Guideline name: Chronic heart failure in adults: diagnosis and management [NG106]
Update type: Replaces NICE guideline CG108 (August 2010)
Published: September 2018
- A specialist heart failure (HF) multidisciplinary team should diagnose HF.
- Patients with proven heart failure should be monitored every 6 months.
- Management of HF should be done by a primary care team in collaboration with a core multidisciplinary team (MDT) comprising a lead physician with subspecialty training in heart failure (usually a consultant cardiologist) who is responsible for making the clinical diagnosis, a specialist heart failure nurse, and a healthcare professional specialising in prescribing for HF.
- Responsibilities of MDT:
- Diagnose heart failure
- Educate newly diagnosed patients
- Manage newly diagnosed decompensated or advanced heart failure
- Optimise treatment
- Initiate drug therapy requiring specialist supervision
- Continue managing HF after an interventional procedure
- Manage treatment-resistant HF
- Write a care plan
- Responsibilities of the primary care team:
- Ensure communication across services
- Completely review an individual's HF care
- Follow-up and update clinical records every 6 months
- Discuss and share updates in clinical records with patients and MDT
- Arrange access to specialist heart failure services
Diagnosis of HF
- Obtain a detailed history and conduct a clinical examination and appropriate tests for confirmation of HF.
- Measure N-terminal pro-B-type natriuretic peptide (NT-proBNP) in suspected individuals. Very high levels are associated with a poor prognosis.
- Those with NT-proBNP levels >2,000 ng/litre should be seen for specialist assessment and transthoracic echocardiography (TTE) within 2 weeks, while those with levels between 400 to 2,000 ng/litre should be seen within 6 weeks.
- TTE is essential to exclude important valve disease, assess ventricular function, and detect intracardiac shunts.
- Important tests to consider along with an ECG:
- Chest X-ray
- Renal, thyroid, and liver function profile
- Lipid profile
- Complete blood count
- Peak flow or spirometry
- Following the diagnosis of HF, assess for severity, aetiology, precipitating factors, type of cardiac dysfunction and correctable causes.
- Heart failure caused by valve disease requires further specialist assessment.
Treatment of reduced ejection fraction (EF)
- Offer angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker for those with reduced EF.
- Consider using an angiotensin receptor blocker (ARB) if ACE inhibitors are not tolerated.
- If symptoms of heart failure are still present, add a mineralocorticoid receptor antagonist to the ACE inhibitor + beta blocker regimen.
- Ivabradine, Sacubitril valsartan, hydralazine + nitrate, and digoxin are other drugs used in specialist treatment of chronic HF.
Management of all types of HF
- Diuretics are recommended for relieving congestive symptoms and fluid retention. Low to medium dose of loop diuretics are preferred for patients with preserved EF.
- Avoid the use of calcium channel blockers in patients with reduced EF.
- Consider anticoagulants in patients with HF and atrial fibrillation (AF) based on the NICE guidance on AF. In absence of AF, HF patients with a history of thromboembolism, left ventricular aneurysm or intracardiac thrombus may also require anticoagulation.
- 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.
- Monitoring of HF patients includes:
- Clinical evaluation of functional capacity, fluid status, cardiac rhythm, cognitive status, and nutritional status
- Medication review
- Renal function
- More detailed monitoring is needed if there is a significant comorbidity or worsening of the condition since the last review.
This summary is reviewed by Prof. Rishabh Prasad MBBS, MA, MSC, FRCGP FRSA