This is an updated guideline on heart failure from NICE published in September 2018. Most of this is what we are currently doing. They have pulled several different guidelines together to make this more comprehensive. There are a few new things which I'll lay out, then I'll give a brief summary of management:
They now refer to 'Heart failure with reduced ejection fraction' (ie LVSD) and 'Heart failure with preserved ejection fraction' (diastolic dysfunction).
Multidisciplinary team MDT
They formally lay out the need for an MDT to diagnose heart failure, manage it, optimise medication and start specialist only medications. The MDT should be able to refer onto other relevant teams (eg rehab, elderly care or palliative care). They should also lay out the care plan for the patient.
They only advise using this now (as compared to bog-standard BNP). Among several other things, being of Afro-Caribbean race can give you lower levels of NTproBNP, so it may make diagnosing heart failure harder in this population.
Medication changes and blood pressure monitoring
In ACEi, ARB (angiotensin 2 receptor blocker) and aldosterone antagonists, measure BP before and after any dose increase. Once the target dose is reached, measure the BP monthly for 3m then every 6m thereafter, or if they become unwell.
There is no differentiation made between spironolactone and eplerenone. Add them in if they are still symptomatic despite being on an ACEi or ARB and a b-blocker.
Hydralazine and nitrate.
This should be considered if the patient can't use an ACEi or ARB. It should be initiated under specialist advice.
This has been bought into the guidance, though it was already advised by NICE in a separate technology appraisal. It should be started by a specialist once a patient has been stable on standard medication for 4w. It is an option if the patient meets the following criteria:
- NYHA III or IV AND
- is in sinus rhythm AND
- with a heart rate of 75 bpm or more AND
- it is used with an ACEi or ARB and a b-blocker (unless contraindicated) and an aldosterone antagonist AND
- they have an LVEF 35% or less.
We should seek specialist advice before initiating digoxin.
Angiotensin receptor/neprilysin inhibitor (eg sacubitril valsartan).
This has also been bought into the guidance, though was already advised. It should be started by a specialist if the patient meets the following criteria:
- symptomatic heart failure with NYHA II - IV AND
- LVF of 35% or less AND
- already on a stable dose of ACEi / ARB.
Patients with heart failure and CKD.
If the patient has a GFR of or 30 or more, use the standard treatments, but consider lower doses and slower titrations. If the patient has a GFR of under 30, the MDT should consider liaison with the renal team.
Summary of Management
This is a big guideline and most of it hasn't really changed. The above points highlight the changes. There is an excellent flow chart of diagnosis in the full guideline (pages 23-24).
Use NTproBNP. If there is a history of MI, refer without doing NTproBNP. If NTproBNP is over 400 it is raised. Under 400 makes heart failure unlikely (though some things can artificially lower NTproBNP like obesity, being of Afro-Caribbean origin, or being on medications for heart failure).
Do an Echo if NTproBNP is raised.
Consider an ECG, bloods (UE, TFT, LFT, lipids, HbA1c, and FBC), CXR, spirometry or PEF and urinalysis.
Medications for people with heart failure with reduced ejection fraction.
1st line medications:
- ACEi / ARB AND
2nd line medications that can be considered if symptoms persist:
- Aldosterone antagonist (spironolactone or eplerenone).
- Hydralazine and nitrate (specialist only).
- Ivabradine (specialist only).
- Digoxin (specialist only advised now).
- Angiotensin receptor / neprilysin inhibitor (sacubitril valsartan) (specialist only).
Heart failure with preserved ejection fraction (diastolic dysfunction).
You can use furosemide to treat symptoms, but none of the other medications have yet been shown to be beneficial enough to advise them. Co-morbidities should be well managed (eg diabetes, hypertension and IHD).
Advice for all patients with heart failure.
Most of the advice is pretty obvious stuff. They don't advise to limit salt, unless the patient has a high intake. They also don't advise to fluid restrict, unless there is dilutional hyponatraemia or if they have high levels of fluid intake.
Diuretics will benefit patients with all forms of heart failure.
Aspirin is only helpful if there is co-existent IHD.
Statins are not advised either if there is only heart failure and no other indication.
Should be 6 monthly. The following should be measured:
- NYHA score.
- Pulse (or ECG).
- Fluid status.
- Cognitive / psychological status.
- Nutritional status.
- Medication review.
- UE bloods.
- NTproBNP. The MDT may choose to monitor this to try to optimise treatment. It is only advised in the under 75s and if the GFR is > 60.
Offer an exercise based rehabilitation programme, unless their condition is unstable. It should include a psychological and educational element.