The updated NICE guidance on the management of chronic heart failure includes key recommendations for multidisciplinary working, diagnosis and treatment. The new guideline replaces the previous version published in 2010.
NICE states that all patients with suspected heart failure should have a blood test to check N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels.
Because very high levels of NT-proBNP carry a poor prognosis, patients with levels above 2000ng/l need an urgent referral for specialist assessment and transthoracic echocardiography within 2 weeks. The previous recommendation that patients with a history of MI should be referred directly for echocardiography has been removed.
Patients with NT-proBNP levels 400—2000ng/l should be referred for specialist assessment and transthoracic echocardiography within 6 weeks.
A diagnosis of heart failure is less likely if NT-proBNP levels are below 400ng/l and alternative causes should be considered.
All patients with heart failure may benefit from diuretic therapy to reduce fluid overload. Fluid and salt restriction are no longer recommended unless intake is particularly high. For patients who have preserved ejection fraction, treatment is otherwise limited to modification of comorbidities such as diabetes and hypertension.
For patients with a reduced ejection fraction, first-line treatment remains ACE inhibitors (or angiotensin receptor blockers if ACE inhibitors are not tolerated) and beta-blockers. If symptoms persist, NICE recommends that a mineralocorticoid receptor antagonist be offered in addition to an ACE inhibitor/angiotensin receptor blocker and beta-blockers. Close monitoring of renal function, particularly potassium, is required with triple therapy.
Further second-line options, such as sacubitril-valsartan and ivabradine, are managed by the specialist team. It is important to note that sacubitril-valsartan replaces the ACE inhibitor/angiotensin receptor blocker so the medication screen in the patient record may need to be updated.
All patients should be offered an exercise-based cardiac rehabilitation programme tailored to their needs, once their condition is stable.
Multidisciplinary team working
The updated guidance emphasises that the primary care team should work in collaboration with the specialist MDT.
Newly diagnosed patients should have an extended first consultation with the specialist team to ensure the diagnosis is fully explained. The MDT should initiate and optimise treatment for new or unstable patients and provide a detailed care plan covering the medicines prescribed, monitoring requirements and social care needs.
The guidance recommends that the primary care team take over the routine management of heart failure as soon as the condition is stabilised and its management is optimised. Any changes to medications or clinical status should be communicated to the MDT with referral back if required.