Chronic heart failure is both common and complex, and Dr Peter Savill advises GPs to review this modified SIGN guideline

In February 2007, the Scottish Intercollegiate Guidelines Network (SIGN) issued several new or updated cardiology guidelines, one of which was SIGN 95: Management of chronic heart failure.1 It has been 4 years since the publication of the National Institute for Health and Care Excellence (NICE) guideline on chronic heart failure (CHF)2 and I was interested to see whether there were any new recommendations.

The definition of CHF used by SIGN indicates that it can be associated with left ventricular systolic dysfunction (LVSD) and/or left ventricular diastolic dysfunction (LVDD). The guideline also mentions right ventricular dysfunction in the later stages of the disease.1

Diagnosis

Clinical symptoms and signs can be useful in alerting the clinician to the possibility of CHF, but they are not sensitive or specific enough to make the diagnosis without recourse to additional tests. The guideline recommends the usual battery of basic tests. The following should be included:1

  • full blood count
  • blood glucose
  • renal function and electrolytes
  • thyroid function
  • urinalysis
  • chest X-ray.

Chest X-ray is included to add support to the diagnosis and to investigate other potential causes of breathlessness. However, requesting this investigation may delay progression through the diagnostic pathway, and clinical judgement must be exercised with regard to the usefulness of this test in informing decision making in primary care.

Resting electrocardiogram (ECG) and/or brain natriuretic peptide (BNP) are recommended as screening tests to determine when to proceed to echocardiography. If either test gives an abnormal result, then an echocardiogram should be performed. The guideline view on BNP is very practical, with advice to use it if available. Rather than setting an arbitrary cut-off point for deciding on a level at which the risk of heart failure increases, the guideline development group felt it was more realistic to view a very high level of BNP as indicating a greater likelihood of heart failure, with a very low level providing reassurance. Intermediate values would require further consideration. Testing should take place before treatment is started, and should take into consideration variables such as age, sex, and ethnicity.

If BNP is not available, a normal resting ECG result makes heart failure unlikely. Personally, if only one test were available, I think I would be more reassured by a normal BNP. If both tests are normal then heart failure is very unlikely.

Investigations

An echocardiogram is recommended to confirm the diagnosis and to exclude other causes of heart failure such as valve disease, as valve disorders can be accurately delineated on echocardiogram. It should only be performed by suitably trained individuals using modern equipment. This applies particularly to community echocardiogram services, where there may be no access to support from trained peers and a lack of senior review.

Clinical assessment, including resting ECG and echocardiogram, will often determine the underlying aetiology of LVSD; as such, the routine use of other imaging techniques to look for coronary disease (myocardial perfusion imaging and angiography) is not recommended. The guideline does not recommend routine assessment of myocardial viability by dobutamine stress echocardiogram, magnetic resonance imaging, and positron emission tomography in patients with coronary disease. There is insufficient evidence to show that revascularisation will benefit such patients, and routine coronary angiography and revascularisation are not recommended.1

Behavioural modification

Excessive alcohol consumption is to be avoided by patients with CHF and abstinence is advised where alcohol is felt to be a contributing factor. Smoking cessation/avoidance is also recommended in all patients with CHF.

Low intensity walking exercise was found to benefit patients with stable heart failure, and the guideline recommends that these people might be encouraged by motivational techniques to partake in regular low intensity physical activity. Walking is advocated, but swimming is not advised because of concerns over blood pressure responses during immersion and adverse haemodynamics. There was also support for organised moderate intensity exercise programmes in stable patients.

The guideline advises patients with CHF to avoid a salt intake of >6 g/day and not to use low salt alternatives because of their high potassium content. Patients are also to be encouraged to weigh themselves daily and report weight gains of more than 1.5–2.0 kg over 2 days to their GP.

Pharmacological therapies

There were no great surprises in this section of the guideline, although evidence from the CHARM,3 SENIORS,4 and EPHESUS5 trials was incorporated for candesartan, nebivolol, and eplerenone, respectively.

Angiotensin-converting enzyme inhibitors (ACEI) should be considered for all patients with heart failure due to LVSD, or an angiotensin-receptor blocker (ARB) for those patients who are intolerant of ACEIs. Beta blocker therapy is recommended for patients with CHF due to LVSD once their condition is stable, although this is contraindicated if the patient has a history of asthma, heart block, or symptomatic hypotension. Nebivolol has been added to the familiar picking list of bisoprolol and carvedilol.

Patients who remain symptomatic, despite being given an ACEI and a beta blocker, may benefit from the addition of candesartan following specialist advice, based on data from the CHARM-Added trial.6

Spironolactone remains in favour for patients with moderate to severe heart failure due to LVSD, and this should be considered following specialist advice, although renal function and potassium levels must first be considered. Eplerenone is only recommended if gynaecomastia occurs with spironolactone, or in the setting of a recent myocardial infarct with an ejection fraction of ?40% and symptoms of heart failure or diabetes.1 However, eplerenone is contraindicated if there is renal impairment or a high potassium concentration.

Diuretics remain the mainstay of treatment for peripheral and/or pulmonary oedema and digoxin is to be considered for patients in sinus rhythm who remain symptomatic despite optimal therapy.1

Many patients with CHF will already be taking aspirin and the guideline observed that there was no compelling evidence for aspirin use or withdrawal. No specific recommendations were made concerning warfarin, although the guideline includes as a good practice point that patients with CHF who are taking warfarin should not drink cranberry juice or take St John’s wort as these may interact with the drug. The guideline advises consideration of hydralazine and isosorbide dinitrate in African Americans with advanced heart failure due to LVSD, and in patients who are intolerant of ACEI/ARB due to renal dysfunction or hyperkalaemia.1

There was no specific guidance for patients suffering from heart failure with preserved LV systolic function (so-called diastolic heart failure), due to a dearth of evidence in this situation. The only putative evidence base comes from the CHARM-Preserved trial,7 with a slight trend indicating benefit from using candesartan in such patients, although the results were not statistically significant.

The guideline has common sense advice for managing heart failure patients with other conditions such as gout, angina, and renal impairment, and for CHF in the elderly. One pneumococcal vaccination and annual influenza vaccinations are also advised.1

Interventional procedures

Cardiac resynchronisation therapy (biventricular pacing or CRT) has the potential to improve dyssynchronous LV contraction dramatically, and with it patient symptoms; however, this is a resource-intensive intervention. As such, the guideline suggests only considering CRT in patients who remain in sinus rhythm with drug refractory symptomatic heart failure due to LVSD with an ejection fraction ?35%, who are in New York Health Association class III or IV, and who have a QRS duration of >120 ms. The use of implantable cardiac defibrillators, often in combination with biventricular pacing, is to be considered on a case by case basis. The guideline also briefly mentions referring appropriate patients to transplant centres and using LV assist devices (LVADs) as a bridge to transplantation.1

Models of care

The importance of appropriate discharge planning, with links to community teams is emphasised in the guideline, and, in particular, nurse-led telephone and/or home-based support programmes. Nurses can advise on lifestyle issues and review medication with appropriate physician support. The role of multidisciplinary teams is highlighted, with pharmacists having a role in monitoring compliance with medication and the optimisation of drug regimens. It was encouraging to see a section devoted to palliative care, and this contained sound advice on communication, symptom management, and decisions on discontinuing treatment.

Summary

This new guideline from SIGN is robust and clear, and manages to cover the broad spectrum of CHF from diagnosis through to end-of-life issues. There was little included here that was not covered in the earlier NICE guidance,2 but repetition is no bad thing when dealing with such a common and complex syndrome. I would recommend that GPs have a flick through the full guideline, even if they do not have a specific interest in cardiology.

  • CHF can, in most cases, be effectively diagnosed and excluded in primary care without specialist referral
  • Commissioners should ensure:
      • basic tests have been conducted prior to specialist referral
      • primary care has direct access to ECG, chest X-ray, echocardiography, and ideally BNP investigations
  • CHF is a significant cause of unplanned medical admissions
  • Good primary care management reduces emergency admissions
  • Simple pharmacotherapy can be initiated in primary care
  • There is no national tariff for echocardiography, chest X-ray, and BNP testing
  • Tariff price for heart failure admission:1 £2684 (age >69 years)
  • Tariff price for cardiology outpatient:1 £155 (new), £82 (follow-up)
  1. Scottish Intercollegiate Guidelines Network. Management of chronic heart failure. A national clinical guideline. SIGN 95. Edinburgh: SIGN, 2007.
  2. National Institute for Clinical Excellence. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. Clinical guideline 5. London: NICE, 2003.
  3. McMurray J, Ostergren J, Pfeffer M et al; CHARM committees and investigators. Clinical features and contemporary management of patients with low and preserved ejection fraction heart failure: baseline characteristics of patients in the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme. Eur J Heart Fail 2003; 5 (3): 261–270.
  4. Flather M, Shibata M, Coats A et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J 2005; 26 (3): 215–225.
  5. Pitt B, Remme W, Zannad F et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003; 348 (14): 1309–1321.
  6. McMurray J, Ostergren J, Swedberg K et al. Effects of candesartan in patients with chronic heart failure and reduced left ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial. Lancet 2003; 362 (9386): 767–771.
  7. Yusuf S, Pfeffer M, Swedberg K et al. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved trial. Lancet 2003; 362 (9386): 777–781G