In guidance published today NICE has called for hospitals to ensure that people who are acutely unwell as a result of suspected heart failure are seen by a specialist team within a heart failure service.

“Acute heart failure accounts for over 67,000 hospital admissions in England and Wales each year and is the leading cause of hospital admission in people 65 years or older. It is usually caused because the heart muscle has become too weak or stiff to pump enough blood to meet all the needs of the body” says Professor Mark Baker, Director of the Centre for Clinical Practice at NICE. “Acute heart failure is life-threatening so it’s important to diagnose the problem correctly so patients get the best treatment.”

People with acute heart failure are usually admitted through the accident and emergency department. Those who are very sick tend to be admitted to intensive care units, high dependency units or the coronary care units.

The remaining patients go into either the general medical wards or to the cardiology wards, depending on what treatment they need.

This practice is not standardised across hospitals and different factors affect the decision, including the person’s age, whether they have any other illnesses and where the available beds are.

“The treatment patients with acute heart failure receive, and how successful that treatment is, varies depending on the unit they are admitted to” says Professor Jonathan Mant, Chair of the Guideline Development Group. “Patients admitted to hospital with acute heart failure should have early and continued input from a specialist heart failure team. In addition, immediate access to natriuretic peptide testing (which assesses the levels of stress the heart is under), timely access to echocardiography to show how well the heart is working, and use of proven drug therapies are important components of care which if used optimally will reduce death and ill health associated with this condition.”

In the UK, the most common cause of heart failure is coronary artery disease, with many patients having suffered a heart attack in the past. Symptoms and signs of heart failure include breathlessness, fatigue and fluid retention.

Unlike chronic heart failure, which is more common and which develops slowly over time and worsens gradually, acute heart failure develops suddenly. This can either happen following a heart attack that has caused damage to an area of the heart or, more commonly, because the body can no longer compensate for chronic heart failure (acute decompensated heart failure).

Dr Suzanna Hardman, Consultant Cardiologist and member of the Guideline Development Group, said: “Untreated acute heart failure kills and can have a serious long-term impact on quality of life, but this can be transformed with specialist care.

“This Guideline should ensure all patients admitted to hospital with acute heart failure are cared for by a specialist consultant-led multidisciplinary heart failure team. For most, this care will be delivered by a heart failure unit within a cardiology ward but for the few whose needs prioritise care elsewhere, the specialist team will be involved on an outreach basis.

“The use of tests (natriuretic peptides and early echocardiography) for possible new heart failure will prevent delayed diagnoses. The requirement for specialist team review within two weeks of going home will minimise readmissions and integrate acute and community care as outlined in NICE’s chronic heart failure guideline. This should result in a reduction in the number of people who die as a result of acute heart failure, improved well-being and less pressure on hospital beds."

Jayne Masters, Lead Heart Failure Nurse and member of the Guideline Development Group, said: “This guideline will help improve the care people receive when they are admitted to hospital as a result of acute heart failure. It will ensure that all acute heart failure patients are able to access the expertise of a multi-disciplinary heart failure team. It should also ensure that they are followed up in a timely manner by the appropriate clinician, thus reducing the likelihood of re-admission and complications and providing patients and carers with the reassurance of knowing who they can contact.”

Peter Bolton, a patient representative on the Guideline Development Group, said: “The information for patients published alongside this guideline gives patients with acute heart failure a good insight into their illness and the various treatments to help them recover.

“It includes helpful definitions plus the clarification of the differences between ‘acute heart failure’ and ‘chronic heart failure’, which require different treatment.

Very importantly it provides some questions for patients to ask their consultant or GP, which following the trauma of emergency hospitalisation will be most helpful, not just for patients, but for their relatives and carers as well.

“As a patient, it was an honour to be part of a group of such dedicated and competent heart and associated specialists and to be able to promote the patient’s perspective in the debates about the most suitable treatments for this very serious condition.”

As well as the role of specialist management units the guideline considers the role of echocardiographyⁱ and early blood tests (natriuretic peptide testing) to diagnose acute heart failure, the use of breathing support, and drug treatments for acute heart failure. The guideline also addresses treatment after acute heart failure has been stabilised, including surgery, and starting drug treatments that are used in the management of chronic heart failure.

ENDS

The guideline is dedicated to the memory of Christopher Jones, patient member of the Guideline Development Group, who ensured that the patient voice was heard during its development.

Notes for editors

About the acute heart failure guideline

1. The acute heart failure clinical guideline is available to view on the NICE website (from 00:01 on Wednesday 8 October. Embargoed copies are available from the NICE press office on request.
2. Key recommendations in the guideline are:

Organisation of care

• All hospitals admitting people with suspected acute heart failure should provide a specialist heart failure team that is based on a cardiology ward and provides outreach services.
• Ensure that all people being admitted to hospital with suspected acute heart failure have early and continuing input from a dedicated specialist heart failure team.

Diagnosis, assessment and monitoring

• In people presenting with new suspected acute heart failure, use a single measurement of serum natriuretic peptides (B-type natriuretic peptide [BNP] or N-terminal pro-B-type natriuretic peptide [NT-proBNP])ⁱⁱ and the following thresholds to rule out the diagnosis of heart failure:
  - BNP less than 100 ng/litre
  - NT-proBNP less than 300 ng/litre
• In people presenting with new suspected acute heart failure with raised natriuretic peptide levels, perform transthoracic Doppler 2D echocardiography to establish the presence or absence of cardiac abnormalities.
• In people presenting with new suspected acute heart failure, consider performing transthoracic Doppler 2D echocardiography within 48 hours of admission to guide early specialist management.

Treatment after stabilisation

• In a person presenting with acute heart failure who is already taking beta-blockers, continue the beta-blocker treatment unless they have a heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock.
• Start or restart beta-blocker treatment during hospital admission in people with acute heart failure due to left ventricular systolic dysfunction, once their condition has been stabilised – for example, when intravenous diuretics are no longer needed.
• Ensure that the person’s condition is stable for typically 48 hours after starting or restarting beta-blockers and before discharging from hospital.
• Offer an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker if there are intolerable side effects) and an aldosterone antagonist during hospital admission to people with acute heart failure and reduced left ventricular ejection fraction. If the angiotensin-converting enzyme inhibitor (or angiotensin receptor blocker) is not tolerated an aldosterone antagonist should still be offered.

Explanation of terms

1. An echocardiogram is a test that uses sound waves to create a moving picture of the heart. The picture is much more detailed than a plain x-ray image and involves no radiation exposure. An echocardiogram allows doctors to see the heart beating, and to see the heart valves and other structures of the heart.
2. BNP and NT-proBNP are cardiac biomarkers released into the blood when the heart is damaged. Measurement of the levels of these biomarkers is used to help diagnose, risk stratify, monitor and manage people with suspected heart failure. The level of BNP or NT-proBNP in the blood is related to its severity. Higher levels of BNP or NT-proBNP are often associated with a worse prognosis for the person. Normal results indicate that the person's symptoms are likely due to something other than heart failure.

About acute heart failure

1. Acute heart failure is a common cause of admission to hospital (over 67,000 admissions in England and Wales per year), and the leading cause of hospital admission in people 65 years or older in the UK.
2. According to the 2010/11 UK National Heart Failure Audit, most people admitted to hospital with acute heart failure are aged over 60, with 25% aged between 60 and 74 and 68% over 75.
3. Men and women seem to be equally affected by acute heart failure, but men are usually 5 years younger than women at the time of hospital admission (mean age 75 years for men and 80 years for women).