Dr Clare Taylor and Dr Jim Moore highlight five key learning points to take away from the updated NICE guideline on chronic heart failure in adults
Read this article to learn more about:
- symptoms that suggest heart failure and when to refer to a specialist
- the role of GPs in managing patients with heart failure
- treatment options for people with heart failure with reduced ejection fraction.
Heart failure affects around 920,000 people in the UK.1 The average age at diagnosis is 77 years1 but heart failure can occur in younger people.2 It often exists in the context of multimorbidity,3 which can make diagnosis and treatment more complex and, overall, the prognosis for people with heart failure is worse than for most cancers.4–6
Timely diagnosis, appropriate referral, and optimal treatment across primary and secondary care are key to improving outcomes for these patients. The updated NICE Guideline (NG) 106, Chronic heart failure in adults: diagnosis and management,1 provides practical recommendations to guide diagnosis and management. This article highlights the five areas most relevant to GPs.
1. Symptoms suggestive of heart failure call for a natriuretic peptide test
Making a diagnosis of heart failure can be challenging. Symptoms such as breathlessness, fatigue, and ankle swelling are common, particularly in older people, and may also occur because of other co-morbidities or prescribed medication. Natriuretic peptides are released by the myocardium when the heart is under strain and are raised in people with heart failure. NICE recommends natriuretic peptide testing for any patient presenting in primary care with symptoms and signs suggestive of heart failure.1 NICE previously recommended that patients with a history of myocardial infarction should be referred directly for echocardiography, but this recommendation has been removed following the update.1
N-terminal pro-B-type natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) are both available. Where there is a choice, NICE recommends using NT-proBNP as the level remains stable in blood samples over a longer period and it is not affected by the newer heart failure drugs.1
NICE recommends that all patients with suspected heart failure and a NT-proBNP level above 400 pg/ml should be referred urgently and assessed by the specialist team within 6 weeks. If the NT-proBNP level is greater than 2000 pg/ml then the assessment should take place within 2 weeks. An electrocardiogram (ECG) should also be recorded and other tests, such as a chest X-ray and blood tests, should be considered to evaluate aggravating factors and/or alternative diagnoses, but the decision to refer should be based on clinical suspicion and a raised NT-proBNP level.1
2. Refer to a heart failure specialist for diagnosis
NICE Guideline 106 recommends that the diagnosis of heart failure is made by a lead physician with subspecialty training in heart failure. Imaging of the heart is also required to assess for any structural or functional abnormality with echocardiography recommended as the most appropriate modality. The time between referral and being seen by a specialist is dependent on the NT-proBNP level because high levels of natriuretic peptide are associated with worse prognosis, and hospital admission, so diagnosis and treatment should be prioritised for those with high levels.1
‘Heart failure’ is a frightening (and somewhat misleading) term that can be difficult for patients to understand. NICE recommends offering an extended first consultation with the specialist multidisciplinary team (MDT) to people newly diagnosed with heart failure, followed by a second consultation within 2 weeks, to ensure that the diagnosis is fully explained to patients and their family or carers, and that they have an opportunity to ask any questions.1
3. Heart failure management requires a team-based approach
People with heart failure require primary and secondary care teams to work together to provide the best care. The transition between teams within the healthcare system can be difficult for patients and the clinicians involved in their care. The updated guideline specifically tackles this problem by clearly defining the responsibilities of each team. The MDT should work in collaboration with the primary care team and include a lead physician with training in heart failure, a specialist heart failure nurse, and healthcare professional with expertise in specialist prescribing for heart failure. The specialist MDT should diagnose heart failure, initiate and optimise treatment for patients with a new diagnosis or worsening symptoms, and provide a written care plan that should be shared with the primary care team and the patient.1
The role of primary care includes referral for diagnosis and monitoring stable patients once their treatment has been optimised by the specialist MDT, ensuring that any changes to the clinical record (e.g. medications, clinical status) are understood by the patient and communicated to the specialist MDT, with referral back if clinically indicated e.g. for second line therapies or in advanced heart failure. Patients with heart failure should be reviewed at least every 6 months, although many will be seen more frequently.1
4. The type of heart failure determines management
Heart failure is a clinical syndrome that occurs when the heart is unable to meet the metabolic needs of the body. There are many causes including hypertension, diabetes, ischaemic heart disease, arrhythmias, valvular heart disease, and genetic disorders. The management of arrhythmia is through rate and/or rhythm control and valvular heart disease may require surgical intervention.1
The updated NICE guideline focuses on the classification of heart failure based on left ventricular ejection fraction: heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). There is currently no evidence-based pharmacotherapy for HFpEF, and management should aim to optimise the treatment of co-morbidities, but there is a range of prognostically beneficial treatments in HFrEF.1
NICE recommends offering diuretics to all patients with heart failure, for the relief of congestive symptoms and fluid retention. NICE now recommends against routinely advising patients to reduce their salt or fluid consumption; patients should be asked about their salt and fluid consumption and advised to restrict fluids if they have dilutional hyponatraemia, and reduce salt and/or fluid consumption if their intake is particularly high. People with heart failure should be offered a personalised, exercise-based cardiac rehabilitation programme, unless their condition is unstable.1
5. There is a range of treatment options for HFrEF
NICE still recommends offering an angiotensin-converting enzyme inhibitor (ACE-I) and a beta-blocker licensed for heart failure as the first-line treatment option for HFrEF; consider an angiotensin II receptor blocker (ARB) as an alternative to an ACE-I if the patient has intolerable side-effects. NICE now also recommends offering a mineralocorticoid receptor antagonist (MRA) in addition to an ACE inhibitor (or ARB) and beta-blocker if symptoms persist—so called ‘triple therapy’. Close monitoring of renal function, electrolytes, and blood pressure is important, particularly in people with chronic kidney disease where the dose of medication may need to be reduced.1
There are further second-line treatment options for patients with persistent symptoms. A new class of drug has been introduced in the updated guideline called an angiotensin receptor neprilysin inhibitor (ARNI). Sacubitril valsartan, the only available ARNI, is recommended for people with New York Heart Association (NYHA) class II to IV symptoms, a left ventricular ejection fraction of 35% or less, and who are already receiving a stable dose of an ACE-I or ARB. Natriuretic peptides are the body’s response to strain on the heart and help to maintain homeostasis by acting on the kidney to induce diuresis. Neprilysin is an enzyme that breaks down natriuretic peptides. ARNIs inhibit the action of neprilysin so allowing natriuretic peptides to act for longer.7 Initiation and titration of ARNIs is undertaken by the specialist team initially but prescribing may be transferred to primary care in stable patients, depending on local arrangements. GPs need to be aware that ARNIs are composed of both a neprilysin inhibitor and an ARB and therefore replace any prescribed ACE-I or ARB. Medication lists in the patient primary care record should be updated appropriately. Other second-line treatment options recommended by NICE include ivabradine, which acts on the sinoatrial node to control heart rate in people with HFrEF, provided they are in sinus rhythm with a heart rate of 75 beats per minute or more.
The new NICE guidance on chronic heart failure has a welcome person-centred approach and clearly explains the important role of primary care. Timely diagnosis and optimal treatment, along with routine monitoring in primary care that supports seamless care between healthcare providers, is key to achieving the best possible outcomes for patients with heart failure.
CT was lead author for the diagnostic accuracy study (REFER) which was considered in the evidence review for the guideline. A declaration of interest was made, and CT withdrew from the committee during discussion of the health economic model and subsequent recommendations. Roche Diagnostics provided the NT-proBNP testing equipment for the REFER study but did not have any influence on study design, conduct, or reporting.
JM has no competing interests releating to NG106.
The authors would like to acknowledge all of the members of the 2018 Chronic heart failure in adults: diagnosis and management guideline development group.
CT is funded by a National Institute for Health Research (NIHR) Academic Clinical Lectureship at the University of Oxford. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.
Dr Clare J Taylor
GP and GPwSI, Gloucestershire Heart Failure Service
National Institute for Health Research Academic Clinical Lecturer
Member of the guideline development group for NG106
Dr Jim Moore
GPwSI heart failure
Member of the guideline development group for NG106
Implementation actions for STPs and ICSs
written by Dr David Jenner, GP, Cullompton, Devon
The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.
- Review local provision of heart failure services and ensure they can meet the standards required by NICE Guideline 106, especially timely access to specialist opinion
- Underdiagnosis is a key issue so ensure local primary care services are aware of updated NICE Guideline 106 and have access to direct access NT-proBNP and BNP blood tests and echocardiography
- Create a local care pathway based on this guidance to ensure prompt and accurate referral and publish this on local formulary or referral management websites
- Consider employing specialist nurses for chronic heart failure who can help support:
- patients after diagnosis
- GPs in sometimes difficult dose-titration of pharmacotherapies to achieve optimal management.
STP=sustainability and transformation partnership; ICS=integrated care system; NT-proBNP=N-terminal pro-B-type natriuretic peptide; BNP=B-type natriuretic peptide
Implementation actions for clinical pharmacists
written by Gupinder Syan, Training and Clinical Outcomes Manager, Soar Beyond Ltd
The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level.
- Agree scope of patients to be seen within your competence. Although heart failure can be complex and care of patients is often led by specialists, a lot can be done by pharmacists to support their care and reduce hospital admissions and readmissions
- Set up searches to identify patients you would be competent to see in clinic; coding is essential to evaluate interventions made (e.g. identify patients on ACE-Is/ARBs not on maximum tolerated doses)
- Be opportunistic. Some patients you see for other long-term conditions/medicine reviews may also have heart failure and these reviews provide an opportunity for support, medicines optimisation, and lifestyle advice
- Support the wider MDT in the management of patients with heart failure in the following ways:
- assess and identify symptoms during LTC/medication reviews with prompt referral to GP/specialists when required
- assess concordance to and appropriateness of medication and take appropriate action as needed, e.g. optimise doses of ACE-I/ARBs/beta-blockers, ensure ACE-I and ARBs are stopped when the patient is started on an ARNI
- assess and identify symptoms, with prompt referral to specialists when required
- help patients to understand their symptoms and how their medications can help relieve these
- reinforce and support patients with diet and lifestyle changes (e.g. ask about salt intake and fluid restrictions, smoking cessation, alcohol consumption, and referral to cardiac rehabilitation services), establish current QoL and where they would like to be, assess mood and refer on appropriately
- support care planning with the aim of improving symptoms, QoL, and preventing deterioration by setting realistic and achievable goals with the patient and wider MDT
- Familiarise yourself with local guidelines, formularies, and referral pathways to ensure cost-effective practice
- Ensure you adopt an MDT approach and involve other HCPs when managing more complex patients. Know when and how to refer to local services
- When evaluating your contribution to patients that you have managed in heart failure reviews, think about the following:
- how many patients with heart failure have you reviewed?
- how much time have you saved and freed up for additional appointment slots for other HCPs?
- what local cost-effective switches have you made?
- how many patients have you improved symptoms of heart failure/QoL/mood/lifestyle for?
- how many patients have you optimised therapy for?
ACE-I=angiotensin-converting enzyme inhibitor; ARB=angiotensin II receptor blocker; ARNI=angiotensin receptor neprilysin inhibitor; MDT=multidisciplinary team; LTC=long-term care; QoL=quality of life; HCP=healthcare practitioner
- NICE. Chronic heart failure in adults: diagnosis and management. NICE Guideline 106. NICE, 2018. Available at: www.nice.org.uk/ng106
- Roger V. Epidemiology of heart failure. Circ Res 2013; 113 (6): 646–659.
- Conrad N, Judge A, Tran J et al. Temporal trends and patterns in heart failure incidence: a population-based study of 4 million individuals. Lancet 2018; 391 (10120): 572–580.
- Braunwald E. The war against heart failure: the Lancet lecture. Lancet 2015; 385 (9970): 812–824.
- Cancer Research UK. Cancer survival statistics for all cancers combined. www.cancerresearchuk.org/health-professional/cancer-statistics/survival/all-cancers-combined (accessed 22 November 2018).
- Taylor C, Ryan R, Nichols L et al. Survival following a diagnosis of heart failure in primary care. Fam Pract 2017; 34 (2): 161–168.
- Jhund P, McMurray J. The neprilysin pathway in heart failure: a review and guide on the use of sacubitril/valsartan. Heart 2016; 102: 1342–1347.