Dr Abdallah Al-Mohammad and Professor Jonathan Mant discuss the updated NICE recommendations on the diagnosis and treatment of chronic heart failure


Heart failure is a complex syndrome of symptoms and signs associated with abnormalities of the heart’s structure and function. It is characterised by the heart’s inability to meet the needs of metabolising tissues.1 Heart failure leads to high rates of hospitalisation that are frequently prolonged, and also re-hospitalisation and mortality. It affects 900,000 people in the UK, and its prevalence is expected to rise with the ageing population and the improved survival of patients with conditions likely to result in heart failure (e.g. hypertension, ischaemic heart disease, and diabetes mellitus).2,3

The advances in the knowledge of the diagnosis, pharmacological treatment, monitoring, and rehabilitation of patients with chronic heart failure prompted NICE to release a partial update in 2010 to the original guideline published in 2003.4,5

The updated guideline, Clinical Guideline 108 (see: www.nice.org.uk/guidance/CG108), covers diagnosis, pharmacological treatment, rehabilitation, monitoring, and discharge planning, and the key priorities for implementation and are included in Box 1.

Box 1: Key priorities for implementation5

Diagnosis

  • Refer patients urgently to have echocardiography and specialist assessment within 2 weeks of presentation if they have a history of myocardial infarction and are suspected of having heart failure (new 2010)
  • Measure the serum natriuretic peptide (BNP or NT-pro-BNP) in all patients suspected of having heart failure who do not have a history of myocardial infarction (new 2010)
  • Because very high levels of natriuretic peptides are associated with poor prognosis, refer patients with suspected heart failure who have high levels of natriuretic peptide (BNP >400 pg/ml [>116 pmol/l] or NT-pro-BNP >2000 ng/ml [>236 pmol/l]) urgently to have a transthoracic 2D Doppler echocardiogram and a specialist assessment within 2 weeks (new 2010).

Pharmacological

  • Offer both ACE inhibitors and beta blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgment when deciding which agent to commence first (new 2010)
  • Offer a beta blocker licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including:
    • older adults and
    • patients with:
      • diabetes mellitus
      • peripheral vascular disease
      • erectile dysfunction
      • interstitial lung disease
      • chronic obstructive pulmonary disease, without reversibility (new 2010)
  • Refer a patient who remains symptomatic despite optimal therapy with first-line therapy to a specialist who will consider adding:
    • an aldosterone antagonist licensed for the use in heart failure, especially if the heart failure is moderate to severe or if the patient had a myocardial infarction in the last 4 weeks, or
    • an angiotensin receptor blocker licensed for use in heart failure, especially if the heart failure is mild to moderate, or
    • a combination of hydrazine and nitrates in patients with moderate to severe heart failure, particularly if the patient is of African or Caribbean origin (new 2010).

Rehabilitation

  • Offer a group exercise-based rehabilitation programme designed for heart failure patients:
    • Ensure that the patient is stable and does not have a condition or a device that could preclude the safe use of the exercise-based rehabilitation programme
    • Include educational and psychological components in the programme
    • The programme could be incorporated into an existing cardiac rehabilitation programme (new 2010).

Monitoring

  • All patients with chronic heart failure require monitoring. This usually includes: clinical assessment of their functional capacity, fluid status, cognitive ability, heart rhythm (minimum of examining their pulse); a review of medication; and monitoring of weight, blood pressure, serum urea, creatinine, electrolytes, eGFR, and their fluid balance (2003, updated in 2010)
  • When a patient is admitted to hospital with heart failure, seek advice on their management plan from a specialist in heart failure (new 2010).

Discharge planning

  • Patients with chronic heart failure should generally be discharged only when their condition is stable and their treatment is optimised. The timing of discharge should take into consideration the wishes of the patient and the carers, and the level of care and services available to them in the community (2003).

BNP=B-type natriuretic peptide; NT-pro-BNP=N-terminal pro-BNP; ACE=angiotensin-converting enzyme; eGFR=estimated glomerular filtration rate


Diagnosis of heart failure

Diagnosis of heart failure is based on four factors:6,7

  • Detection of the clinical syndrome (symptoms and signs, such as dyspnoea, fluid retention, tiredness, raised jugular venous pressure, gallop rhythm, and pulmonary congestion)
  • Likelihood of cardiac dysfunction based on patient history (past history of myocardial infarction) or evidence of increased myocardial stretch or pressure (raised natriuretic peptide level)
  • Imaging evidence of cardiac dysfunction (echocardiography)
  • Cardiac specialist’s assessment.

Once heart failure is suspected, diagnosis should be confirmed quickly to prevent high hospitalisation and mortality rates in the first few weeks after clinical onset.5 Patients with suspected heart failure and a prior myocardial infarction should be referred urgently to have an echocardiogram and receive specialist assessment within 2 weeks. Serum natriuretic peptide (B-type natriuretic peptide [BNP] or N-terminal pro-BNP [NTproBNP]) should be measured in patients with suspected heart failure but without prior myocardial infarction:

  • Patients with a serum natriuretic peptide below the diagnostic threshold (i.e. a serum BNP level of 100 pg/ml [29 pmol/litre] or an NTproBNP level of 400 pg/ml [47 pmol/litre]), and who are not on treatment known to lower the level of natriuretic peptides are unlikely to have heart failure
  • Those individuals with an intermediate rise of serum natriuretic peptide (i.e. a serum BNP level of 100–400 pg/ml [29–116 pmol/litre] or an NTproBNP level of 400–2000 pg/ml [47–236 pmol/litre])
    should be referred to have echocardiography and receive specialist clinical assessment within 6 weeks
  • Patients with a high serum natriuretic peptide level (i.e. BNP >400 pg/ml
    [>116 pmol/l] or NT-pro-BNP >2000 ng/ml [>236 pmol/l]) should be referred urgently to have an echocardiogram and a specialist assessment within 2 weeks.

In individuals who have had prior myocardial infarction but have no obvious abnormality on echocardiography, the specialist may decide (if clinical suspicion persists) to measure serum natriuretic peptide.

The role of the specialist is not only to interpret the echocardiogram and the result of the serum natriuretic peptide test, but also to advise a management plan that includes: advice on therapy, prognosis, investigations to determine the cause of heart failure, and further treatment where appropriate.

Pharmacological treatment

Heart failure is categorised into two types on the basis of the left ventricular contraction: heart failure due to left ventricular systolic dysfunction (HF-LVSD) and heart failure with preserved left ventricular ejection fraction (HFPEF).5 Most of the available evidence is for HF-LVSD, which is the main focus of this article.

Diuretics are given to patients with either type of heart failure where there is evidence of congestion and fluid retention.5

Patients with HFPEF and a co-morbid condition (e.g. ischaemia, hypertension, diabetes mellitus) should be appropriately treated.5

Heart failure due to left ventricular systolic dysfunction
The NICE guideline recommends that patients with HF-LVSD should be commenced on both angiotensin-converting enzyme (ACE) inhibitors and beta blockers licensed for heart failure as first-line therapy. Contrary to common practice, an angiotensin receptor blocker (ARB) should replace an ACE inhibitor only where the side-effects of this latter therapy are intolerable.5 The patient will be considered for combined hydralazine and nitrates if neither ACE inhibitors nor ARBs are tolerated (e.g. patients with advanced chronic kidney disease without renal replacement therapy and patients with angio-oedema).5

Patients with HF-LVSD and continuing symptoms despite optimal first-line therapy (with an ACE inhibitor and a beta blocker) should be referred back to the specialist for an opinion on second-line therapy, which includes using:5

  • an aldosterone antagonist in cases of moderate to severe heart failure, and in patients with recent myocardial infarction
  • an ARB licensed for HF in cases of mild to moderate HF
  • combined hydralazine and nitrate in moderate to severe HF, especially if the patient is of African or Caribbean origin.

The specialist may consider cardiac re-synchronisation therapy (CRT) where appropriate for patients with continuing symptoms despite optimal first- and second-line therapy.8 Alternatively, the specialist may add digoxin even in the absence of atrial fibrillation and will advise on the need for implantable cardioverter defibrillator at any stage, where appropriate.9

Rehabilitation

Group exercise-based rehabilitation that includes educational and psychological support is recommended for all patients with stable heart failure.5

Monitoring

Heart failure is a progressive disease, characterised by relapses that may lead to hospitalisation, and can lead to complications which affect the heart and other organs. The latter problems can be caused by the heart failure syndrome itself, or as a result of complications resulting from drug treatment for the condition. Thus monitoring of patients with heart failure is an important task for the primary care physician and all other healthcare professionals represented in the multidisciplinary heart failure team. This enables the patient to have timely and appropriate interventions.

Monitoring should include renal function, fluid status, body weight, blood pressure, pulse rate, 12-lead electrocardiogram (ECG), and nutritional status. The frequency of monitoring varies between at least every 2 weeks (where the patient’s condition is unstable or treatment is being altered) and every 6 months in stable patients.5

Management of patients with heart failure who are admitted to hospital should be guided by the opinion of the specialist.5

Based on currently available evidence, telemonitoring was deemed by the Guideline Development Group not to be superior to specialist heart-failure medical and nursing care. Finally, natriuretic peptides monitoring is advocated for use by the specialist in some recently hospitalised patients, and as an aid to uptitration in others.7

Referral

Patients should be referred for specialist advice:

  • at the outset, for establishing the diagnosis and the management plan
  • when the patient remains symptomatic despite optimal first-line therapy
  • when the patient remains symptomatic despite first- and second-line therapy
  • when heart failure is resistant to control as an outpatient
  • when heart failure is caused by or associated with valve disease, unstable coronary artery disease, or pregnancy.

Multidisciplinary team

The group of healthcare professionals caring for patients with heart failure is chaired by a specialist in this clinical area (usually a consultant cardiologist) and includes professionals from different disciplines from both primary and secondary care. The team may include colleagues from tertiary care (such as interventional cardiologists, electrophysiologists, and cardiac surgeons) as well as colleagues from palliative care.5

Discharge planning

Adequate discharge planning is an essential element in the prevention of readmission. The hallmarks of good discharge planning are good communication and inclusiveness of all those who need to care for the patient with heart failure both in the community and in hospital.5

Uncertainties in the management of heart failure

There are a number of uncertainties relating to inadequate or contradictory evidence, including the optimal treatment of HFPEF and the role of telemonitoring and natriuretic peptides in the monitoring of patients with heart failure.7

Information and support

Patients with heart failure should receive continuing education and support throughout their illness.5

Summary

The partial update of the NICE guideline on chronic heart failure has led to major changes in the recommendations on the diagnosis and management of this condition. Implementation of these changes will improve quality of life and reduce hospitalisation and mortality rates for people with heart failure. The initial increased expenditure required to apply the guideline will be offset by reduced hospitalisation costs.10

Implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 108 on The management of adults with chronic heart failure in primary and secondary care. The tools are now available to download from the NICE website: www.nice.org.uk

Audit support

Audit support has been developed to support the implementation of this guideline. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.

Baseline assessment tool

The baseline assessment tool 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.

Costing tools

A costing report and local cost templates for the guideline have been produced:

  • Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline
  • Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.

Slide set

The slides provide a framework for discussing the NICE guideline with a variety of audiences and can assist in local dissemination. This information does not supersede or replace the guidance itself.

Educational resource

Clinical case scenarios for primary care (text and powerpoint formats) are available.

Online educational tool

Educational modules are also available online.

  • Effective early diagnosis and proactive management in primary care can help prevent expensive emergency admissions and increase life expectancy
  • A simple diagnostic algorithm as in the NICE guidance can quickly identify patients with heart failure who should be referred for specialist opinion; and also reduce unnecessary referrals
  • The NICE guideline recommends that referrals for echocardiograms in people with suspected heart failure are always accompanied by specialist assessment—commissioners should review local arrangements to ensure this
  • A primary care GPwSI or specialist nurse service (with appropriate links to specialist opinion) can help optimise treatment of chronic heart failure and frequent monitoring
  • The cost of providing rehabilitation to patients with stable heart failure is justified by reduced hospitalisation costs and improved quality of life
  • Commissioners should ensure BNP testing is locally commissioned and that rapid access to specialist services is available from local providers
  • End-of-life care pathways and planning groups should consider the needs of patients with chronic heart failure to avoid inappropriate hospital admissions
  • Tariff prices:a
    • Emergency admission for heart failure = £2322–£3719 (codes EB03H, EB03I)
    • Cardiology outpatient = £215 (new), £103 (follow up) (code 320).

BNP=B-type natriuretic peptide
awww.dh.gov.uk/paymentbyresults

  1. Petersen S, Rayner M, Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation, 2002. Available at: www.heartstats.org/datapage.asp?id=1574
  2. Cowie M, Wood D, Coats A et al. Incidence and aetiology of heart failure; a population-based study. Eur Heart J 1999; 20 (6): 421–428.
  3. Owan T, Hodge D, Herges R et al. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006; 355 (3): 251–259.
  4. National Institute for Health and Care Excellence. Chronic heart failure: National clinical guideline for diagnosis and management in primary and secondary care. Clinical Guideline 5. London: NICE, 2003. Available at: www.nice.org.uk/guidance/CG5
  5. National Institute for Health and Care Excellence. Chronic heart failure: The management of adults with chronic heart failure in primary and secondary care (partial update). Clinical Guideline 108. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG108 nhs accred
  6. Mant J, Doust J, Roalfe A et al. Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. Health Technol Assess 2009; 13 (32).
  7. National Clinical Guideline Centre for Acute and Chronic Conditions. Chronic heart failure: National clinical guideline for diagnosis and management in primary and secondary care. Clinical Guideline 108. London: NCGC, 2010. Available at: www.nice.org.uk/guidance/CG108 nhs accred
  8. National Institute for Health and Care Excellence. Cardiac resynchronisation therapy for the treatment of heart failure. Technology Appraisal 120. London: NICE, 2007. Available at: www.nice.org.uk/guidance/TA120
  9. National Institute for Health and Care Excellence. Implantable cardioverter defibrillators for arrhythmia: Review of Technology Appraisal 11. Technology Appraisal 95. London: NICE, 2006. Available at: www.nice.org.uk/guidance/TA95
  10. National Institute for Health and Care Excellence. Chronic heart failure: Costing report—Implementing NICE guidance. Clinical Guideline 108. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG108 nhs accredG