NICE issues new guidelines for patients with heart failure

All patients suspected of having heart failure should undergo echocardiography to diagnose the condition and should be offered angiotensin converting enzyme (ACE) inhibitors if they have left ventricular dysfunction, guidance issued this week by the National Institute for Clinical Excellence (NICE) says.

The guidance is designed to clarify the best practice for health professionals caring for adult patients who have or who are suspected of having heart failure. It recommends full evaluation of patients using 12 lead electrocardiography or testing for natriuretic peptide (brain natriuretic peptide (BNP) or N terminal proBNP), where this is available, to exclude a diagnosis of heart failure. If the results of any of these tests are abnormal the patient should then undergo trans-thoracic Doppler two dimensional echocardiography.

Most patients with heart failure need drug treatment, and evidence indicates that some groups of drugs can significantly improve their life expectancy and quality of life. All patients with heart failure resulting from left ventricular systolic dysfunction should be considered for treatment with an ACE inhibitor, as well as diuretics for management of symptoms.

β blockers licensed for use in cases of heart failure should be begun in patients with heart failure resulting from left ventricular systolic dysfunction after treatment with diuretics and ACE inhibitors, regardless of whether or not symptoms persist. β blockers should be introduced in a “start low, go slow” manner, and heart rate, blood pressure, and clinical status should be assessed after each titration.

The clinical condition of patients with heart failure can fluctuate, and many patients require several hospital admissions. The guidance therefore recommends that all patients with chronic heart failure should be monitored on a regular basis—at least every six months in the case of stable patients. Monitoring should include clinical assessment of functional capacity, fluid status, cardiac rhythm, review of medication, and measurement of serum urea, electrolytes, and creatinine.

Martin Cowie, professor of cardiology at Imperial College, London, and a clinical adviser on the guidance, said: “There have been a lot of developments in best practice for heart failure over the past 10 years. The guidance provides an accessible summary of the evidence and translates it into practical management recommendations.” He added: “The quality of heart failure management is currently variable. The guidance should bring everyone up to the best standards of care.”

Management of Chronic Heart Failure in Adults in Primary and Secondary Care is accessible at www.nice.org.uk and at the national collaborating centre's website (www.rcplondon.ac.uk)