with acute pulmonary oedema; however, there is accumulating evidence of potential harm from opiates5 and these should no longer be used routinely in acute heart failure.2 Nitrates have limited, if any, evidence of benefit,5 and should also not be routinely used, but may be considered in specific circumstances (myocardial ischaemia, severe hypertension, regurgitant aortic or mitral valve disease) if appropriate monitoring is available.2 Diuretic therapy should be given intravenously by either bolus or infusion,2 as outcomes are similar. A bolus is easier for smaller doses, but an infusion may be preferred for large doses, although this requires associated nursing skill and monitoring. Careful monitoring of the patient's renal function, weight, and urine output should be performed while they are receiving IV diuretics.2 Inotropes and/or vasopressors should not be used routinely, but may be life-saving in people with potentially reversible cardiogenic shock. If needed, they should be administered in a cardiac care or critical care unit.2

Initial non-pharmacological therapy

Non-invasive ventilation

Continuous positive airways pressure (CPAP) or non‑invasive positive pressure ventilation (NIPPV) is not recommended routinely in people with acute heart failure and cardiogenic pulmonary oedema, but if required, CPAP or NIPPV should be available without delay, particularly in patients who have severe dyspnoea and acidaemia at acute presentation or in those who fail to respond to initial medical therapy.2 Further deterioration should prompt consideration of invasive ventilation.2

Ultrafiltration

Ultrafiltration is a technique that uses dialysis-type machines to remove fluid, but does not provide renal replacement therapy. It may have a role in individual cases where diuretic resistance is confirmed, but should not be routinely used over and above diuretic therapy.2

Treatment after stabilisation

In order to prevent recurrent admission and improve long-term prognosis, it is necessary to try to optimise evidence-based medical treatments. For people with heart failure associated with left ventricular systolic dysfunction, better outcomes are apparent in those who receive an angiotensin-converting enzyme inhibitor (ACE-I), a beta blocker (BB), and an aldosterone antagonist (AA), with the combination leading to reduced morbidity and improved life expectancy.1 During the hospital admission and in the absence of contraindications, an ACE-I, BB, and AA should be commenced and at least the initial dose titration started. There is a small risk of further decompensation following BB use, so a period of stability should be ensured prior to discharge (48 hours has been suggested).1,2 In general, if a patient is already receiving a BB and is admitted for an acute decompensation, there is no need to stop it unless they have a heart rate less than 50 beats per minute, second- or third-degree atrioventricular block, or shock. In-patient and subsequent out-patient monitoring of a person's renal function, electrolytes, heart rate, blood pressure, and overall clinical status will be needed2 (see also NICE CG1083).

Valvular surgery and percutaneous intervention

It is important in almost all cases to try to identify the underlying cause of the acute heart failure, as many reversible causes exist. In the case of severe aortic stenosis, surgical aortic valve replacement should be considered, or the newer transcatheter aortic valve implantation (TAVI) may be considered in selected people assessed as unsuitable for surgical aortic valve replacement.2 Similarly, surgical mitral valve repair or replacement should be considered for people with heart failure due to severe mitral regurgitation (who are assessed as suitable for surgery).2 Revascularisation of ischaemic heart disease may take place as an emergency measure in the case of acute heart failure due to an ST-elevation myocardial infarction, or be required after an interval in some patients.3

Mechanical assist devices

Significant advances have been made in short-term, intermediate-term, and longterm devices that can provide mechanical assistance to the left, right, or even both ventricles. These devices may provide a 'bridge to recovery' of cardiac function or may be a 'bridge to transplantation' in those whose function does not recover. In the UK at present, implantable devices are limited to patients who may be transplant candidates; however, due to the rapidly changing technology and the complexity of patient selection, it is recommended that the specialist should discuss cases of patients with potentially reversible severe acute heart failure at an early stage with a centre providing mechanical circulatory support.2

Challenges to implementation

NICE CG187 recommends a number of organisational and structural changes to the care or treatment of a patient with heart failure.2 The provision of a specialist heart failure team, routine serum natriuretic peptide testing, and echocardiography within 48 hours is likely to require some resource redistribution that may not be welcome in a cost-constrained environment; however, downstream benefits will be realised. At an individual level, practice may need to change, as the guideline no longer recommends routinely using opiates, nitrates, and non-invasive ventilation for people with cardiogenic pulmonary oedema. Implicit throughout the guideline is the change in attitude required as well; morbidity and mortality due to heart failure are too high, and therefore changes at individual and organisational level are needed in order to focus on acute heart failure. This type of change may be slowest, but could be significantly assisted by financial initiatives such as the proposed national Best Practice Tariff for heart failure6 or other measures developed locally by commissioners.

Some useful sources of information for patients, families, and carers can be found in Box 3, below; links to information to aid implementation of NICE CG187 can be found in the 'NICE implementation tools' below.

Box 3: Useful sources of information for patients, families, and carers

*all weblinks accessed 4 February 2015


NICE implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 187 (CG187) on Acute heart failure.

  • Tools to help professionals with implementation and audit are available at: *www.nice.org.uk/guidance/cg187/resources
  • Projected costing information is available at: *www.nice.org.uk/guidance/cg187/costing

NICE support for service improvement systems and audit

Baseline assessment tool audit.jpg

The baseline assessment is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.

NICE support for commissioners

Costing statement Commissioning

A costing statement has been produced because of wide variation in practice, therefore a national resource impact would be challenging to estimate. The statement has been prepared in consultation with experts working in this area and has been approved for publication by NICE.

*weblinks accessed 4 February 2015

Key to NICE implementation icons

Commissioning.epsNICE support for commissioners

  • Support package for commissioners and others for quality standards
  • NICE guide for commissioners
  • NICE cost impact support for guidance (selection from national report/local template/costing statement, dependent on topic)

Audit.epsNICE support for service improvement systems and audit

  • Forward planner
  • 'How to' guides (generic advice on processes)
  • Local government briefings (with Centre for Public Health Excellence)
  • Baseline assessment tool for guidance
  • Audit support including electronic data collection tools
  • E-learning modules (commissioned)

Education.epsNICE support for education and learning

  • Clinical case scenarios
  • Learning packages including slide sets
  • Podcasts
  • Shared learning and other local best practice examples

Conclusion

The new NICE guideline on acute heart failure recommends significant changes in the structure of care and standard treatment of patients with acute heart failure. Implementation of these changes is likely to improve quality of life and reduce re-hospitalisation and mortality rates for people with heart failure. An initial increase in expenditure required to apply the guidelines will be offset by reduced downstream costs.

Key points

  • Acute heart failure is often a medical emergency and usually requires the resources of hospital-based care
  • A large proportion of patients hospitalised with heart failure have decompensated chronic heart failure, which may have been gradually worsening for days/weeks prior to requiring hospital admission. Rapid identification and appropriate management of these patients may prevent an acute admission, and early discussion with the community- or hospital-based heart failure team should be considered
  • Opiates are no longer routinely recommended for use in emergency management of acute heart failure, unless for the treatment of pain
  • In the acute community setting, the GP should consider administering oxygen if the patient has pulmonary oedema, as well as a bolus of intravenous furosemide
  • Nitrates are no longer routinely recommended but may have a role in concomitant ischaemia, hypertension, or regurgitant mitral valve disease
  • Following discharge, the GP should expect the majority of patients with severe left ventricular systolic dysfunction to be prescribed an ACE-I, a BB, and an AA. In the case of medication intolerance, the reasons should be identified and documented
  • Follow up with a member of the specialist heart failure team should occur within 2 weeks of discharge.

ACE-I=angiotensin-converting enzyme inhibitor; BB=beta blocker; AA=aldosterone antagonist

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GP commissioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • Commissioners should consider meeting with local cardiology providers to define new care pathways that will meet the standards laid out in this new NICE guideline:
    • these pathways should specify the required changes in out-of-hospital as well as in-hospital care and be published and shared with all providers of acute care (including ambulance and GP out-of-hours services)
  • The changes to hospital care may require resource investment from provider trusts but for commissioners these services are covered by the PbR tariff
  • Commissioners:
    • could build the requirements to provide an acute heart failure service in hospital into contracts with providers
    • may wish to consider funding community-based specialist heart failure nurses through community providers or agreeing a local tariff to ensure these services are available to support local GP practices
  • Education programmes for GPs and other clinicians on the difference between the management of heart failure with impaired LV function and of HFPEF would help ensure patients received the right treatment for both conditions
  • Tariff costs for cardiology outpatients: £164 new, £92 follow up. Echocardiogram (out patient): £74a

awww.gov.uk/government/publications/national-tariff-payment-system-2014-to-2015
PbR=Payment by Results; LV=left ventricular; HFPEF=heart failure with preserved ejection fraction

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References

  1. National Institute for Cardiovascular Outcomes Research.National Heart Failure Audit (April 2012–March 2013). National Institute for Cardiovascular Outcomes Research, 2013. Available at: www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2013-14/UCL-HF-2013-Report-2013-ONLINE-v2.pdf
  2. NICE. Acute heart failure: diagnosing and managing acute heart failure in adults. Clinical Guideline 187. NICE, 2014. Available at: www.nice.org.uk/guidance/CG187
  3. NICE. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. Clinical Guideline 108. NICE, 2010. Available at: www.nice.org.uk/guidance/CG108
  4. Dworzynski K. Diagnosing and managing acute heart failure in adults: summary of NICE guidance. BMJ 2014; 349: g5695
  5. National Clinical Guideline Centre. Acute heart failure: diagnosing and managing acute heart failure in adults. Methods, evidence and recommendations. NCGC, 2014. Available at: www.nice.org.uk/guidance/cg187/evidence
  6. Monitor—NHS England. 2015/16National Tariff Payment System: engagement on national prices. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/332217/NationalTariff2015-16_EngagementNationalPrices.pdf