NICE guidance - chronic heart failure (CHF)

Last edited 10/2018 and last reviewed 05/2023

NICE have defined various key recommendations concerning the management of heart failure (1):

Diagnosis

• refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks (1)

• refer people with suspected heart failure and an NT-proBNP level above 2,000 ng/litre (236 pmol/litre) urgently, to have specialist assessment and transthoracic echocardiography within 2 weeks - because very high levels of NT-proBNP carry a poor prognosis
  
  
• refer people with suspected heart failure and an NT-proBNP level between 400 and 2,000 ng/litre (47 to 236 pmol/litre) to have specialist assessment and transthoracic echocardiography within 6 weeks
  
  
• review alternative causes for symptoms of heart failure in people with NTproBNP levels below 400 ng/litre. If there is still concern that the symptoms might be related to heart failure, discuss with a physician with subspeciality training in heart failure
  
  
• perform transthoracic echocardiography to exclude important valve disease, assess the systolic (and diastolic) function of the (left) ventricle, and detect intracardiac shunts
  • if a poor image is produced by transthoracic echocardiography
    • consider alternative methods of imaging the heart (for example, radionuclide angiography [multigated acquisition scanning], cardiac MRI or transoesophageal echocardiography)
      
      
• note that:
  • obesity, African or African-Caribbean family origin, or treatment with diuretics, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, angiotensin II receptor blockers (ARBs) or mineralocorticoid receptor antagonists (MRAs) can reduce levels of serum natriuretic peptides
    
    
  • high levels of serum natriuretic peptides can have causes other than heart failure (for example, age over 70 years, left ventricular hypertrophy, ischaemia, tachycardia, right ventricular overload, hypoxaemia [including pulmonary embolism], renal dysfunction [eGFR less than 60 ml/minute/1.73m2], sepsis, chronic obstructive pulmonary disease, diabetes, or cirrhosis of the liver)

First line treatment:

• offer both angiotensin-converting enzyme (ACE) inhibitors and beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction. Use clinical judgement when deciding which drug to start first
  • ACE inhibitor
    • NICE recommends that all patients with left ventricular dysfunction should be taking an ACE inhibitor (1,2)
    • specialist referral is required for patients requiring high doses of diuretics, or exhibiting worsening renal function at any stage - note that some degree of detioration of renal function after initiating ACE inhibitors is inevitable, but if this is only small only monitoring is necessary
  • beta blockers
    • introduce beta-blockers in a 'start low, go slow' manner. Assess heart rate and clinical status after each titration. Measure blood pressure before and after each dose increment of a beta-blocker
      • beta-blocker therapy should be started at a very low dose (e.g. carvedilol 3.125mg once daily) and titrated slowly over a period of weeks or months. The beta-blocker should be up-titrated at fortnightly intervals (or longer in more sensitive patients) to a target dose of carvedilol 25-50mg bd or bisoprolol 10mg od (2,3)
  • offer beta-blockers licensed for heart failure to all patients with heart failure due to left ventricular systolic dysfunction, including:
    • older adults and
    • patients with:
      • peripheral vascular disease
      • erectile dysfunction
      • diabetes mellitus
      • interstitial pulmonary disease and
      • chronic obstructive pulmonary disease (COPD) without reversibility
  • mineralocorticoid receptor antagonists (MRA) (aldosterone receptor antagonists) e.g. spironolactone
    • an MRA should be offered, in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure
    • measure serum sodium and potassium, and assess renal function, before and after starting an MRA and after each dose increment
    • measure blood pressure before and after after each dose increment of an MRA
    • once the target, or maximum tolerated, dose of an MRA is reached, monitor treatment monthly for 3 months and then at least every 6 months, and at any time the person becomes acutely unwell

Alternative first line treatment

• angiotensin II receptor antagonists (ARB’s) - can be used as an alternative in patients who are intolerable to ACE inhibitors

Second line treatment

• specialist advice should be obtained before commencing second line therapy in patients with HF due left ventricular systolic dysfunction
• specialist treatment options include (must seek specialist advice):
  • ivabradine
    • an option for treating chronic heart failure for people:
      • with New York Heart Association (NYHA) class II to IV stable chronic heart failure with systolic dysfunction and
      • who are in sinus rhythm with a heart rate of 75 beats per minute (bpm) or more and
      • who are given ivabradine in combination with standard therapy including beta-blocker therapy, angiotensin-converting enzyme (ACE) inhibitors and aldosterone antagonists, or when beta-blocker therapy is contraindicated or not tolerated and
      • with a left ventricular ejection fraction of 35% or less
  • sacubitril valsartan
    • an option for treating symptomatic chronic heart failure with reduced ejection fraction, only in people:
      • with New York Heart Association (NYHA) class II to IV symptoms and
      • with a left ventricular ejection fraction of 35% or less and
      • who are already taking a stable dose of angiotensin-converting enzyme (ACE) inhibitors or ARBs
  • hydralazine in combination with nitrate
    • seek specialist advice and consider offering hydralazine in combination with nitrate (especially if the person is of African or Caribbean family origin and has moderate to severe heart failure [NYHA class III/IV] with reduced ejection fraction)
  • digoxin
    • recommended for worsening or severe heart failure with reduced ejection fraction despite first-line treatment for heart failure

Monitoring:

• All patients with chronic heart failure require monitoring. This monitoring should include:

  • a clinical assessment of functional capacity, fluid status, cardiac rhythm (minimum of examining the pulse), cognitive status and nutritional status
    
    
  • a review of medication, including need for changes and possible side effects
    
    
  • serum urea, electrolytes, creatinine and eGFR
    • note that this is a minimum. People with comorbidities or co-prescribed medications will need further monitoring. Monitoring serum potassium is particularly important if a person is taking digoxin or an mineralocorticoid antagonist (e.g. spironolactone)

  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.

For further details of the guidance then consult the complete guideline (1).

Reference:

1. NICE (September 2018).Chronic heart failure in adults: diagnosis and management
2. NICE (August 2010). Chronic heart failure
3. Geriatric Medicine (2005); 35 (1):37-42