CG5NICEguideline for CHF

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National Institute for

Clinical Excellence

NHS

Chronic heart failure

Management of chronic heart failure inadults in primary and secondary care

Clinical Guideline 5July 2003

Developed by the NationalCollaborating Centre for Chronic Conditions



Clinical Guideline 5Chronic heart failureManagement o f chroni c heart f ailure in adult s in pr imary and secondary care

Issue date: July 2003

To order copiesCopies of th is guideline can be ordered f rom the NHS Response Line; t elephone 0870 1555 455 and

quote reference number N0247. A version f or people who want to understand what NICE has told t he

NHS, called Management of Heart Failure. Understanding NICE Guidance – Information for People with

Heart Failure, Their Carers, and the Public, is also available from the Response Line; quote reference

number N0248 for an Engli sh on ly version and N0249 for an Engli sh and Welsh version.

This guidance is written in the following context:This guidance represents the view of the Insti tu te, which was arrived at af ter careful considerat ion

of the evidence available. Health prof essionals are expected t o take it f ully int o account w hen

exercising t heir clinical judgment The guidance does not , however, override t he individual

responsibility of health prof essionals to make decisions appropriat e to the circumstances of the

individual patient, in consultati on w ith the pat ient and/or guardian or carer.

National Institute forClinical Excellence

MidCity Place

71 High Holborn

London

WC1V 6NA

Web: www.nice.org.uk

ISBN: 1-84257-323-3

Published by the National Institute for Clinical Excellence

July 2003

Typeset by Icon Design

Print ed by Abba Litho Sales Limited, London

© Copyright National Insti tu te f or Clinical Excellence, July 2003. All ri ght s reserved. This material may be freely

reproduced f or education al and not -for-profit purposes wit hin t he NHS. No reproduction by or f or commercial

organisations is allowed without the express written permission of the National Institute for Clinical Excellence.

This document has been circulated to t he fo llow ing:

• PCT Chief Execut ives

• NHS Trust Chief Executives in England and Wales

• Local Health Board General Managers

• Str ategi c Health Aut hor it y Chief Execut ives in England and Wales

• Medical and Nursing Directors in England and Wales• Clini cal Governance Leads in England and Wales

• Audit Leads in England and Wales

• NHS Trust, PCT and LHB libraries in England and Wales

• NHS Director Wales

• Chief Execut ive of the NHS in England

• Directors of Directorates of Health and Social Care in England and Wales

• Special Health Aut hor it y Chief Execut ives

• Community Health Councils in England and Wales

• Patient Advocacy Groups

• Commission for Health Improvement

• NHS Clinical Governance Support Team

• Chief Medical Officers, Nursing Officers and Pharmaceutical Officers in England and Wales

• Medical Director & Head of NHS Qualit y - Welsh Assembly Government

• Practice Nurses in England and Wales

• GP part ners in England and Wales

• Chief Pharmacists, Heads of Drug Purchasing, Heads of Drug Information,

GP Prescribing Advisors and Purchase Advisors in England and Wales

• Consultant Cardiologists in England and Wales

• Representative bodies for health services, professional organisations and statutory bodies, Royal

Colleges



Contents

Heart failure 2

Key recommendations 3

1 Guidance 4

1.1 Diagnosing heart failure 4

1.2 Treating heart failure 7

1.3 Monitoring 17

1.4 Referral and approach to care 19

1.5 Supporting patients and carers 20

1.6 Anxiety and depression 22

1.7 End of life issues 22

2 Notes on the scope of the guidance 23

3 Implementation in the NHS 24

3.1 In general 24

3.2 Audit 24

4 Research recommendations 24

5 Full guideline 24

6 Related NICE guidance 25

7 Review date 25

Appendix A: Grading scheme 26

Appendix B: The Guideline Development Group 27

Appendix C: The Guideline Review Panel 30

Appendix D: Further information on pharmacological treatment 31

Appendix E: Technical detail on the criteria for audit 38



2 NICE Guideline – Chronic heart failure

Heart failure

Heart failure is a complex syndrome t hat can result f rom anyst ructural or funct ional cardiac disorder t hat impairs the ability of theheart to function as a pump to support a physiological circulation.

The syndrome of heart failure is characterised by symptoms such asbreathlessness and f atigue, and signs such as f luid retent ion.

This guideline of fers best pract ice advice on t he care of adult patients(aged 18 years or older) who have symptoms or a diagnosis of chronicheart failure. It aims to def ine the most effect ive combinat ion ofsympt oms, signs and invest igations required to establish a diagnosisof heart failure, and those which wil l inf luence therapy or provideimportant prognostic information. It also gives guidance on thetreatment, monitoring and support of patients with heart failure.



NICE Guideline – Chronic heart failure 3

Key recommendations

The following recommendations have been identified as prioritiesfor implementat ion.

Diagnosis

1 The basis for historical diagnoses of heart failure should bereviewed, and only patients whose diagnosis is confirmed shouldbe managed in accordance with t his guideline.

2 Doppler 2D echocardiographic examinat ion should beperformed to exclude important valve disease, assess the systolic(and diastolic) function of the (left) ventricle and detectint racardiac shunts.

Treatment

3 All patients wit h heart failure due to lef t ventricular systolicdysfunction should be considered for treatment with an ACEinhibitor.

4 Beta blockers licensed for use in heart failure should be init iatedin pat ients with heart failure due to left vent ricular systolicdysfunct ion aft er diuretic and ACE inhibit or t herapy (regardlessof whether or not symptoms persist ).

Monitoring

5 All patients wit h chronic heart failure require monitoring. Thismonit oring should include:• a clinical assessment of functional capacit y, f luid status,

cardiac rhythm, and cognitive and nutritional status• a review of medication, including need for changes and

possible side effects• serum urea, electrolytes and creatinine.

Discharge

6 Patients with heart failure should generally be discharged fromhospital only when their clinical condition is stable and themanagement plan is opt imised.

7 The primary care team, pat ient and carer must be aware of themanagement plan.

Supporting patients and carers

8 Management of heart failure should be seen as a sharedresponsibi lit y betw een patient and healthcare prof essional.



The f ol lowing guidance is evidence based. The grading scheme usedfor the recommendations (A, B, C, Good Practice Point [GPP], NICE) isdescribed in Appendix A; a summary of the evidence on w hich theguidance is based is provided in the ful l guideline (see Sect ion 5).

1 Guidance

1.1 Diagnosing heart failure

The full evaluat ion of heart failure is more than stating whether thesyndrome is present or not ; it requires considerat ion of theunderlying abnormality of the heart, the severity of the syndrome,the aetiology, precipitating and exacerbating factors, identification ofconcomitant disease relevant to t he management , and an est imat ionof prognosis. It is important to exclude other conditions that may

masquerade as heart failure (see Table 1).

The recommendat ions for diagnosing heart failure are summarised inan algori thm (Figure 1) on page 5.

Table 1 Conditions presenting with similar symptoms

1.1.1 Cardiac assessment

1.1.1.1 Take a careful and detailed history, and perform a clinicalexamination. These should be combined with tests toconfirm the presence of heart failure and make a completediagnosis.


Other conditions that may present with similar symptoms

• Obesity

• Chest disease – includinglung, diaphragm or chest wall

• Venous insufficiency in lowerlimbs

• Drug-induced ankle swelling(e.g. dihydropyridine calciumchannel blockers)

• Drug-induced fluid retention(e.g. NSAIDs)

• Hypoalbuminaemia

• Intrinsic renal or hepaticdisease

• Pulmonary embolic disease

• Depression and/or anxietydisorders

• Severe anaemia or thyroid

disease

• Bilateral renal artery stenosis

GPP



Figure 1 Algorithm summarising recommendations for the diagnosisof heart failure


Suspected heart failurebecause of history, symptoms, and

signs

Seek to exclude heart failurethrough:

• 12-lead ECG• and/or natriuretic peptides

(BNP or NTproBNP) – whereavailable

Both normal –heart failure unlikely

consider alternative diagnosis

Other recommended tests:(mostly to exclude other

conditions)Chest X-ray

Blood tests: U&Es, creatinine, FBC,TFTs, LFTs, glucose, and lipids

Urinalysis, peak flow or spirometry

One or more abnormal

Imaging by echocardiography*

No abnormality detectedHeart f ailure unlikely, but ifdiagnostic doubt persists considerdiastolic dysfunction and considerreferral for specialist assessment

AbnormalAssess heart failure severity,aet iology, precipit ating and

exacerbating factors and type ofcardiac dysfunction

Correctable causes must beidentified

Consider referral

* Alt ernative methods of imaging t he heart should be considered when a poor image is

produced by transthoracic Doppler 2D echocardiography – alternatives includetransoesophageal Doppler 2D echocardiography, radionuclide imaging or cardiac magnetic

resonance imaging

Key:BNP B-t ype nat riuret ic pept ideECG ElectrocardiogramFBC Full blood countLFTs Liver funct ion t estsNTproBNP N-terminal pro-B-type natriuretic peptideTFTs Thyroid f unct ion t est s

U&Es Urea and electrolytes



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GPP

GPP

GPP

1.1.1.2 Healthcare professionals should seek t o exclude a diagnosisof heart failure through the following investigations:

• 12-lead ECG• and/or nat riuretic pept ides (BNP or NTproBNP) – where

available.

If one or both are abnormal, a diagnosis of heart failurecannot be excluded and transthoracic Doppler 2Dechocardiography should be performed because itconsolidates the diagnosis and provides inf ormation on t heunderlying functional abnormality of the heart.

1.1.1.3 Eff ort s should be made to exclude other disorders that maypresent in a similar manner.

1.1.1.4 To evaluate possible aggravating factors and/or alternativediagnoses the following tests are recommended.

• Chest X-ray• Blood tests:

- biochemical pro f ile including electrolytes, urea andcreatinine

- full blood count- thyroid function tests- liver f unct ion t ests

- fasting lipids- fasting glucose• Urinalysis• Peak flow or spirometry

1.1.1.5 Transthoracic Doppler 2D echocardiographic examinat ionshould be performed to exclude import ant valve disease,assess the systolic (and diastolic) function of the (left)ventricle, and detect intracardiac shunts.

1.1.1.6 Transthoracic Doppler 2D echocardiographic studies should

be performed on high-resolution equipment, by experiencedoperators t rained t o t he relevant professional standards.Need and demand for these studies should not compromisequality.

1.1.1.7 The report ing of echocardiography should be by thoseexperienced in doing so.


B

GPP




1.1.1.8 Alternative methods of imaging the heart should beconsidered when a poor image is produced byechocardiography. Such methods may include radionuclideangiography, cardiac magnetic resonance imaging, ort ransoesophageal Doppler 2D echocardiography.

1.1.2 Diastolic heart failure

1.1.2.1 Where the diagnosis is unclear, or if a diagnosis of diastolicheart failure is being considered, the patient should bereferred for more specialist assessment.

1.1.3 Review of existing diagnoses

1.1.3.1 The basis for historical diagnoses of heart failure should bereviewed, and only patients whose diagnosis is confirmedshould be managed in accordance wit h t his guideline.

1.1.3.2 If the diagnosis of heart failure is st il l suspected, butconfirmation of the underlying cardiac abnormality has notoccurred, then the patient should have appropriate f urtherinvestigation.

1.2 Treating heart failureTreatments are available that can improve the life expectancy andquality of lif e of a person w ith heart f ailure. Treatmentrecommendations are given below, and include aspects of lifestyle,pharmacological therapy, and invasive procedures. It is also helpful toconsider the need t o keep patients fully inf ormed about theircondit ion and t he treatment opt ions, and t his is reflected in t herecommendations.

1.2.1 Lifestyle

Exercise training and rehabil it ation

1.2.1.1 Patients with heart failure should be encouraged to adoptregular aerobic and/or resistive exercise. This may be moreeff ect ive when part of an exercise programme or aprogramme of rehabilitation.

B

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B



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Smoking

1.2.1.2 Patients must be st rongly advised not to smoke. Referral tosmoking cessat ion services should be considered.

Alcohol

1.2.1.3 Patients with alcohol-related heart f ailure should abstainfrom drinking alcohol.

1.2.1.4 Healthcare professionals should discuss alcohol consumpt ionwith the patient and tailor their advice appropriately to theclinical circumstances.

Sexual activity

1.2.1.5 Healthcare professionals should be prepared to broachsensitive issues with patients, such as sexual activity, as theseare unlikely to be raised by the patient.

Vaccination

1.2.1.6 Patients wit h heart failure should be off ered an annualvaccinat ion against inf luenza.

1.2.1.7 Patients with heart failure should be offered vaccination

against pneumococcal disease (only required once).

Air t ravel

1.2.1.8 Air t ravel will be possible for the majority of patients wit hheart failure, depending on their clinical condit ion at thet ime of t ravel.

Driving regulations

1.2.1.9 Heavy Goods Vehicle and Publ ic Service Vehicle licence:

physicians should be up to date wi th t he latest Driver andVehicle Licensing Authority guidelines. Check the website forregular updates: www.dvla.gov.uk/


GPP

C

GPP

GPP

GPP



1.2.2 Pharmacological therapy for patients with heart failure due toleft ventricular systolic dysfunction.

Drug therapy is required for t he vast majority of patients with heartfailure. It is the responsibility of the individual prescriber to check the

dosage of medication. This document should be read as a guide tot reatment rather t han being considered a protocol t hat must befollowed prescriptively in all patients. Treatment should be tailored tothe individual patient, with referral for more specialist advice beingconsidered w here appropriate.

Note that at the time of issue of t his guideline, the following drugsin this guideline are unlicensed in the UK for the treatment of heartfailure or its common signs or symptoms.

• angiot ensin II receptor antagonists• the posit ive inot ropic agent dobutamine• calcium channel blockers.

Recommendat ions on specif ic drugs

Recommendations for pharmacological therapy for patients withheart failure due to left ventricular systolic dysfunction aresummarised in t he algori thm on page 10.

Diuretics

1.2.2.1 Diuret ics (see Appendix D, Table A) should be rout inely usedfor t he relief of congest ive symptoms and fluid retention inpatients with heart failure, and titrated (up and down)according to need f ollow ing t he init iation of subsequentheart failure therapies.

Angiotensin converting enzyme (ACE) inhibitors

1.2.2.2 All patients wit h heart failure due to left ventr icular systolicdysfunction should be considered for treatment with an ACE

inhibitor (see Appendix D, Table B).

1.2.2.3 ACE inhibit or therapy should be inst it uted in pat ients withheart failure due to left ventricular systolic dysfunctionbefore beta-blockade is int roduced.

1.2.2.4 ACE inhibit or therapy should be ini t iated at the appropr iatedose (see Appendix D, Table B), and t it rated upwards atshort int ervals (for example, every 2 weeks) unt il the opt imaltolerated or target dose is achieved.


C

A

A

GPP



Figure 2 Algorithm for the pharmacological treatment ofsymptomatic heart failure due to left ventricular systolic dysfunction

Patients with symptomatic heart failure due to left ventricular systolicdysfunct ion should be t reated wit h the following drugs (if t olerated

and not cont raindicated) and in the sequence indicated. The readermust refer to the text of the guideline for more detailed discussionand explanation.

Please note:• Diuretic is first-line therapy when a patient presents with acute pulmonary

oedema• Please refer t o Appendix D for starting doses of drugs• The arrow on the left -hand margin indicates the increasing l ikelihood of the

need for specialist input.


Start ACEinhibitor

and titrateupwards

Add beta-blocker and

titrateupwards

Add spironolactoneIf patient remains

moderately toseverely symptomatic

despite opt imal drugtherapy listed above

Seek specialist advicefor further options

Or if ACE inhibit or nottolerated (e.g. due to

severe cough)Consider angiotensin II

receptor antagonist

New diagnosis

Add diureticDiuretic therapy is

likely to be requiredto controlcongestive

symptoms and fluidretention

Add digoxinIf a patient in sinus

rhythm remainssymptomatic

despite therapywi th a diuretic, ACE

inhibitor (orangiotensin II

receptorantagonist) and

beta-blocker

or if patient is inatrial fibrillation

then use as f irst-linetherapy

(see page 11)

Specialist

Generalist

S p e c i a l i s t i n p u t {




GPP

A

C

GPP

A

1.2.2.5 Blood biochemist ry (urea, creat inine and elect rolytes) shouldbe measured af ter ini t iat ion and at each dose increment.

Beta-blockers

1.2.2.6 Beta-blockers licensed for use in heart f ailure should beinitiated in patients with heart failure due to left ventricularsystolic dysfunction af ter diuret ic and ACE inhibi tor therapy(regardless of whether or not symptoms persist ). SeeAppendix D, Table C.

1.2.2.7 Beta-blockade therapy for heart f ailure should be int roducedin a ‘start low, go slow ’ manner, with assessment of heart rate,blood pressure, and clinical status aft er each t it ration.

1.2.2.8 Patients who develop heart failure due to lef t ventr icular

systolic dysfunction and who are already on treatment with abeta-blocker for a concomitant condition (for example,angina, hypertension) should cont inue with a beta-blocker – either their current beta-blocker or an alternative licensedfor heart failure treatment.

Aldosterone antagonists

1.2.2.9 Patients wit h heart failure due to left ventr icular systolicdysfunction who remain moderately to severely symptomat ic

despite optimal therapy (as outlined in the algorithm) shouldbe prescribed spironolactone at a dose of 12.5 to 50 mg onceper day (see Appendix D, Table D) – specialist advice shouldbe sought .

1.2.2.10 Patients with heart failure taking spironolactone should haveblood potassium and creatin ine levels moni tored f or signs ofhyperkalaemia and/or deteriorat ing renal f unct ion.* Ifhyperkalaemia is a problem then the dose of spironolactoneshould be halved and biochemistry rechecked.

* See Sect ion 1.3, page 17 for f urt her details

Digoxin

1.2.2.11 Digoxin is recommended for :

• worsening or severe heart failure due to left ventricularsystolic dysfunction despite ACE inhibitor, beta-blockerand diuretic therapy

• patients with atrial f ibrillation and any degree of heartfailure.

GPP

A

C



GPP

B

GPP

Angiotensin II receptor antagonists

1.2.2.12 At the time of issue of t his guideline, angio tensin II receptorantagonists (Appendix D, Table E) are not licensed in the UKfor heart failure and studies are ongoing. However,

angiotensin II receptor antagonists may provide analternative to ACE inhibi tors for patients intolerant o f ACEinhibi tors (for example, because of cough).

1.2.2.13 The tr iple combination of ACE inhibit or, beta-blocker andangiot ensin II receptor antagonist should be avoided,pending t he result s of further t rials.

Amiodarone

1.2.2.14 The decision to prescribe amiodarone should be made in

consult ation wit h a specialist .

1.2.2.15 The need to cont inue the prescript ion should be reviewedregularly.

1.2.2.16 Patients taking amiodarone should have a rout ine 6-monthlyclinical review, including liver and thyroid function test, andincluding a review of side eff ects.

Anticoagulants

1.2.2.17 Ant icoagulat ion is indicated for patients with thecombination of heart failure and atrial f ibrillation (see alsopage 16).

1.2.2.18 In patients with heart f ailure in sinus rhythm, ant icoagulat ionshould be considered for t hose with a history ofthromboembolism, left ventricular aneurysm, or intracardiacthrombus.

Aspirin

1.2.2.19 Aspirin (75–150 mg once daily) should be prescribed forpatients with the combination of heart failure andatherosclerotic arterial disease (including coronary heartdisease).

Statins (hydroxymethylglutaryl-coenzyme A reductase inhibitors)

1.2.2.20 Patients with the combinat ion of heart failure and knownatherosclerotic vascular disease should receive statins only inaccordance wit h current indications. Specif ic tr ials in t his areaare ongoing.


A

GPP

GPP

GPP

GPP

A



Isosorbide/hydralazine combination (specialist initiation only)

1.2.2.21 An isosorbide/hydralazine combination may be used inpatients with heart failure who are intolerant of ACEinhibi tors or angiotensin II receptor antagonists.

Inotropic agents (specialist use only)

1.2.2.22 Intravenous inotropic agents (such as dobutamine, milr inoneor enoximone) should only be considered for t he short -termtreatment of acute decompensation of chronic heart failure.This wil l require specialist advice.

Calcium channel blockers

1.2.2.23 Amlodipine should be considered f or t he treatment of

co-morbid hypertension and/or angina in patients with heartfailure, but verapamil, diltiazem or short-acting dihydropyridineagents should be avoided.

Major co-morbidities that impact on the pharmacologicalmanagement of heart failure

The presence of certain co-morbidities may affect the drugs that canbe used for t he t reatment of heart failure, or increase the likelihoodof side eff ects. The major co-morbidit ies that impact on t he

management of heart failure are summarised in Appendix D, Table F.

Side effects of drugs commonly used in the treatment of heart f ailure

All drugs have side effects. See the Summary of Product Characteristicsfor individual drugs for details.

Improving adherence to pharmacological t herapy

1.2.2.24 Dosing regimens should be kept as simple as possible, andthe healt hcare professional should ensure that the patient

and carer are full y informed about t heir medication.


A

A

A

B




A

C

C

1.2.3 Invasive procedures

Although drug therapy is the mainstay of t reatment of heart failure,some patients will also benefit from diagnostic or interventionalinvasive procedures. These procedures are normally organised by a

specialist. This guideline can only give general advice, and specialistadvice is strongly recommended where such procedures might beconsidered.

Coronary revascularisation

1.2.3.1 Coronary revascularisation should not be rout inely consideredin pat ients with heart f ailure due to systolic lef t vent ricularimpairment, unless they have refractory angina.

Cardiac transplantation

1.2.3.2 Specialist referral f or t ransplantat ion should be considered inpat ients with severe refractory symptoms or refractorycardiogenic shock.

Cardiac resynchronisation therapy

1.2.3.3 Resynchronisation t herapy should be considered in selectedpatients with left ventricular systolic dysfunction (leftventricular ejection fraction ≤ 35%), drug refractory symptoms,

and a QRS duration > 120 ms. The results of ongoing trials willhelp guide appropriate patient selection.

Implantable cardioverter-defibrillators (ICDs)

1.2.3.4 Recommendation from NICE Technology Appraisal GuidanceNo. 11, Guidance on t he use of implantable cardioverterdef ibri llators for arrhythmias (see Sect ion 6, page 25).

The use of implantable cardioverter defibrillators (ICDs)should be rout inely considered f or pat ients in t he fo llow ing

categories:

1. Secondary prevent ion, that is for pat ients who present, inthe absence of a treatable cause, with:

• cardiac arrest due to either ventricular tachycardia (VT)or ventricular fibrillation

• spontaneous sustained VT causing syncope or significanthaemodynamic compromise

• sustained VT wi thout syncope/cardiac arrest , and w hohave an associated reduction in ejection fraction (lessthan 35%) but are no worse than Class III* of the NewYork Heart Association functional classification of heartfailure.

NICE

2000



2. ‘Primary prevention’ f or patients wit h:

• a history of previous myocardial infarction and all ofthe following:

i) non-sustained VT on Holter (24-hour ECG)monitoring

ii) inducible VT on elect rophysiological test ing

iii) left ventricular dysfunction w ith an ejection f ract ionless than 35% and no w orse than Class III* of theNew York Heart Association functional classificationof heart failure.

• A familial cardiac condition with a high risk of sudden

death, including long QT syndrome, hypertrophiccardiomyopathy, Brugada syndrome, arrhythmogenicright ventricular dysplasia and following repair oftetralogy of Fallot.

* Marked limi tat ion of physical activit y. Although pat ients are comfortable at

rest, less than ord inary physical activit y wi ll lead to symptoms

(symptomat ically ‘moderate’ heart failure)

1.2.4 Oxygen therapy and continuous airway pressure

The evidence for oxygen t herapy and cont inuous posit ive airwaypressure w as considered during development of this guideline, but itwas not possible to make specific recommendations because of thesmall evidence base. For further details, see the full guideline (seeSection 5).

1.2.5 Recommendations for treatment of heart failure not due toleft ventricular systolic dysfunction

Valve disease

1.2.5.1 Patients with heart failure due to valve disease should bereferred for specialist assessment and advice regardingfollow-up.

1.2.5.2 ACE inhibitor therapy should not be initiated in a patientwith a clinical suspicion of haemodynamically significantvalve disease, until the valve disease has been assessed by aspecialist.


C

C



A

A

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Diastolic dysfunction

1.2.5.3 The diagnosis and treatment of diastolic dysfunct ion shouldbe made by a specialist, and other conditions that present ina similar way may need to be considered. Patients in whom

this diagnosis has been made should usually be treated witha low to medium dose of loop diuretics (for example, lessthan 80 mg f urosemide per day). Patients who do notrespond to this treatment will require further specialistadvice.

Other causes

The management of other causes of heart failure requires specialistinput. This would include congenital heart disease, cardiomyopathies,and specif ic heart muscle disease such as amylo id.

1.2.6 Recommendations for patients with heart failure and atrialfibrillation

1.2.6.1 For patients wit h heart failure and atr ial fibril lation,specialist advice should be sought as to whether the aim isimprovement of heart rate cont rol or cardioversion (returnto sinus rhythm).

1.2.6.2 Anticoagulation is indicated for patients wit h heart failureand atr ial f ibr illation (see also ant icoagulat ion sect ion,page 12).

1.2.7 Recommendations for different subgroups of patients withheart failure

Age

1.2.7.1 The management of heart failure should be determined byclinical criteria, irrespective of the age of the patient.

1.2.7.2 Tolerance of drugs may be lower and side effects requirecloser and more f requent monit oring in older patients.

Gender

1.2.7.3 The principles of pharmacological management of heartfailure should be the same for men and women.

1.2.7.4 The potential teratogenic effects of drugs should beconsidered.


GPP

C



Pregnancy

1.2.7.5 In women of reproductive age who have heart failure,cont racept ion and pregnancy should be discussed. Ifpregnancy is being considered or occurs, specialist advice

should be sought. Subsequently, specialist care should beshared between t he cardiologist and obstetr ician.

Ethnicity

1.2.7.6 The principles of pharmacological management should bethe same for all patients with heart failure, regardless ofethnicity.

1.3 Monitoring

The clinical condition of a person w ith heart f ailure may f luctuateand repeated admission to hospit al is common, part icularly f orpatients wi th more severe heart failure. Monit oring of clinical statusis necessary and will involve healthcare professionals in both primaryand secondary care. Patients and their carers are playing anincreasing role in monitoring, but this requires appropriate educationand support.

1.3.1 Clinical review

1.3.1.1 All patients wit h chronic heart failure require monitoring.This monit oring should include (see Table 2, page 18):

• a clinical assessment of functional capacit y, f luid status,cardiac rhythm (minimum of examining the pulse),cognitive status and nutritional status

• a review of medication, including need f or changes andpossible side effects

• serum urea, elect rolytes and creatinine * .

* This is a minimum. Patients wit h co-morbid it ies or co-prescribed medications

wi ll require further monitoring. Monitoring serum potassium is particularly

import ant if a pati ent is taking digoxin or spironolactone.

1.3.1.2 More detailed monitoring will be required if the patient hassigni f icant co-morbidi ty or has deteriorated since theprevious review.

1.3.1.3 The f requency of monit oring should depend on the clinicalstatus and stability of the patient. The monit oring int erval

should be short (days to 2 w eeks) if the clin ical condi t ion ormedication has changed, but is required at least 6 mont hlyfor stable pat ients wi th proven heart f ailure.

NNICE Guideline – Chronic heart fai lure 17

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1.3.1.4 Patients who w ish to be involved in monitoring of theircondit ion should be provided wi th suff icient education andsupport f rom t heir healthcare professional t o do this, wi thclear guidelines as to what to do in the event ofdeterioration.

1.3.2 Therapeutic drug monitoring of serum digoxin concentrations

1.3.2.1 Rout ine monitoring of serum digoxin concentrations is notrecommended. A digoxin concentration measured within8–12 hours of the last dose may be useful to confirm aclin ical impression of toxicit y or non-compl iance.

1.3.2.2 The serum digoxin concentrat ion should be interpreted inthe clinical context as toxicity may occur even when the

concentrat ion is wi thin t he ‘therapeutic range’.

Table 2 Assessments to be made at clinical review


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Assessment of Chiefly from history, but more objectivelyfunctional capacity by use of New York Heart Association

class, specif ic qualit y-of-lif equest ionnaires, 6-minute walk t est , ormaximal exercise test. Note: not all ofthese tests are likely to be necessary, or

appropriate, at each assessment.

Assessment of fluid Chiefly by physical examinat ion – changesstatus in body weight , extent of jugular venous

distension, lung crackles andhepatomegaly, extent of peripheraloedema, and lying and standing bloodpressure (postural drop in blood pressuremay indicate hypovolaemia)

Assessment of Chief ly by clin ical examinat ion, but may

cardiac rhythm require 12-lead electrocardiogram (ECG)or 24-hour electrocardiographic(‘Holter’) monitoring if suspicion ofarrhythmia

Laboratory assessment Checking of serum biochemistry (urea,electrolytes, creat inine) is essent ial, butother tests (such as thyroid function,haematology, liver function, level ofanticoagulat ion) may also be required

depending on t he medication prescribedand co-morbidit y



1.4 Referral and approach to care

The management of heart failure is likely to be shared betweenhealthcare professionals in both primary and secondary care. Patientsand their carers are increasingly involved in management decisions.

Work with patient focus groups suggests that the major failings ofmanagement relate to poor communicat ion between healthcareprofessionals, and between patients and the professionals caring forthem.

1.4.1 Referral for more specialist advice

1.4.1.1 Patients with heart failure require specialist advice in thefollowing situations.

• Heart failure due to valve disease, diastolic dysfunctionor any other cause except left ventricular systolicdysfunction.

• One or more of the co-morbidit ies out lined in AppendixD, Table F.

• Angina, atrial fibrillation or other symptomaticarrhythmia.

• Women who are planning a pregnancy or who arepregnant.

1.4.1.2 The follow ing situations also require referral.

• Severe heart failure.• Heart f ailure that does not respond t o t reatment as

discussed in this guideline and out lined in thealgorithm.

• Heart failure that can no longer be managed effectivelyin t he home sett ing.

1.4.2 Discharge planning

1.4.2.1 Patients with heart failure should generally be dischargedfrom hospital only when their clinical condition is stable andthe management plan is opt imised. Timing of dischargeshould t ake into account patient and carer wishes, and thelevel of care and support that can be provided in thecommunity.


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1.4.2.2 The primary care team, patient and carer must be aware ofthe management plan.

1.4.2.3 Clear inst ruct ions should be given as to how thepat ient /carer can access advice part icularly in the high-risk

period immediately follow ing discharge.

1.4.3 Multidisciplinary team approach to heart failure management

1.4.3.1 Heart f ailure care should be delivered by a mult idisciplinaryteam w it h an in tegrated approach across the healt hcarecommunity.

1.4.4 Non-NHS agencies

1.4.4.1 Standard One of The Older People NSF states:Social care services will not use age in their eligibility criteriaor policies to restrict access to available services. This appliesto patients wit h heart failure. (Seewww.doh.gov.uk/nsf/olderpeople.htm)

1.4.4.2 Management plans for patients wit h heart failure should bediscussed with non-NHS agencies where they are involved inor responsible for the care of a person with heart failure.

1.4.4.3 The principles of pharmacological management for a pat ientcared for in a non-NHS inst it ut ion should be simi lar to t hosefor any other patient w ith heart failure.

1.4.4.4 The education needs of non-NHS agency carers should beconsidered.

1.5 Supporting patients and carers

Understanding the inf ormation needs of pat ients and carers is vital.

Key issues ident if ied by patient focus groups include the importanceof honesty and accurate information, and the potential value ofsupport groups. The recommendations below are based on earlierconsensus guidelines produced by a Royal College of Physicians’working party.

1.5.1 Communication

1.5.1.1 Good communicat ion between healthcare prof essionals andpatients and carers is essential for the best management ofheart failure.


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1.5.1.2 Guidelines for good communication.

• Listen to patients and respect their views and beliefs.• Give patients the information they ask for or need

about their condit ion, it s t reatment and prognosis, in a

way they can understand, including information aboutany serious side eff ects of drugs to be prescribed.

• Provide the most important information first.• Explain how each i tem will aff ect patients personally.• Present information in separate categories.• Make advice specif ic, detailed and concrete.• Use words the patients will understand; conf irm

understanding by questions; define unfamiliar words;writ e down key words; draw diagrams and keep a copyin the medical not es.

• Repeat the information using the same words each time.

• Prepare material, written or taped, to back uphandwritten notes.

• Share informat ion wit h pat ients' partners, close relativesor carers if they ask you to do so. When patients cannotindicate their consent for such sharing of information, itis advisable to share the inf ormation t hat those close tothe pat ient need or want t o know, except w here youhave reason t o believe that t he patient would object ifable to do so.

1.5.1.3 The content, style and t iming of information provision shouldbe tailored to the needs of the individual patient.

1.5.1.4 Healthcare prof essionals should assess cogni t ive abilit y whensharing information.

1.5.1.5 Carers and relat ives of patients who are cognit ively impairedshould be made aware of t reatment regimens for t hepatients they care for and be encouraged to identify anyneed for clinical support.

1.5.1.6 Management of heart failure should be seen as a sharedresponsibi lit y betw een patient and healthcare prof essional.

1.5.1.7 Unless specif ically excluded by the patient , carers and relativesshould be involved in the management of the patient,particularly where the patient cannot look after him- or herself.

1.5.2 Prognosis

1.5.2.1 Prognosis should be discussed w ith patients and carers in asensit ive, open and honest manner.


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1.5.3 Support groups

1.5.3.1 Healthcare professionals should be aware of local cardiacsupport networks and provide this information to patientsand carers.

1.6 Anxiety and depression

Depression tends to be more common in patients with heart failurethan in t he general populat ion. Drug therapy wit h ant idepressantsmay lead t o complicat ions such as f luid retent ion, hypotension andarrhythmias.

1.6.1.1 The diagnosis of depression should be considered in allpatients wi th heart failure.

1.6.1.2 Where depression is likely to have been precipit ated by heartfailure symptoms then reassessment of psychological statusshould be undertaken once the physical condition hasstabilised follow ing t reatment for heart failure. If thesymptoms have improved no furt her specif ic treatment fordepression is required.

1.6.1.3 Where it is apparent t hat depression is co-exist ing w ith heartfailure, then t he patient should be treated for depression

follow ing the NICE guideline (Depression: the managementof depression in primary and secondary care), scheduled forpublicat ion in February 2004.

1.6.1.4 For patients with heart failure, the potential risks andbenefits of drug therapies for depression should beconsidered carefully.

1.6.1.5 Patients wi th heart failure should consult a healthcareprofessional before using over-the-counter therapies fordepression such as St John’s wort (Hypericum perforatum).

Healthcare professionals should be aware of the potentialinteraction with prescribed medication, and always ask aboutself-medication, including the use of herbal products.

1.7 End of life issues

There is substantial evidence for considerable unmet palliative needsof patients with heart f ailure and t heir inf ormal carers. The mainareas of need include symptom control, psychological and socialsupport , planning for t he fut ure, and end of lif e care.

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1.7.1.1 Issues of sudden death and living wi th uncertainty arepertinent to all patients with heart failure. The opportunityto discuss these issues should be available at all stages ofcare.

1.7.1.2 The palliative needs of pat ients and carers should beidentified, assessed and managed at the earliest opportunity.

1.7.1.3 Patients with heart failure and their carers should haveaccess to professionals with palliative care skills within theheart failure team.

2 Notes on the scope of the guidance

All NICE guidelines are developed in accordance with a scopedocument t hat def ines what t he guideline will and wil l not cover. Thescope of this guideline was established at the start of thedevelopment of this guideline, follow ing a period of consultation; itis available from: www.nice.org.uk/docref.asp?d=22427

The guideline covers the care provided by primary and secondaryhealthcare prof essionals who have direct contact wit h, and makedecisions concerning, t he care of patients with heart failure. It alsoaddresses issues concerning the int erface between pr imary and

secondary care, includ ing in w hat circumstances pat ient s should bereferred to or admitted to secondary care.

The guideline addresses all the key areas of managing chronic heartfailure, including diagnosis, and pharmacological and non-pharmacolog ical t reatment s.

This guideline does not include specific reference to ‘acute’ heartfailure, but does include comment on exacerbation of the syndromeand t he causes and t reatment of this, recognising that chron ic heartfailure of ten has an undulat ing course. It does not address the

screening or diagnosis of people w ho are asymptomat ic, themanagement of patients with right heart failure as a consequence ofrespiratory disease, or post -transplant care. In addi t ion, the guidelinedoes not cover t he organisational aspects of heart failuremanagement . It does not therefore address models of care, the rolesor composition of primary or secondary healthcare teams andcompetencies, skil l mix or t raining requirements.

This guideline was developed for the NHS, and although i t comment son the interface with other sectors, it does not consider them indetail.


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3 Implementation in the NHS

3.1 In general

Local health communities should review their existing serviceprovision f or t he management of heart failure against this guidelineas they develop their Local Delivery Plans. The review should considerthe resources required to implement f ully the recommendat ions setout in Section 1 of this guideline, the people and processes involved,and the timeline over which full implementation is envisaged. It is inthe interests of patients that the implementation timeline is as rapidas possible.

Relevant local clinical guidelines and protocols should be reviewed inthe light of this guidance and revised accordingly.

3.2 Audit

Suggested audit criteria are listed in Appendix E.

4 Research recommendations

Research recommendations have been identified during thedevelopment of this guideline. They are detailed in the fu ll guideline(see Section 5).

5 Full guideline

The National Institute for Clinical Excellence commissioned thedevelopment of this guidance from the National Collaborating Centrefor Chronic Conditions. The Centre established a Guideline

Development Group (see Appendix B), which reviewed the evidenceand developed the recommendat ions.

The full guideline, Chronic Heart Failure: Management of ChronicHeart Failure in Adults in Primary and Secondary Care, is pub lished bythe National Collaborating Centre for Chronic Conditions; it isavailable on its website (www.rcplondon.ac.uk/college/ceeu/ ncccc_index.htm), the NICE website (www.nice.org.uk) and on thewebsite of the National Electronic Library for Health(www.nelh.nhs.uk).




The members of the Guideline Development Group are listed inAppendix B. Information about the Inst it ute’s Guideline Review Panelis given in Appendix C.

The booklet The Guideline Development Process – Information for

the Public and the NHS has more information about the Inst it ute’sguideline development process. It is available f rom the Inst it ute’swebsite and copies can also be ordered by telephoning0870 1555 455 (quote reference N0038).

6 Related NICE guidance

National Inst it ut e for Clinical Excellence (2000). Guidance on the useof implantable cardioverter def ibril lators for arrhythmias. NICE

Technology Appraisal Guidance No. 11. London: Nat ional Inst it ute forClinical Excellence. Available from:www.nice.org.uk/Docref.asp?d=10239

7 Review date

The process of reviewing the evidence is expected to begin 4 yearsafter the date of issue of this guideline (July 2007). Reviewing may

begin earlier than 4 years if signi f icant evidence that aff ects theguideline recommendat ions is ident if ied sooner. The updatedguideline will be available wi thin 2 years of the start of the reviewprocess.


A version of this guideline for patients with heart failure, their carers and

the public is available from the NICE website (www.nice.org.uk) or fromNHS Response Line (0870 1555 455; quote reference number N0248for an English version and N0249 for an English and Welsh version)



Appendix A: Grading scheme

The grading scheme and hierarchy of evidence used in this guidelineare shown in the table below.

Hierarchy of evidence Typical grading of recommendations

Level Type of evidence Grade Evidence

Ia Evidence obtained f romsystematic review of meta-analysis of randomisedcontrolled trials

Ib Evidence obtained from at leastone randomised controlled trial

IIa Evidence obtained from atleast one well-designedcontrolled study withoutrandomisation

IIb Evidence obtained from at leastone other type of well-designedquasi-experiment al study

III Evidence obtained from wel l-designed non-experimental

descriptive studies, such ascomparat ive studies, correlationstudies and case studies

IV Evidence obtained from exper tcommit tee reports or opinionsand/or clinical experience ofrespected authorities

DS Evidence from diagnost icstudies

NICE Evidence from NICE guidelinesor health technology appraisalprogramme

A At least one randomisedcont rolled t rial as part of abody of li terature of overallgood qualit y and consistencyaddressing the specificrecommendation(evidence levels Ia and Ib)

B Well-conduct ed clinicalstudies but no randomisedclinical trials on the topic ofrecommendat ion (evidencelevels IIa, IIb, III)

C Expert commit t ee report s oropin ions and/or clinicalexperience of respectedauthorit ies. This gradingindicates that directlyapplicable clinical studies orgood qualit y are absent(evidence level IV)

GPP Recommended good practicebased on the clinical experienceof the Guideline DevelopmentGroup

DS Evidence f rom d iagnost icstudies

NICE Evidence from NICE guidelinesor health t echnology appraisalprogramme

Adapt ed f rom: National Inst it ute fo r Clin ical Excellence (2001). The Guideline Development Process – Information for National Collaborating Centres and Guideline Development Groups. London: National Institute for Clinical Excellence. Available from www.nice.org.uk.




Appendix B: The Guideline Development Group

Ms Audrey AlimoNurse Consultant for Heart Failure, Central Middlesex Hospital,

London

Dr Graham ArchardGeneral Practitioner, Christchurch

Mr Steven BarnesHealth Services Research Fellow in Guideline Development, NationalCollaborat ing Centre for Chron ic Condi t ions

Professor Martin Cowie (Clinical Advisor)Professor of Cardiology, National Heart and Lung Institute, ImperialCollege, London

Ms Stephanie CruickshankHeart failure patient and carer representat ive; Cardiomyopathy NurseSpecialist , St George’s Hospital, London

Dr Perry ElliottSenior Lecturer in Cardiology, St George’s Hospital Medical School,London

Professor Rose Anne KennyProfessor of Geriatric Medicine, University of Newcastle

Dr Jonathan Mant (Lead)Senior Lecturer in Public Health, University of Birmingham

Mr Derrick MastersHeart failure patient and carer representative

Dr Jennifer RobertsSenior Lecturer in Health Economics, School of Health and Related

Research, University of Sheffield

Professor Mojgan SaniConsultant Pharmacist, Guys’ and St Thomas’ Hospital Trust andVisiting Professor, School of Pharmacy and Pharmacology, Universityof Bath

Ms Hasina ShaikhInformation scientist, National Collaborating Centre for ChronicConditions




Dr Lip-Bun TanConsultant Cardiologist, Leeds General Infirmary

Dr Ann TaylorChartered Physiotherapist, School of Biomedical Sciences, King’s

College London; Research Officer, Association of CharteredPhysiotherapists in Cardiac Rehabil it ation

Ms Sarah WilliamsProject manager, Nat ional Collaborat ing Centre for Chron icConditions

Consensus reference group (CRG)

To support the development of this guideline, a Consensus Reference

Group (CRG) was formed. The CRG met early in the developmentprocess to ensure that the aims and the clinical questions addressedby the guideline were appropriate. The CRG met again at the end ofthe process to review t he recommendat ions draf ted by the GuidelineDevelopment Group. The group used formal consensus techniques intheir consideration of clinically important areas where there wasinsuf f icient evidence or disagreement over the interpretation of theevidence.

Professor John Camm (Chair)

President, British Cardiac Society; Professor of Cardiology, St George’sHospital M edical School, London

Professor John ClelandProfessor of Academic Cardiology, Universit y of Hull

Dr Michael GammageConsultant Physician in Cardiovascular Medicine, Queen ElizabethHospit al, Birmingham

Dr Louise Gibbs*

Consultant Physician in Pall iat ive Care, St Christopher’s Hospice,Surrey

Professor Richard HobbsProfessor of General Pract ice, Universit y of Birmingham

Ms Lee HooperResearch Associat e in Evidence-Based Care and Systemat ic Review,University Dental Hospital of Manchester

Dr Malcolm MetcalfeConsultant Cardiologist, Aberdeen Royal Infirmary




Ms Chris MonacoCardiology Department, Calderdale Royal Hospital

Dr Kevin O'Shaughnessy*Universit y Lecturer in Clinical Pharmacology & Honorary Consultant

Physician, Addenbrooke’s Hospital, Cambridge

Dr Chakravarthi Rajkumar*Senior Lecturer and Consultant Physician, Care of the Elderly, ImperialCollege School of Medicine, London

Ms Sara RichardsChair, Royal Col lege of Nursing Practice Nurses’ Associat ion; NursePractitioner, Slough NHS Walk-In Centre

Professor Jonathan Richards*

External Professor of Primary Care, Universit y of Glamorgan

Dr David RobertsConsultant Cardiologist, Victoria Hospital, Blackpool

Dr Chris Spencer-JonesDirector of Public Health, Dudley Health Authority

* Att ended and contribut ed to at least one GDG meeting




Appendix C: The Guideline Review Panel

The Guideline Review Panel is an independent panel that overseesthe development of the guideline and takes responsibility for

moni toring it s qualit y. The Panels include experts on guidelinemethodology, healt h professionals and people w it h experience of theissues aff ect ing patient s and carers. The members of the GuidelineReview Panel for this guideline were as follows.

Dr Bernard Higgins (Chair)Consultant Chest PhysicianFreeman HospitalNewcastle upon Tyne

Dr Robert HigginsConsultant in Renal and General MedicineUniversit y Hospitals Coventry and Warw ickshire

Dr Marcia KelsonDirectorPatient Involvement Unit for NICECollege of HealthLondon

Dr Peter Rutherford

Senior Lecturer in Nephrology, Medical DirectorUniversity College of Wales College of Medicine

Dame Helena ShoveltonChief ExecutiveBrit ish Lung Foundation

Fiona WiseAct ing Director of ModernisationBedfordshire and Hertf ordshire St rategic Health Aut horit y

Dr John YoungMedical DirectorMerck Sharp and Dohme




Appendix D: Further information on pharmacologicaltreatment

Table A Diuretics (oral): dosages and side effects


Drug Initial dose (mg) Maximum recommendeddaily dose (mg)

Loop diureticsBumetanide 0·5–1·0 5–10Furosemide 20–40 250–500Torasemide 5–10 100–200

Thiazides*Bendrof lumethiazide 2.5 5

(previously calledbendrofluazide)Indapamide 2·5 2·5Metolazone 2·5 10

Potassium-sparing diuretics +ACEI –ACEI +ACEI –ACEIAmiloride 2·5 5 20 40Triamterene 25 50 100 200

For spironolactone, see page 9ACEI, angiotensin converting enzyme inhibit or

* May be effective when added to loop d iuretics when f luid r etention is resistant , but can

promote dramati c diuresis and disturbance in f luid balance and electrol ytes. Patient must

be closely monitored and specialist advice is required



Table B Practical recommendations on the use of ACE inhibitors


Which ACE inhibitor and what dose?

Licensed ACEI Starting dose (mg) Target dose (mg)

Captopr il 6.25 three t imes daily 50–100 three t imes dailyCilazapril* 0.5 once daily 1–2.5 once dailyEnalapril 2.5 twice daily 10–20 twice dailyFosinopril* 10 once daily 40 once dailyLisinopri l 2.5–5.0 once daily 30–35 once dailyPerindopril* 2.0 once daily 4 once dailyQuinapril* 2.5–5.0 once daily 10–20 once dailyRamipr il 2.5 once daily 5 twice daily or 10 once

daily

* Target dose based on manuf actu rer’s recommendation rather than large outcome study

How to use

• Start with a low dose (see above)• Seek specialist advice where the patient is on a high dose (e.g. furosemide

80 mg) of a loop diuretic• Double dose at not less than 2 weekly in tervals• Aim for target dose (see above) or, failing that, the highest tolerated dose• Remember some ACE inhibit or i s bett er than no ACE inhibit or• Monitor blood electrolytes (in particular potassium), urea, creatinine, and

blood pressure• When to stop up-titration/down-titration – see ‘Problem solving’

Advice to patient• Explain expected benefi ts

• Treatment is given to improve symptoms, to prevent worsening of heartfailure and to increase survival• Symptoms improve wit hin a few weeks to a few months• Advise patients to report principal adverse effects (i.e. dizziness/symptomatic

hypotension, cough)

Problem solving• Asymptomat ic low blood pressure does not usually requi re any change in

therapy

Symptomatic hypotension• If dizziness, light-headedness and/or confusion and a low blood pressure

consider d iscont inuing nit rates, calcium channel blockers* and ot her

vasodilators• If no signs/symptoms of congestion consider reducing diuretic dose• If these measures do not solve problem seek specialist advice

* Calcium channel b lockers shou ld be discont inued unless absolut ely essent ial (e.g. for

angina or hypertension).

Continued




Which ACE inhibitor and what dose? Continued

Cough• Cough is common in patients with chronic heart failure, many of whom have

smoking-related lung disease• Cough is also a sympt om o f pulmonary oedema which should be excluded

when a new or worsening cough develops• ACE inhibitor induced cough rarely requires treatment discontinuation• If the patient develops a troublesome dry cough which interferes with sleep

and is likely to be caused by an ACE inhibitor, consider substituting anangiotensin II receptor antagonist for the ACE inhibitor

Worsening renal function• Some rise in urea, creatinine and K+ is to be expected aft er init iation o f an

ACE inhibitor; if the increase is small and asymptomatic no action is necessary• An increase in creatinine of up to 50% above baseline, or to 200 µmol/litre,

which ever is the smaller, is acceptable• An increase in K+ to ≤ 5.9 mmol/litre is acceptable

• If urea, creatinine or K+ do rise excessively consider stopping concomitantnephrot oxic drugs (e.g. NSAIDs), non-essent ial vasodi lators (e.g. calciumantagonists, ni t rates), K+ supplements/retaining agents (tri amterene,amiloride) and, if no signs of congestion, reducing the dose of diuretic

• If greater r ises in creatin ine or K+ than those out lined above persist despit eadjustment of concomitant medications the dose of the ACE inhibitor shouldbe halved and b lood chemist ry rechecked, if there is st ill an unsatisfactoryresponse specialist advice should be sought

• If K+ rises to ≥ 6.0 mmol /lit re or creatinine increases by > 100% or t o above350 µmol /lit re the dose of ACE inhibit or should be stopped and specialistadvice sought

• Blood electrolyt es should be monitored closely unt il K+ and creatinine

concentrations are stable

Note: it is very rarely necessary to stop an ACE inhibit or and clini cal deteriorat ionis likely if t reatment is wit hdrawn; ideally, specialist advice should be soughtbefore t reatment discont inuation

Adapted f rom European Journal of Heart Failure 2001, 3, 495-502 (McMurray et al.

Practi cal recommendat ions for the use of ACE inhibit ors, beta-blockers and spironolactone

in heart failure: put ti ng guidelines into practice), copyright (2001), w ith permission from

European Society of Cardiology.



Table C Practical recommendations on the use of beta-blockers


Which beta-blocker and what dose?

Which beta-blocker and what dose?Only two beta-blockers are licensed for the treatment of heart failure in the UKat t he time of issue of th is guideline.

Starting dose (mg) Target dose (mg)Bisoprolol 1.25 once daily 10 once dailyCarvedilol 3.125 twice daily 25–50 twice daily*

* Carvedilol: maximum dose 25 mg t wice daily if severe heart failure. For pat ientswi th mild t o moderate heart f ailure maximum dose 50 mg tw ice daily if weightmore t han 85 kg – otherw ise maximum dose 25 mg t wice daily

How to use• Start with a low dose (see above)

• Double dose at not less than 2 weekly in tervals• Aim for target dose (see above) or, failing that, the highest tolerated dose• Remember some beta-blocker is bett er than no beta-blocker• Monitor heart rate, blood pressure, clinical status (symptoms, signs, especially

signs of congestion, body weight)• Check blood elect rolyt es, urea and creatinine 1–2 weeks aft er ini t iat ion and

1–2 weeks after final dose titration• When t o down-tit rate/stop up-tit ration, see ’Problem solving’

Advice to patient• Explain expected benefi ts• Emphasise that treatment given as much to prevent worsening of heart failure

as to improve sympt oms; beta-blockers also increase survival• If symptomat ic improvement occurs, this may develop slow ly (3–6 mont hs or

longer)• Temporary symptomatic deterioration may occur (estimated 20–30% of cases)

during initiation/up-titration phase• Advise patient to report deterioration (see ’Problem solving’) and that

deterioration (tiredness, fatigue, breathlessness) can usually be easily managedby adjustment of other medication; patients should be advised not to stopbeta-blocker therapy without consulting their physician

• Patients should be encouraged t o weigh t hemselves daily (aft er waking,before dressing, after voiding, before eating) and to consult their doctor ifthey have persistent weight gain

Problem solving

Worsening symptoms/signs (e.g. increasing dyspnoea, fatigue, oedema,weight gain)• If increasing congest ion, double dose of diuretic and/or halve dose of beta-

blocker (if increasing diuretic does not work)• If marked f atigue (and/or bradycardia, see below) halve dose of beta-blocker

(rarely necessary)• Review patient in 1–2 weeks; if not improved seek specialist advice• If serious deterioration, halve dose of beta-blocker or stop this treatment

(rarely necessary); seek specialist adviceContinued




Which beta-blocker and what dose? Continued

Low heart rate• If < 50 beats/min and worsening symptoms – halve dose beta-blocker or, if

severe deterioration, stop beta-blocker (rarely necessary)• Consider need t o continue t reatment w ith ot her drugs that slow the heart

(e.g. digoxin, amiodarone, dilt iazem) and discont inue if possible• Arrange ECG to exclude heart block• Seek speciali st advice

Asymptomatic low blood pressure• Does not usually requi re any change in therapy

Symptomatic hypotension• If low blood pressure causes dizziness, light -headedness or confusion, consider

discontinuing drugs such as nitrates, calcium channel blockers and othervasodilators

• If no signs/symptoms of congestion consider reducing diuretic dose

• If these measures do not solve problem seek specialist advice

Note: beta-blockers should not be stopped suddenly unless absolutely necessary(there is a risk of a ‘rebound’ increase in myocardial ischaemia/inf arct ion andarrhythmias); ideally specialist advice should be sought befo re t reatmentdiscontinuation


Pract ical recommendations for t he use of ACE inh ibit ors, beta-blockers and spironolactone

in heart failure: put ting gu idelines int o practice), copyright (2001), wi th permission from




Table D Practical recommendations for the use of spironolactone

Which dose of spironolactone?

Dose (mg)12.5–25 daily *

* 50 mg may be advised by a specialist i f heart f ailure deteriorat es and no problem w it h

hyperkalaemia

How to use• Start at 25 mg once daily• Check blood chemistry at: 1, 4, 8 and 12 weeks; 6, 9 and 12 months; 6 monthly

thereafter• If K+ rises to between 5.5 and 5.9 mmol/litre or creatinine rises to 200 µmol/litre

reduce dose to 25 mg on alt ernate days and monitor b lood chemistry closely• If K+ rises to ≥ 6.0 mmol/litre or creatinine to > 200 µmol/litre stop

spironolactone and seek specialist advice

Advice to patient• Explain expected benefi ts• Treatment is given to improve symptoms, prevent worsening of heart failure

and t o increase survival• Symptom improvement occurs within a f ew w eeks to a f ew mont hs of starting

treatment• Avoid NSAIDs not prescribed by a physician (self-purchased ‘over the counter’

treatment, e.g. ibuprofen)• Temporarily stop spironolactone if diarrhoea and/or vomiting and contact

physician

Problem solving

Worsening renal function/hyperkalaemia:• See ’How to use’• Major concern is hyperkalaemia (≥ 6.0 mmol/litre) though this was uncommon

in t he RALES clinical t rial; a pot assium level at t he higher end of the normalrange may be desirable in patients with heart failure, particularly if takingdigoxin

• Some ‘low salt ’ substi tut es have a high K+ content• Male patients may develop breast discomf ort and/or gynaecomast ia


Pract ical recommendat ions fo r t he use of ACE inhibit ors, beta-blockers and spironolactone

in heart failure: put ting gu idelines into p racti ce), copyright (2001), wi th permission from






Table E Currently available angiotensin II receptor antagonists

Table F Major co-morbidities that impact on the management ofheart failure

Drug* Daily dose (mg)

Candesartan 4–16

Eprosartan 400–800

Irbesartan 150–300

Losartan 50–100

Telmisartan 40–80

Valsartan 80–320

* None of t hese drugs is currently li censed for the treatment of heart failure in the UK

Co-morbidity Comments

COPD/asthma/ Beta-blockers are cont raindicated in pat ient s wit hreversible airways reversible airways disease. The British National disease Formulary (45th edition, 2003) states ‘Beta-blockers should

be avoided in patients with a history of asthma or chronicobstructive airways disease; if there is no alternative, acardioselect ive beta-blocker may be used w it h ext remecaution under specialist supervision’.

Renal dysfunction ACE inhibit ors and angiot ensin-II receptor antagonists

(e.g. serum creatin ine may be contraindicated. Patient requi res specialist> 200 µmol /l it re) assessment.

Anaemia Anaemia is common in pat ient s w it h moderat e t o severeheart failure and where due to t he heart failure (and notother causes) treatment with erythropoeit in and irontherapy may improve symptoms and reduce the risk ofhospitalisation for worsening heart failure. The results ofseveral large RCTs addressing this issue are awaited.

Thyroid disease Severe thyroid dysfunction may cause or precipitate heartfailure.

Peripheral vascular Not an absolut e cont raindication to beta-blocker therapy.disease High index of suspicion f or renal art ery st enosis required.

Urinary frequency Requires appropriate specialist referral. Alpha-blockers maycause hypotension or fluid retention, but are notabsolutely cont raindicated in patients wit h heart f ailure.Diuret ics likely to be less well t olerated.

Gout Avoid non-st eroidal ant i-inf lammat ory drugs. Gout can beexacerbated by diuretics and may have an atypicalpresentation in patients with heart failure. Colchicine maybe useful f or the treatment of an acute att ack of gout .Allopurino l may be useful at reducing t he risk of fu rther

attacks of gout , but should not be started at the t ime ofan acute episode of gout.



A p p e n d i x E : T e c h n i c a l d e t a i l o n t h e c r i t e r i a f o r a u d i t

K e y r e c o m m e n d a t i o n s

D e n o m

i n a t o r

O t h e r r e

l e v a n t

E x c e p t i o n

s

D e f i n i t i o n o

f t e r m s

r e c o m m e n d a t i o n s

1 . 1 . 3 . 1 :

T h e b a s i s f o r h i s t o r i c a l

d i a g n

o s e s o f h e a r t f a i l u r e

s h o u l d b e r e v i e w e d , a n d

o n l y p

a t i e n t s w h o s e

d i a g n

o s i s i s c o n f i r m e d

s h o u l d b e m a n a g e d i n

a c c o r d a n c e w i t h t h i s

g u i d e

l i n e

1 . ‘ D i s e a s e r e g i s t e r ’

% o f p a

t i e n t s o n g e n e r a l

p r a c t i c e

h e a r t f a i l u r e

r e g i s t e r

s w h o h a v e h a d

t h i s d i a g n o s i s c o n f i r m e d .

W h e r e t h e d i a g n o s i s o f

h e a r t f a i l u

r e i s s t i l l

s u s p e c t e d , b u t

c o n f i r m a t i o n o f t h e

u n d e r l y i n g c a r d i a c

a b n o r m a l i t y h a s n o t

o c c u r r e d t h e n t h e p a t i e n t

s h o u l d h a

v e a p p r o p r i a t e

f u r t h e r i n v e s t i g a t i o n .

P a t i e n t c h o i c e ; o r w h e r e

t h i s w o u l d b e

i n a p p r o p r i a

t e ( e . g .

t e r m i n a l i l l n

e s s )

T h e d i a g n o s t i

c a l g o r i t h m

( s e e p a g e 5 ) s

u m m a r i s e s

h o w a d i a g n o

s i s o f h e a r t

f a i l u r e s h o u l d

b e

c o n f i r m e d .

1 . 1 . 1 . 5 :

T r a n s t h o r a c i c D o p p l e r 2 D

e c h o c

a r d i o g r a p h i c

e x a m i n a t i o n s h o u l d b e

p e r f o r m e d t o e x c l u d e

i m p o r

t a n t v a l v e d i s e a s e ,

a s s e s s

t h e s y s t o l i c ( a n d

d i a s t o

l i c ) f u n c t i o n o f t h e

( l e f t ) v e n t r i c l e a n d d e t e c t

i n t r a c

a r d i a c s h u n t s

2 . E c h o c a r d i o g r a p h y

% o f p a

t i e n t s w i t h a n e w

d i a g n o s i s o f h e a r t f a i l u r e

( i n t h e p r e v i o u s 1 2

m o n t h s

) w h o h a v e h a d a n

e c h o c a r

d i o g r a m

–

P a t i e n t c h o i c e ; p a t i e n t

d e c l i n i n g f u

r t h e r

i n v e s t i g a t i o

n , o r w h e r e

t h i s w o u l d b e

i n a p p r o p r i a

t e ( e . g .

t e r m i n a l i l l n

e s s )

–

1 . 2 . 2 . 2 :

A l l p a

t i e n t s w i t h h e a r t

f a i l u r e d u e t o l e f t

v e n t r i c u l a r s y s t o l i c

d y s f u n c t i o n s h o u l d b e

c o n s i d

e r e d f o r t r e a t m e n t

w i t h a n A C E i n h i b i t o r

3 . A C E

i n h i b i t o r s

% o f p a

t i e n t s w i t h h e a r t

f a i l u r e d u e t o l e f t

v e n t r i c u

l a r s y s t o l i c

d y s f u n c

t i o n w h o a r e

p r e s c r i b

e d a n A C E

i n h i b i t o

r o r a n a n g i o t e n s i n

I I r e c e p t o r a n t a g o n i s t , i f

A C E i n h

i b i t o r s a r e c o n t r a -

i n d i c a t e

d

A t t h e t i m

e o f i s s u e o f t h i s

g u i d e l i n e , a n g i o t e n s i n I I

r e c e p t o r a

n t a g o n i s t s a r e

n o t l i c e n s e d i n t h e U K f o r

h e a r t f a i l u

r e a n d s t u d i e s

a r e o n g o i n g . H o w e v e r ,

t h e y m a y

p r o v i d e a n

a l t e r n a t i v e t o A C E

i n h i b i t o r s

f o r p a t i e n t s

i n t o l e r a n t

o f A C E

i n h i b i t o r s

( f o r e x a m p l e ,

b e c a u s e o

f c o u g h ) .

P a t i e n t c h o i c e ;

c o n t r a i n d i c a t i o n s ( s e e

g u i d e l i n e t e

x t ) ; o r

d o c u m e n t e d a d v e r s e

e v e n t s l e d t

o w i t h d r a w a l

o f A C E i n h i b i t o r ; h e a r t

f a i l u r e n o t d u e t o l e f t

v e n t r i c u l a r s y s t o l i c

d y s f u n c t i o n

.

–










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NHS

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