Management of Chronic Heart Failure in Adults: Guidelines From the National Institute for Health and Clinical Excellence FREE

The National Institute for Health and Clinical Excellence (NICE) develops recommendations for the National Health Service in the United Kingdom.

Heart failure occurs when the heart becomes unable to pump blood efficiently. Symptoms include difficulty with breathing and leg swelling. Although many things can cause heart failure, high blood pressure and narrow blood vessels of the heart are common causes.

Echocardiography and serum natriuretic peptide measurement can help to diagnose and monitor heart failure. Echocardiography uses sound waves to take pictures of the heart and assess its pumping and relaxation functions. When pumping function is impaired, the cause of heart failure is left ventricular systolic dysfunction. When pumping function is preserved but there is evidence of impaired relaxation of the heart, heart failure is associated with preserved ejection fraction. Serum natriuretic peptide measurement involves a blood test; levels are classified as normal, raised (somewhat abnormal), or high (very abnormal).

Some patients with heart failure benefit from electronic devices surgically placed under the skin, which involve wires to the heart. Cardiac resynchronization therapy (CRT) synchronizes the ventricles. An intraventricular cardiac-defibrillator (ICD) monitors the rhythm of the heart and, if needed, delivers a shock to normalize it.

This update of the 2003 NICE recommendations used information from published studies, health economic analyses, expert opinion, and patient views.

NICE found new information about heart failure and the role of serum natriuretic peptide levels, echocardiography, drug therapy, CRT, ICDs, and disease monitoring.

The guideline includes many specific recommendations, but the main ones state that diagnosis should begin with a history and physical examination. If heart failure is suspected in patients with a previous heart attack, perform echocardiography first and obtain a clinical evaluation by a specialist. In patients without previous heart attack, measure serum natriuretic peptide first. Obtain echocardiography and specialist evaluation within 2 weeks if there is a history of heart attack or serum natriuretic peptide levels are high and within 6 weeks if serum natriuretic peptide levels are raised.

If an echocardiogram shows heart failure associated with preserved ejection fraction, use a diuretic to remove excess fluid and treat underlying conditions, such as high blood pressure. If the ejection fraction is low (left ventricular systolic dysfunction), use a beta-blocker and an angiotensin-converting enzyme inhibitor. Patients unable to tolerate these initial drugs should receive a second-line drug. If patients continue to have symptoms despite this therapy, consider adding another second-line drug.

Patients with very low ejection fraction and specific electrocardiogram changes are likely to benefit from CRT or an ICD. Supervised exercise programs can reduce hospitalization and improve quality of life for patients with stable heart failure.

These recommendations may change when new studies become available.