In July 2003, the National Institute for Clinical Excellence issued a guideline to the NHS in England and Wales on the management of chronic heart failure.1 Its recommendations cover all aspects of the care pathway from first suspicion of the diagnosis, through chronic disease management, to end-of-life issues. Why did NICE choose heart failure, and will this guideline make any difference?
In terms of health burden, heart failure is certainly worthy of attention. At least 900 000 people in the UK have heart failure, and for many, the condition has a major impact on their quality of life. Despite advances in therapy many patients remain symptomatic, with breathlessness and fluid retention impairing their ability to do all they want.
The prognosis of heart failure is serious – 40% of individuals with a new diagnosis of heart failure die within a year; thereafter annual mortality drops to about 10% per year.2 This prognosis is worse than for many cancers, but it is rarely discussed with patients and their families.
Heart failure is responsible for 1-2% of healthcare expenditure in most developed countries, and the UK is no exception. Around 70% of this cost relates to the cost of hospitalisations, which may be recurrent and prolonged. 3 Most individuals with heart failure will be seen in primary care between 11 and 14 times per year, and are often prescribed many different medications.3
The NICE guideline builds on the National Service Framework for Coronary Heart Disease.4 The framework provided a goal for heart failure management, and milestones along the way.The NICE guideline provides evidence-based recommendations for best practice. The two documents should therefore be viewed as complementary.
The evidence base
There have been many advances in the management of heart failure in recent years – both in terms of diagnosis and treatment. The full version of the guideline summarises the evidence on which the recommendations are based.5
Much of the evidence comes from large randomised controlled trials and the recommendations are graded level A. However, other aspects of care such as diagnostic methods, lifestyle advice, and communication issues, do not lend themselves to such examination and although the grade of evidence in the strict scheme recommended by NICE appears lower, this does not mean that the recommendations are less important or valid.
Undoubtedly, further research is required, and recommendations for this are given in the full version of the guideline. Nevertheless, there is ample evidence on which to base good practice.
Eight recommendations have been identified as key in that they are likely to have a major impact on the outcome of care for patients. The Department of Health considers these priorities for implementation, and will be producing advice on how to do this.
The guideline suggests that these recommendations may be used to guide the selection of audit criteria for the NHS. The recommendations are:
- The basis for a historical diagnosis of heart failure should be reviewed, and only patients whose diagnosis is confirmed should be managed in accordance with the guideline.
- Doppler 2D echocardiographic examination should be performed to exclude important valve disease, assess the systolic (and diastolic) function of the left ventricle and detect intra-cardiac shunts.
- All patients with heart failure caused by left ventricular systolic dysfunction should be considered for treatment with an ACE inhibitor.
- Beta-blockers licensed for heart failure should be initiated in patients with heart failure caused by left ventricular systolic dysfunction after diuretic and ACE inhibitor therapy (regardless of whether or not symptoms persist after such therapy).
- All patients with chronic heart failure require monitoring, which should include:
- clinical assessment of functional capacity, fluid status, cardiac rhythm, and cognitive and nutritional status
- review of medication, including need for changes and possible side-effects
- serum urea, electrolytes and creatinine.
- Patients with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised.
- The primary care team, patient and carer must be aware of the management plan.
- Management of heart failure should be seen as a shared responsibility between patient and healthcare professional.
Diagnosing heart failure
The guideline provides a simple algorithm for diagnosis (Figure 1, below). Recognising that the limited resource of echocardiography must be used well, the guideline suggests that primary care physicians may use either the 12-lead ECG or a blood test for one of the natriuretic peptides (BNP or NTproBNP) to rule out heart failure.
|Figure 1: Diagnostic algorithm recommended by NICE|
|Reproduced from Chronic heart failure: management of chronic heart failure in adults in primary and secondary care by kind permission of the National Institute for Clinical Excellence|
In such patients, alternative diagnoses should be considered first. If there are good grounds for suspecting heart failure, other tests are also recommended, chiefly to detect comorbidity or exacerbating factors.
If the echocardiogram is abnormal, then the diagnosis is usually secure, although in cases of doubt specialist input may be required.
Diastolic dysfunction remains a difficult area, for which referral to a specialist is advised.
The evidence base for treatment of heart failure is enormous.The guideline group reviewed thousands of papers, and has made reference to several hundred in the full version of the guideline. An algorithm for drug treatment of left ventricular systolic dysfunction is also provided (Figure 2, below), along with recommendations on lifestyle management, and practical recommendations on how to titrate drug therapy and monitor for adverse effects.
|Figure 2: Algorithm for pharmacological management of heart failure caused by left venticular systolic dysfunction recommended by NICE|
The guideline also defines situations in which specialist referral is likely to be necessary (Box 1, below). The term ‘specialist’ does not only mean a consultant cardiologist, but includes any healthcare professional with special knowledge and experience in the diagnosis and management of patients with heart failure. Increasingly, this may be a GP with a special interest, or a heart failure nurse specialist.
|Box 1: Recommendations for specialist referral|
|Specialist advice is required in the following situations:
One interesting theme that emerged time and time again from the patient representatives on the guideline group, and was backed up by the patient focus group, was the need to improve communication between healthcare professionals and patients and their carers. Often the term ‘heart failure’ is not used, leaving all concerned to use the type of euphemisms that were common in cancer practice 30 years ago. This is viewed as counterproductive and prevents collaborative working. [See ‘Listening to patients helps improve heart failure care']
Implementing the guideline
NICE is not charged with implementing the guideline, but categorically states that "local health communities should review their existing service provision for the management of heart failure against this guideline as they develop their Local Delivery Plans.The review should consider the resources required to implement fully the recommendations set out ..., the people and processes involved, and the timeline over which full implementation is envisaged.” It notes that it is in the best interests of patients that the guideline is implemented as rapidly as possible.
Will resources be provided to aid implementation? No new funding has been allocated by the Department of Health, although spending on cardiovascular disease has increased markedly in recent years. Furthermore, as NICE considers the recommendations to be clinically and cost-effective the message for providers is clear. For many healthcare communities the recommendations can be achieved (if they have not been already) by process redesign, and the CHD collaboratives have provided examples of this.
The new GMS contract for GPs includes a left ventricular dysfunction subset of coronary heart disease as one of the ten disease areas in the clinical ‘domain’. Practices that have a register of patients with coronary heart disease and left ventricular dysfunction, and can demonstrate that the diagnosis is confirmed by echocardiography (target 90%), and that an ACE inhibitor (or A2 antagonist) is prescribed (target 70%) will qualify for additional funding.
Guidelines achieve nothing if they just sit on the shelf. There is considerable goodwill for improving the standards of care for heart failure across the country. There is a broad consensus internationally on what needs to be done, and the NHS now has a single authoritative source of information that should improve uptake of appropriate diagnostic procedures and treatments for this condition. It should also improve coordination and sharing of information between healthcare professionals and reduce regional variation in the quality of care patients with heart failure receive. Is this just a pipe dream? I don’t believe so.
- The National Institute for Clinical Excellence. Management of Chronic Heart Failure in Adults in Primary and Secondary Care. NICE Guideline No 5. July 2003, www.nice.org.uk.
- Cowie MR,Wood DA, Coats AJ et al. Survival of patients with a new diagnosis of heart failure: a population-based study. Heart 2000; 83: 505-10.
- Petersen S, Rayner M,Wolstenholme J. Coronary Heart Disease Statistics:Heart Failure Supplement. London: British Heart Foundation, 2002.
- Department of Health.National Service Framework for Coronary Heart Disease: Modern Standards and Service Models. London: DoH, 2000.
- National Collaborating Centre for Chronic Conditions. Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care. Royal College of Physicians of London: London: July 2003, www.rcplondon.ac.uk.