Chronic heart failure: what does NICE recommend in its latest guidance?

Guideline name: Chronic heart failure in adults: diagnosis and management [NG106]

Update type: Replaces NICE guideline CG108 (August 2010)

Published: September 2018

Takehome

• A specialist heart failure (HF) multidisciplinary team should diagnose HF.
• Patients with proven heart failure should be monitored every 6 months.

Management planning

• 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.
• Levels <400 ng/litre are unlikely to be indicative of heart failure. In such patients, evaluate alternative causes for symptoms similar to heart failure.
• 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
  • HbA1c
  • Complete blood count
  • Urinalysis
  • 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.

Monitoring

• 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.