Management of Chronic Heart Failure in Adults: Synopsis of the National Institute for Health and Clinical Excellence Guideline


The following are points to remember about the management of chronic heart failure (HF) in adults:

  1. The National Institute for Health and Clinical Excellence (NICE) develops clinical practice guidelines for the National Health Service of England and Wales. Based on literature searches (cut-off date, October 2009), the guidelines development group (GDG) of NICE made new recommendations for the diagnosis and management of HF.

  2. Their studies found a net savings of £19,000 per 100,000 persons if all of these recommendations were implemented.

  3. The American College of Cardiology Foundation/American Heart Association guidelines focus on the assessment of HF rather than determining whether a patient has this syndrome. The European Society of Cardiology guidelines on diagnosis recommend that all patients with symptoms suggestive of HF undergo echocardiography and measurement of serum natriuretic peptide levels, whereas NICE recommends discerning utilization of these diagnostic tests.

  4. Diagnosis: In diagnosis, the NICE guideline focuses on using both a history of myocardial infarction and an increase in serum natriuretic peptide levels to guide further assessment. It also recommends time limits within which patients should receive both echocardiography and clinical assessment by a specialist. Their review of the literature concluded that clinical signs and symptoms are of limited use in the diagnosis of HF, and that measurement of serum natriuretic peptide levels (both B-type natriuretic peptide [BNP] and N-terminal pro-BNP) has high sensitivity, but only moderate specificity for diagnosis of HF. Therefore, they recommend that:

    1. Patients without previous myocardial infarction should undergo measurement of serum natriuretic peptide with subsequent echocardiography, and specialist evaluation is indicated only if these levels are elevated.

    2. Patients with a history of myocardial infarction should proceed directly to echocardiography and specialist evaluation (based on economic analysis which suggested that it was more cost-effective to directly refer patients with a higher probability of HF for echocardiography without first measuring serum natriuretic peptide); if the echocardiogram is normal, then clinicians should consider measuring serum natriuretic peptide. (The GDG reviewed the evidence for possible indicators of high probability of HF from the history and clinical features and considered that a history of myocardial infarction was the most reliable of the clinical features predictive of HF when ascertained by a generalist. Patients with normal serum natriuretic peptide levels are unlikely to have HF and, therefore, do not require referral for echocardiography).

    3. They opined that prompt diagnosis enables timely use of effective treatment. Thus, they recommended that echocardiography and specialist evaluation should be available within 2 weeks of presentation if patients have a history of myocardial infarction or high serum natriuretic peptide levels, and no later than 6 weeks after presentation if the serum natriuretic peptide levels are increased, but not high.

  5. Management: The NICE recommendation for therapy of HF includes:

    1. The GDG encourages increased use of beta-blockers and angiotensin-converting enzyme inhibitors as first-line therapy in patients with HF and left ventricular systolic dysfunction, and proposes options for second-line therapy (aldosterone antagonists, angiotensin-receptor blockers, or combination therapy with a nitrate and hydralazine).

    2. In patients with persistent symptoms, they opined that specialist referral is warranted for consideration of additional drug therapy, cardiac resynchronization therapy, and an implantable cardioverter defibrillator.

    3. The GDG also recommends offering group exercise-based rehabilitation programs to all patients with HF with stable symptoms and no definite contraindications.

    4. The GDG opined that sufficient evidence did not exist to recommend any specific pharmacologic therapies for HF with preserved ejection fraction or to recommend telemonitoring. They recommended that the focus ought to be on managing comorbid conditions, such as hypertension, ischemic heart disease, and diabetes mellitus in patients with preserved ventricular function.

    5. Serial measurement of serum natriuretic peptide levels was recommended for selected patients receiving specialist care.

  6. EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure), the RAFT (Resynchronisation/Defibrillation for Ambulatory Heart Failure Trial), and SHIFT (Systolic Heart Failure Treatment with the If Inhibitor Ivabradine Trial) clinical trials have been reported since the publication of these guidelines, and the authors opined that these therapies may be incorporated if there is cost benefit.


Clearly, the National Health Service has to allocate scarce resources and, hence, the NICE guidelines focus on what is cost-effective in the British system to diagnose and treat HF. For example, there is a limited pool of specialists and cardiologists in the UK and, therefore, often the management of milder HF has to be done by general practitioners. Therefore, these guidelines may be appropriate in the UK, where resource allocation has to be done in a measured fashion. However, the cumulative risk reduction if all of the three therapies (i.e., ACE inhibitors, beta-blockers, and aldosterone receptor blockers) are used was 63% and absolute risk reduction was 22%. Therefore, the number needed to treat = 5 (Fonarow G, et al., Braunwald’s Atlas of Heart Diseases, Volume 15, Chapter 5, Current Medicine).

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Exercise

Keywords: Angiotensin Receptor Antagonists, Wales, Biological Markers, Exercise Therapy, Heart Failure, Defibrillators, Implantable, Cardiac Resynchronization Therapy, Natriuretic Peptide, Brain

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