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NICE guidance - chronic heart failure (CHF)

Authoring team

NICE have defined various key recommendations concerning the management of heart failure (1):

Diagnosis

  • refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks (1)
  • refer people with suspected heart failure and an NT-proBNP level above 2,000 ng/litre (236 pmol/litre) urgently, to have specialist assessment and transthoracic echocardiography within 2 weeks - because very high levels of NT-proBNP carry a poor prognosis

  • refer people with suspected heart failure and an NT-proBNP level between 400 and 2,000 ng/litre (47 to 236 pmol/litre) to have specialist assessment and transthoracic echocardiography within 6 weeks

  • review alternative causes for symptoms of heart failure in people with NTproBNP levels below 400 ng/litre. If there is still concern that the symptoms might be related to heart failure, discuss with a physician with subspeciality training in heart failure

  • perform transthoracic echocardiography to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts
    • if a poor image is produced by transthoracic echocardiography
      • consider alternative methods of imaging the heart (for example, radionuclide angiography [multigated acquisition scanning], cardiac MRI or transoesophageal echocardiography)

  • note that:
    • obesity, African or African-Caribbean family origin, or treatment with diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin II receptor blockers (ARBs) or mineralocorticoid receptor antagonists (MRAs) can reduce levels of serum natriuretic peptides

    • high levels of serum natriuretic peptides can have causes other than heart failure (for example, age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], renal dysfunction [eGFR less than 60 ml/minute/1.73m2], sepsis, chronic obstructive pulmonary disease, diabetes, or cirrhosis of the liver)

First line treatment:

  • offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first
    • ACE inhibitor
      • NICE recommends that all patients with left ventricular dysfunction should be taking an ACE inhibitor (1,2)
      • specialist referral is required for patients requiring high doses of diuretics, or exhibiting worsening renal function at any stage - note that some degree of detioration of renal function after initiating ACE inhibitors is inevitable, but if this is only small only monitoring is necessary
    • beta blockers
      • introduce beta-blockers in a 'start low, go slow' manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta-blocker
        • beta-blocker therapy should be started at a very low dose (e.g. carvedilol 3.125mg once daily) and titrated slowly over a period of weeks or months. The beta-blocker should be up-titrated at fortnightly intervals (or longer in more sensitive patients) to a target dose of carvedilol 25-50mg bd or bisoprolol 10mg od (2,3)
      • offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including:
        • older adults and
        • patients with:
          • peripheral vascular disease
          • erectile dysfunction
          • diabetes mellitus
          • interstitial pulmonary disease and
          • chronic obstructive pulmonary disease (COPD) without reversibility
    • mineralocorticoid receptor antagonists (MRA) (aldosterone receptor antagonists) e.g. spironolactone
      • an MRA should be offered, in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure
      • measure serum sodium and potassium, and assess renal function, before and after starting an MRA and after each dose increment
      • measure blood pressure before and after after each dose increment of an MRA
      • once the target, or maximum tolerated, dose of an MRA is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell

Alternative first line treatment

  • angiotensin II receptor antagonists (ARB’s) - can be used as an alternative in patients who are intolerable to ACE inhibitors

Second line treatment

  • specialist advice should be obtained before commencing second line therapy in patients with HF due left ventricular systolic dysfunction
  • specialist treatment options include (must seek specialist advice):
    • ivabradine
      • an option for treating chronic heart failure for people:
        • with New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and
        • who are in sinus rhythm with a heart rate of 75 beats per minute (bpm) or more and
        • who are given ivabradine in combination with standard therapy including beta-blocker therapy, angiotensin-converting enzyme (ACE) inhibitors and aldosterone antagonists, or when beta-blocker therapy is contraindicated or not tolerated and
        • with a left ventricular ejection fraction of 35% or less
    • sacubitril valsartan
      • an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people:
        • with New York Heart Association (NYHA) class II to IV symptoms and
        • with a left ventricular ejection fraction of 35% or less and
        • who are already taking a stable dose of angiotensin-converting enzyme (ACE) inhibitors or ARBs
    • hydralazine in combination with nitrate
      • seek specialist advice and consider offering hydralazine in combination with nitrate (especially if the person is of African or Caribbean family origin and has moderate to severe heart failure [NYHA class III/IV] with reduced ejection fraction)
    • digoxin
      • recommended for worsening or severe heart failure with reduced ejection fraction despite first-line treatment for heart failure

Monitoring:

  • All patients with chronic heart failure require monitoring. This monitoring should include: The frequency of monitoring should depend on the clinical status and stability of the person. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is needed at least 6-monthly for stable people with proven heart failure.
    • a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status

    • a review of medication, including need for changes and possible side effects

    • serum urea, electrolytes, creatinine and eGFR
      • note that this is a minimum. People with comorbidities or co-prescribed medications will need further monitoring. Monitoring serum potassium is particularly important if a person is taking digoxin or an mineralocorticoid antagonist (e.g. spironolactone)

For further details of the guidance then consult the complete guideline (1).

Reference:

  1. NICE (September 2018).Chronic heart failure in adults: diagnosis and management
  2. NICE (August 2010). Chronic heart failure
  3. Geriatric Medicine (2005); 35 (1):37-42

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