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National Institute for Health and Clinical Excellence

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NICE publishes draft recommendations on the management of chronic heart failure in adults

NICE is in the process of updating its clinical guideline on the management of chronic heart failure in adults and has now published its draft recommendations for public consultation. Since the original guideline was published in 2003, new high-quality evidence from randomised controlled trials in diagnosis, treatment and monitoring have been published. This partial update will ensure that the recommendations take into account the new evidence available.

Heart failure is a complex clinical syndrome of symptoms and signs such as breathlessness, fatigue and fluid retention  that suggest the efficiency of the heart is impaired. The most common cause of heart failure in the UK is coronary artery disease, with many patients having suffered a myocardial infarction (heart attack) in the past. The draft recommendations cover the diagnosis and treatment of heart failure, including defining the combination of symptoms, signs and investigations which together are most effective in confirming a diagnosis of heart failure and influencing subsequent optimum treatments.

old-heart-attack1Dr Fergus Macbeth, Director, Centre for Clinical Practice at NICE said: “The prevalence of heart failure is expected to rise in the future as more people live longer generally, people survive longer with coronary artery disease and there are better treatments for heart failure. Currently some 900,000 people in the UK have had a diagnosis of heart failure, with almost as many again who may have damaged hearts but as yet no symptoms. It’s clearly very important that clinicians working in this area have a guideline that is based on the most up-to-date evidence of what works best. This new draft guideline outlines a comprehensive approach to the management of heart failure, and  ultimately seeks to improve the length and quality of life of people with the condition.”

Dr Macbeth continued:The draft guideline clearly indicates those recommendations that are new or have been changed from the original. For example, the original guideline recommended the use of echocardiography to help confirm a diagnosis of heart failure only after other tests were inconclusive. However, based on a review of new evidence about the best way for primary care physicians to diagnose heart failure published since the original NICE guideline, the updated draft recommends that people with suspected heart failure and who have had a previous heart attack should be referred urgently for echocardiography and specialist assessment.

The draft recommendations are available on the NICE website at: http://www.nice.org.uk/guidance/index.jsp?action=folder&o=46793 Anyone wishing to submit comments on the draft guidance is invited to do so via the NICE website between 14 January  and 10 March.

About heart failure

  1. Both the incidence and prevalence of heart failure increase steeply with age, with the average age at first diagnosis being 76 years.
  2. Heart failure has a poor prognosis with just under 40% of patients diagnosed with the condition dying within a year – thereafter the mortality rate is less than 10% per year.
  3. Patients on GP heart failure registers, representing prevalent cases of heart failure have a 5-year survival rate of 58% compared with 93% in the age and sex-matched general population.
  4. Heart failure accounts for a total of 1 million inpatient bed days – 2% of all NHS inpatient bed-days – and 5% of all emergency medical admissions to hospital.
  5. Hospital admissions because of heart failure are projected to rise by 50% over the next 25 years – largely as a result of the ageing population.

About the draft guideline

New recommendations include:

1. Diagnosis

  • People with suspected heart failure and previous myocardial infarction (MI) should be referred urgently and have echocardiography and specialist assessment with 2 weeks.
  • Refer patients with suspected heart failure and very high levels of serum natriuretic peptides for urgent echocardiography and specialist assessment within 2 weeks.
    • Refer patients with suspected heart failure and raised levels of natriuretic peptides for echocardiography and specialist assessment.

2. 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. The order in which these drugs are initiated should be based on clinical judgement.
  • Offer an aldosterone antagonist to patients with heart failure due to left ventricular systolic dysfunction if moderate to severe symptoms persist despite optimal therapy with an ACE inhibitor and beta-blocker.
  • Offer isosorbide/hydralazine to black patients who remain symptomatic with ACE inhibitors and beta-blockers.
  • Do not substitute angiotensin II receptor antagonists (ARBs) for ACE inhibitors in patients with heart failure due to left ventricular systolic dysfunction unless there are intolerable side effects with ACE inhibitors.
  • Consider adding an ARB to an ACE inhibitor and a beta-blocker in patients with heart failure due to left ventricular systolic dysfunction who remain symptomatic and are intolerant of aldosterone antagonists. This decision should be made by a specialist.

Published on: January 20, 2010

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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